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HomeMy WebLinkAbout1076A 1077A (5) WORKERS"GOMPENSATION 6ECLARATION � -� � �� �'' y�� " `"-� � -� I he�e6y affi- �ihor I hove a cert�f ca�e of ronsent ro self ._ e , insure,orocertifi<ateofWarkers'Cqmpensationlnsurvnce, � lIPPLICATION FOR --BCJ�ILDING.�pERMIT � _._ -� � or o certified.copy ihereof(Sec.3800,Lab.C.) � � - - - - � � � - �� '� Po�;�yNo. WCP$648�9�,�o„Y Great AmeriCan COUNTY OF LOS ANGELES BUILDINGmAND SAFETY � Cer�ified copy�is hereby f�rn�shed �� ���� � - �FD(�Ap��C,4NT T�FI�L I�14 AD'DI2E55� ��'j Q a ` l � Ce�tiffed-copy is filed with)he munty bu�lding inspeo- BUIIDING 2OGOO CI1ID��2Y' DYlV2 � tion.deporfinen�. , ADDRESS - � Date 6�9�HS � ApplicantR. aienier � cirv -Rowl3nd Hei hts zia._.� . . �:. .._..� �ocaurv � � . . - CERTIFICATE OF EXEMPTION FROM WORKERS'. � . �- NO.�Of BiDGS , �.�_�- . -���" NEaRFST� � � COMPENSA710N INSURRNCE � � SiZE OF LOi� NOW ON LO7 cR055 SL�-- (This secfion nead no1 be completed if tha permif is for one� - . .33(3( ].6 ASSESSOR-- hundred dollars($100)or less.) - TRACT BLOCK . LOT NO. Mp,P.BOOK - PAGE PARCEL . . --TEL. USE ZONE �P � _ �. OWNER PRESLEY OF SO Cb1L NO. E)SO—OE)6O NO. I cartify thot�in the performance af�he work for.which this -- - - - - - -. . _.. .. �D p � permii is issued,�I�shall noi emplay any person in any manner !� �p SPECIAL �� AD�RE55 1 � CANDITIONS �S so ds to becoma subject to the Workers'Compensation Laws. - � . . . . . _ (J c�nlrvine z�v 92714 �, U. Data - Appli[aM _ - - � - - � �� - PISTRICT GROUP TVPE FIRE BRQCESSED BY O� NOTICE TO APPLICANT•Jf, after makin ��his Cartificata of� ARCHiTE�pg_� 9 ENGINEEp-iid��-eS S�T1d�JEr NO 547-3203 CONST. ZONE i � ►— Exempfion,-�you should become subjact fo the Workers' - - --- ----- --�� � � �--�� --�-- �a" � i (� Compensation provisions of.Ihe Labor Code,you must forth- qDORE - �" � �. � L—Q-a-- �-. wifh comply wilh soth provisions or this parmit shall be � -- ' �TEL. -� -�- � -"'��� STAT�STICALCLASSIiICATION-- �- � AP1. CONDO. tq daemed revoked. CONTRACTOR S�TtE 35 OW11eY NO - - �/ Z LICENSE��CONTRACTORSDECLARATION � - - � -���, '���-��� '"� CLASSNO.�DWELL.UNIT$J_ -" I here6y offirm lhaf I am Ltensed�under provisions of Chapter 9 - ADORESS NO. SEWER MAP�' �- (commencmg wi�F Section 7000)of Drvision 3 of�he Busines;and � -�- "i��, �' � --- � Professions Code,nnd my licenee-is in full force and affect. CITY CtA55 � BK � VALIDATION 527293 gl s°.FT. 2665 NO.Of 2 NO.OF 1 CHECK License Number'� - ----�� Lia Class 512E - STORIES FAMILIES ONE � . . . .. . .. . - .. � VALUATIQN CoMraclor p�SL�Y �F SO CF�ate 6�9�g$ DESCRIPTION OF WORK S311 �-2 FalYLI-�- W1 Ew s �-�[[? ���- �- - ADD 7!1' , .� ❑I om exempt under Sec. .. .. . dttdCY12C� dTa e P�"an 4.. qLTER .. . . . . 1 - ?-J�J� � . ; kau ��i B.&P.C.for ihis reawn REPAIR � - Date: USE OF. .. .._ .. - _ . :. _ . DEMOI r� �= � P i. . .... .. . EXISTING 9LDG. �-1 1 ��-1'.1_-�"J i . APPIICANT � �_� y . s9�m��e aeiNT R. Ci�enier No 660-0660 F�Nw� �y l:.�.� � :::�; i� l OWNER-BUIIDERDECIARATION � - � �� ��- . � -�- UATE € . - I hereby affirm that i am exempt from the Cont�a�ta�slicense � • • � Law for the follawing rea;on(Sectwn 7031.5 Business and ADDRESS 17991 .Mitehell South ZYV]112 FINAL '�� ^ / E1's v 1 .-:-'S� �- � � Professions Code)! � PRE EN . . . . . .. . ..... . . . .... BY tl�`� '7� - . . - , _� I, as owner of ihe properiy, or my employees wiih ADDR SS , . _ . � � �-- wages os iheir sole compensotion,will do the wock and F y--z �� � ihe structure is noi in�ended or offered for sale(Seciion iOCA�ITY � 704d,Business and Profess ons Code). MOVING . _ TE�� �. .� . ' f ^L� (r�'�1 � I,as owner of the property,qm ezclusively confra<ting CONTRACTOR �_ NO. with{icensed coMracfors to c6nsiruct the project(Sec- q6DRE55 � v � .-.�. v� . � tion 7044,Business and Professions Code). . CONSTRUCTION LENDING AGENCY � � �Qgq�� YARO HWY TOTAPROP.ONE���� WIDTH ii���.'�::�--ii��:.'---�- � - I hereby aRirm that there is a constroction lending agency for FRONT �- - �he performan<e of the work for which ihis permi�is issued P.L �: (Sec.3097,Civ.C.7. - � - �� - - SIDE N/A P.�. Lender i Name � -- � - - + p 402,52 676.50 `o"'^Re` " • 6 P.C.fee$ - Permit Fee � , � Lender's Address . _ - � � �- � : -- � � p � ZQ.�JD � ' Q g I certify ihat I have reod this application and state thpt the ._ Issoance Fee LOMA P/C# above informotion is correct.I dqree to<omply with all County Invesrigotion Fee -- - � 6$'�.00 /U 7 f 0 ordinances and ate laws ielating to boilding tonstruction, . - total Pee LDMA Perm.8 � R �a hereby auth �ize representatives of fhis CountyTo-enter - � mu o f e above-� tio ed property for inspection por ses.f . . . . ... - `. .: _-.: , �-. .-� -<.._..., . .,.. . .,.;.. , ... .. ._. . . .. ... . . . .. � tl' - �. � � jJ- SEE REVERSE FOR EXPLANATORY LANGUAGE � Signa�ure of Appli<a Agen1 pa� _ w.�._ � . � �m b,s�=� ,.�s.a..,�� m" o ;e�. �s;�:��ts"r.,� ._. ,;z,{[�r��;. . ,;_ . , , Y..�: �:_ . . � � � _.._ .�,__. � _,� --�--� _ - ,�: �,- .>. --� _ � � �, ' To� j �'�§�.;._r _ . . � �{ � _ '_ _ - _ . ._ . _ _ <,�.. 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