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HomeMy WebLinkAbout1074A 1075A (5) � - � WORKERS'COMPENSATION DECLARATION � � �- - -� ��-�� �--- : �� �-�- � ��- � �� 4 4 � � � '�� �"�;9 83 � I hereby offrm thot�l hove a-certificate�of consent to self qpp��CATI�IV FOR- �t��LD��l�tt�-R��1���3 � i� insure,or o cerfificote of Workers'Compensation�Insurance, ' �� ar a cerrified copy thereof(Sec.3800,�ab.C.) CpUNTY OF LOS ANGELES BUILDING AND SAFETY � Poi,�Y No.WCP86480�mpany Great American _ � CernFied copy is here6y fumished� - � FOR�APPL'ICANT T��FILL W � -�--- � - Buil.oiNG ja - .' " � ADDRESS � / Certified<opy is filed with�he.county building insper gUtLD�N tion depariment. qpoke5�0610 Climber DY1V2 , Date 6 9 88 A u<am -R Chenier �� - �,T,, �land Heights ZP II PP LO�L�n �,� CERTIFICATE OF EXEMPTION FRONi-WORKERS' � � NO.OF e�DGS. NEAREST COMPENSATION INSURANCE� �- � SIZE OF LOT NOW ON LOT � - � � CRQ55 SL � (This section need nor be completed if ihe permit is for one ASSESSOR� � hundred dollars($100)or less.) - � � 7RACT �33636 BLOCK LOT NO. 17 Mqp$OOK � PAGE PARCE� OWNER P�+SLE'Y OF SO CAL 'E`� 660-0660 USE ZONE MAP � � . I certify that�in�the performance of the work for which ihis-� � �--- . N�� � -� NO. �� . � .� permit is issued,I shall not employ any person in any manner qODRE55�.�]991 M1tC110I1 SOU'F�1 �� `�3itl SPECIAL S/ �; so as fo become subjed ta fhe Workers'Compensofion Laws. � ��---�-.--- a� CONDITIONS o; arv ' zia 714 � Date � Appiiwnt - . . .. ��(f� L �:. ARCHITE�7�,Q@�,. TEL. NOTICE TO APPUCANT: If, ofter making-this Certifi<ote of ]_BS Sandber 547-3203 DISTRICT GROUP TYPE FIRE ESSED BY O ENGINEEIP''•"' g NO. Exemption, you should become wbject to �he Workers' � - - - CONST. ZONE F�. Cem ensotion ovisions af the Lolior Code, ou must forth- � � �. � � - ithP omply w fh such provisions or ihis permit shall be ADDRE556�.0 }..�''. 17�1 $'t. #1�5 .SdIT�d ATld � deemed revoked. - � SffiTK: 35 UWf12Y' �TE�� . STATISTICAL CLASSIFICATION APT. CONDO. �� . CONTRACTOR Np, �/-� � LICENSED CONTRACTORS DECLARATION" �-- �i�_ CLnSS NO.L�L� DWELL.11Nrt$_�_ �. I hereby affirm�hpf I om licensed under provisions of Chapter 9 ADDRESS NO. � (wmmencing with$edion 7000)ofDivision 3 of ihe Business and -��� - � SEWER�MAP�' � � Professions Coda,and my license is in full force and effect. - CiN- - CLA55 . BK � _ . VAUDATION SQ.FT. NO.OF NO.OF CHECK License N�mber 527293 i;�.ciass Bl srze -�Q` STORIES 2 FAMIUES�' oNe �PRE�SLEY OF SO.CP� F)�9�HH DESCRIPTION Oi WORK SlIl le FdIIl.11y NEW � :.- VA�UATION� � . Gonfractor ate ;�� :.� with attached garage aoo � ❑i am ezempt under Sec. ❑ . , �� l; !.�:�H . - ALTER - B.&P.C.for this reason-� � - Plffi'1� �� e� � j � . i�e s+e c�-?; - - USE Oi � . REPAIR Date: � � EXISTING BLDG. DEMOL Signature - APPLPRNTT R. Q1P111PS NOCGO�OE)E)O FINAL j7 �. l - -.., OWNER-BUILDER DECLARATION - � - - - � � ISATE J�`��� �' �"� f���"� - � I 6ereby affirm that I am eaempt from the Comractar's Licease s17991 Mi.tehell South I1V]Sl@ � Law for the following reasbn(Section 7031.$, Business ond ADDRES � � p�Np� M,, " � � U c 7:;�_. . . Professions Code): �.. - . - pRe - - . � BY ,vti„c�- :J�s C/ ��.: OBUILDI - . . . . I, os owner of ihe property, or my employees with AD�� wages as iheir sole compensahon,will do the work and - - - . - - . � .. _ S ! �� —r the structure is not inlended or offered for sale(Section ��"��T� � -- ' � � - 7044,Bosiness and Professions Code). �MOVING TEL � � I,as owner of ihe property,am exclusively contraciing CONTRACTOR . Np. � •* � - , � with licensed confracfors to conslruct ihe project(Sec- qDDRESS -- - - -i -�!�,�.�.�i� tion 7044,Business and Professions.Code). .� �. ._.. . � CONSTRUCTION LENDING AGENCY� � SEQf BACK �ARD MVY TOT'4pROPiCNEFR._M � WIDTH `� -I>�'v`-c,—.�.- � - I hereby affirm thar fhere is a mnstrucfion lending ogency for FRONT fhe performonce of-the work for which 1h�is permit is issued p,�, ���-v��`.�F -� � (Sec 3097,Civ.C.). SiDE N�g r.i. Lender's Name - �.q�.�� � Na�i-JV+��/,', L�MA Ref.X 9 Lender's Address - P.C.Fee S "�. Perm�r Fee. ... _ .. ' . 3 • � I certity that I have read this applimtion ond stote that the y Z-�+�a issuance Fee 7-0.5� IDMA piC k �G?� above information is correctl agree to-comply-witfi oll-Counry � �nves�igation Pee �an ordinances and State laws relating to boilding consiruction, _ Toral Pee `� LpMq p¢,m.# �j an ereby authorize representatives of ihis County to enier� � ' up the qbov entioned property for inspection p pose: - - - � ���� �`-- --- -�- � -- �-� � -� - - �� ' � ` `j ,`�2.ox� i^r/i � ij � i,S�C SEE REVERSE FOR EXPIANATORY LANGUA�'iE SignaWre of Applico gent Oare ..�_.�: e� .�__... �_ - � � �� _ ��.�wm.e.�.� , ,� . - S a��3 `��`>n�_ic �.r . . E �..,,r ;�tat^E E:s���v����" . . .-LF 7 - ri _ c 7���1 :____ -... . _.. ,.�::... -- -.,_ ...,,. . . ._ . , _,;. _.. _ ,.., , --�.."��-r .... . ___.._. ..._ . . �,.,�..a._.. „ r; r�c t ..., - ste:u=n��' � . �i .. � . . . "_ . ., i .� � �eJ _ .rn. . . - . . , . 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