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HomeMy WebLinkAbout1072A 1073A WORKERS COMPENSATION DECLARATION -��- - - �- � � � � �� � . ._ ..,.-.� �a . . . � ! hereby off thot I hove o c rrificate of consent ro self -� Ap�p�LICATION -�-Fb�� B��'L��NG PE�R1Vl�T ::�: - � insure,o-d ce t fiw�e o4 Workers Compensotion Insuran<e, . _ o�o<e�hfied copy thereof(Sec.3800,La6.C.) � � .+ . � > _ COUNTY OF!OS ANGELES V BUILDING AND SAFETY � � FIGP86480 m _, .._ ..., ,.�.. . Poccy No. �b pany Great Attx�rican _ eunow� � Cenified copy Is hereby furnished. FOR APPLICAI�7T TO FILL fIV ADDRE55 � __ �",j� Certified copy is-filed wifh 1he-munry building inspec- BU�tD:NG � � �ion departmenf. ADDRESSG0625 Climber Dx'iv@ Date 6I9�$$ Applicanr .R• ��� � . arv �lend-Helghts ziP � . . �ocauTv CERTIFICATE OF EXEMPTION FRONi.YVORKERS'-- -- - � _ _. _ NO.OF BLDGS. _ NEARF57 - COMPENSATION INSURANCE 5RE OF LOi NOW ON LOT CRO55 ST. -P•Z.-?7 (This seclion need no�be completed if 1he permit is for one ASSESSOR hundred dollars($100)or less.) iRACT 33636 BLOCK LOT NO2$ /,Aqp gppK PAGE PARCEL OWNERP�'S�'Y QF `� �iT Np 660-0660 USE ZONE OP � � � I certi4y thaf�in the performance of the work for which this� � � �� � y_ permit is issued,�shall not employ�any person in any manner qD�RE5�799�- �-tC�1e�-�- .�OU'�1 ,- .._.., /�j 0�� CONDITIONS- " (,-,t$ a� _.... so as to become subject to?he Workers'Compensa�ion Laws. I�ne �i� � 92•�14 � U � � . . CITY � ZIA .. ..... � Date ApplicaN � - � D757RIC1 GROUP TYPE FIR ESSED BY O ARCNIT �NOTICE TO RPPIiCANT: ff, afier moking�this Cenificate of� ENGWE��leS San.c3berg Np 547-3203 CONST. ZONF � U Exemprion, you shauld become su6iect ro the Workers' �10��,. l,�{]7 St. #2�5 51Y1�.d �lla '� �. � Compensation provislons of�he Labor Code,you musf forth- qDDRES � � — ---� Q V with cGmply with such provisions or 9his permif shall be � TEI. - STAtIST�CAL CLASSIFICATION� � A 7. CONDO. ��� deemed re�oked. � � CONTRACTOR S2TC� dS OWd1PS NO. LICENSED CONTRACTORS�ECLARATION _ C�n55 n10. �� �WEu._UM75 z- LIC. I hereby affirm>hat I om licensed under provisions of Chapter 9 � - ADDRE55 NO. $EVdER MAP .{[ommencing with Section 7000)of Division 3 of ihe Business and ���, Professions Code;and my license is�in full force and effect. CiTY . � . CiA55 BK � � YAtIDATION � � � 5�.FT. N0.OF � NO.OF - CHECK . .... LicenseNumbery7�729� I�C.Cla55 R� SIZE 2 • STORIES 2 FAMILIES �- ONE . Single F�nily N�,,, vnwanoN DESCRIPTION OF WORK . Confraclor PRESLERZ�OF SO�CA.�te 6I9�HH . . ... . .�.. ADD ; ���"�� , �I am exempt under Sec. � W1�'1 attaehed garage A`�R � �'J��+, . 8.8P.G.far�this repson . . P�-an� �� ���- REPn�R � s '+s e '''� USE OF � Dote� EXISTING BtDG. - -. ���� � � - 9 .. APPLICAjgT Q7P_1212T� - _ .....7E166�-0664 FINAL y� . ��� r cl/;, S.C' ..: $i nafure OWNER-BUIlOER DECLARATION "- � - fPRlitT) NO. .���.DATE A �1� G y��'z ,:J - I hereby affirm that I om exempt from�he Coniracbr's License qDDRES�799�- M�tCY1e1�' SOU�'Il� IY'V1I12 FtlNAL Low for the following reoson(Seciion 7031.5, Business-and ---� - -� --� � -�- y� � . . Professions Code): PRE EN . . ._ � By '�-v�—��'�� � I, as owner ofi the y, y P Y BUILDING� . - properf or m em lo ees wifh A�DRESS ':1 � �-?..� woges as iheir sole compensption,will do ihe work and - � � ' the strocture is not intended or offered for zale(Section �����N -�.� � ' �""" ' a s ` ° � 704a,Bus�ness and Profess�ons Code). n�ovihc . ht . P� � I,as owner of the property,om exdusively contracting CONTRACTOR N�� ,—`__'`.V,_v with licensed mntroctors to coastroct the project(Ser qDDRE55 - tion 704d,Business and Professions Code). -- �-� -� - " - '-"- � ;i, ^"� REOUIRED TOTAI SETBACK " �CONSTRUCTIQN LENDING AGENCY SEI BACK YA4D HWY pqOP.LINE W��7H I hereby affirm ihat ihere is a constru<iion lending agency for FeONT � �'��S Q �-. ihe performance of ihe work for which ihis pernii�.is issued a.�. (Sec.3097,Civ.C}. � 51DE � � � � � � N/A a.�. Lender's Nome - -- � - � ,¢n�__en ����2J�fi3 LOMA Ref.X .'� P.C.Fee.S �v Permit Fee �-1L"T' � Lender'S Add�ess � � �d C�� � ` � I certify that i hove read this applica�ion and slate tbat the K�--``�u Issuonce Fee 1�.5a LDMA 7/C N �67� ' 2 above information is conact.l agree to tomply with all Covnty� - � �nvesriga��on fee cn�� � $' i ordinontes and State laws relating to building consirucfion, 7oral Fee?_��0 LDMA Verm.� ��.�./ � an ereby authori e representafives of this County to enter �"�- -��-'�-�--�� = up n the above-m tioned proparry for irdspection�rposes. � ��-" � ' �� � . _ � . t�� . _ . .. . ._.. .. . .... . .�- _ ______. . . , SEEREVERSEFORExPLANATORYCANGUAGE Signa�ura of Appl ean�or A . �ata . � ' e_. -.�... .;b.,_�(Jry�a`e,il�,.�.\'T��.. . �....�». . . .�.. ..p4tr.��R�Ra'°a���` . ,x :ti1�,6i-fsC€l�? ;iY)�t F„'E.:J.`� . i._...__e._.... �.��,�.,o..q ..s.....�,��5.�., .. . . _ , q .n - . . �' .. ' :l�.c >.e; t� . .-. �_ e. 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