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HomeMy WebLinkAbout1304A 1500A WORKERS'COMPENSATION DECLARATION �� � � � � � �� - � I hereby affrm th.ar I hove o cer+iflcate of consent lo self �pp��CATl0�1 FO� �UILDING� PERMIT !i -�sure,or a certlfi<ale of Workers'Compensahon Insuronce, �� o�a ce�f f�d mpy thereof fSec.38��l�a6�-+C���`AC� � �c-�cl C ' COUNTY OF LO$ANCaELES BUILDING AND SAFETY C; PolicyNo. Compony �'"^�^ �1 `���"...� � � .� . � Certified copy is hereby furoished. OR APPLICANT TO FILL IN 8U1L��N�' ���j ` S nooeEss �„ � Cer�ifled copy is filed wirh�he munry building inspec- gUIIDIN /" � - �ion depar4ment. ADDRESS �L{} - y Date Appl'icant CITv ��.�`"�'` " ZIP ' LOCP.LIiY �, �M�,C� �_ , CERTIFICATE OF EXEMPTION FROM WORKERS', NO.Of�BLDGS. _ NFAREST COMPENSATION INSURANCE �� � � SIZE OF t07 ` NOw ON LOi CRO55 ST. (This sr.ctlon need not be completed i4 the permir is for one ASSESSOR . hundred dollors(5100)o�less.) TRACT BLOCK LOTl/NO. „j h1qP BOOK ' PAGE FARCEL OWNER Nd'� "�C(�'i USE ZONE �� '�� � I certify thal in the performonce of rhe work for hich�hir NO. _ permif is issued,I shall not employ any son in anj'i1nanner SPECIA� . C. � so as to become subjeci to Ihe�o er C pen ows /",1 ADDRESS � . CONDITIONS� � J Date ApplicanY� .,(f CITv r 21P � ��i �} Q ARCNITECT OW T �} DISTRICT GROUP NPE FIRE PRO NOTICE TO APPLICANL If, ofte lna �ng is � of �� .�� ^�S - Ezempiion, you should bem . subject f he I s' ENGMEER �rSG�-$"'k_(� ` N CQMSL.--� ZO ,�,��^,` CompensaYion provisions of(he��Labor Co ,you must h- qDDRE55 i eZ� C�.�il-�Y� � C.,h i� � v �` qY\ - (n wiih comply wdh such provispns or is permit s, II be � deemed revoked. !' E�� STA?ISTICAL CLASSIFICATION APT. fANDO. _, CONTRAC�OR NO.� '�--� tICENSED CONTRACTORS DECLARATION LiC. CLA55 NO. DweLl.UNi75 I hereby affirm that 1 am licensed under provisions of Chapfer 9 � � ADDRESS ��.�'t"�� NO. � (commencing with Section 7000)of Division 3 of the Business and ��� - SEWER MAP Professions Code,and my license is in full force and effect CiTV CLA55 BK � VALIDATION . SQ.FT. NO.OF NO.OF CHECK License Num6er Lic.Class SIZE STORIE� FAMILIES ONE . f�f��C,�cz%{ NEw � VALUATI/O�pN Confractor Dafe DESCRiPTION OF WORK qOD � $ � "-�� �I am exempl under Sec �-�-� �m� r�� L7ER ❑ , ` ! `5���1 B.$P.C.Ior IFlis reaSan REPAIR � S 'y)� � e =7 7 Date: USE OF � 'j.� pEMOL ❑ - - Ex15TING BL + c �%(,p��, Signat�re APPLICANT 't . � TEL� ,T�� FINAL �. ...,_' OWNER-BUILDER DECLARATION PRINT� � � a N�� � ,! DATE l�'-` �'� ..,� - �0 ` "� ����%�%' I hereb affirrti Ihat I am exem t from the Comractor's Lirense ry, � Y P A�CRES � Lr C' �% ''I^ ����� FINAL �, � low for the foliowing reason(Seclion 7031.5, 8usiness�ond ,� G`�:�l 1 —�Y% PrRR4e55ionsCode): PRE EN 1 � 9�& BY - �t� ; � BUILDING ` �_ . ..s y��.. . I, as owner of fhe property, or my employees wifh A�DRE � Y''� �/�. �l.� C��, a+/? � wages as their sole compensation,will do the work and T � � �� fZ�•R W� JT Z��" l �he structure is not in�ended or offered for sale(Sedion IOCA�ITY � �. � ^ F � � � 7044,Business and Professions Code). MOViNG : � 1EL .--�'�� �b' rJ � � CONTRACiOR �e"- ' . �.�-�' - N0- � �- ..✓»�j � I,as owner of the property,am exclusively contrac�ing ,�!�-^ /,/ ��;�'��.>�,-o�+^�!'�' wifh Iicensed conhacfors to wnstrucf Ihe prolect(Se[- qDDRE55 �,,���(,,,..�" � � iion 7044,8usiness and Professions CodeJ. �� � ' CONSTRUCTION LENDING AGENCY SETaBACK �'qR� NW� T�TAPROP.pL NE M WIDTH ��.4��'�'�''�"�`�C'�'� I hereby affirm thar there is o cons/ruclion lending ogency for FRONT /� pi.-„ F �, e � �he performonce of the work for which�his permit is issued RL ' (Sec.309�,Civ.C.). � SIDE ,�' � ::/� �,;.��_ . P.l. � Lender's Name �, �, ` LDMA Re4.p '''4�.L li ti P.G Fee 5 �� Permit fee �� Lender's Address ^ ' I'j',i C—i3 G I cenify thot I have read this appliwtion and stote that fhe tssuance Pee L� , l,` LDMA P/C M above information is correct.I agree b Complywiih oll County Invesrigo�ion Fee 0 ordino ces ond Sto�te lows relating to buil ing construction, Torol fee ' , `i LDMA Perm.N � and eby au,�h ize presentaltives • is Counry to enter � � ry a up t e obo� e tio prop r inspeciion purpo 5, .. .......... ....... '..... .......... ....•. , 4 ' �� �`�" SEE REVERSE FOR E%PLANATORY LAMGU0.GE Sig a�ure ai pp c t or Age�� �a�e _ _._.. _ _ ........ ..... . �_m....,. _ ..�..� ..�..__�.. _.._._,_ _.�..�....__ ..... _...._ .._.__.._...__ __�"�.i � ?x�3�PFi,�.w.,�..4��:"�FW . . .. . i ;:.:ii9+ :I�i�i.. t, I '.':�': , .... .._, , � � � � _ ...,.. . _ . 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