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HomeMy WebLinkAbout0896A (4) WORKERS'COMPENSAiION DECLARATION . � , � �a�abY affirm Iho�I have a�e.,;f;�a,a of.consent�0 9a�f qpp��CAT10N FOR BUiLDIfVG PERMIT insure,or a cer�ificate of Workers'Compenstion Insvrance,or o ce�r�fied copy the�eof(Sec.3800,�a6.C.) COUNTY OF LOS ANGELES HUILDING AND SAFETY � Policy No. Company BUItDING ` � Cerlified copy is hereby fumished. ` ! FOR APPLICANT TO FILL IN o�,�� ���L/ /� aADDRE55 Certifiad copy is filed with the counry 6uilding inspec- /� BNtDING n �A• _1 �/ -7� tion departinent. / A�ORE55 �y� �• ld • � (j�. LOCALITV N�/ ��^� NEARE57 �Q� ' Date ApplicpM� � CITY �/l./ ZIP � CROSS ST. CERTIFICATE OP EXEMPTION FROM WORKERS' NO.OF BLOGS. ASSESSOR . COMPENSATION INSURANCE SIZE OF LOT NOW ON LpT MAP BOOK PAGE VARCEL (This setlion need not be campleted if the permit is for one USE ZONE MAP �j hundred dollars($100)or less.) TRACT BIOCK LOT NO. NO. � y TEL SPECIAI y .I certify that in the performance af rhe work for which this � OWNER 1f1_R/ (a NO. �1• e� CONDiTiONS Q � 1 permit is issued,I shall not employ any person in any manner � C � n_/ DISTRICT G UP TVPE FIRE P E�eY �J so as lo become subject to the Workers'Compensation Laws. ADDRESS D �S�G1 CON57. ZONE CITY � (� C � Z�P c,Z � a -z l` 3 0 Date Applicpnt STATISTICAL CLASSIF CATION APT. CONDO. �J NOTKE TO APPLICANT: If, afier making this Cerfifimle of � ARCH�TECT O 7EL 7/ W Exemption, you should become subject fo the Workeri ENGINEER �er S4,��`ir. No. -� t�� Cta55 n10. � DWELL.UNITS_ d. N Compensafion provisions of the Labor Code,you must-forth- qDDRESS �('(�,f� n SEWEI2 Mna ? ith comply wilh soch provisions or this permit shall be TEL. daemedrevoked. CONTRACTOR- OC'�No. BK. PG, VAIIDAiION L�CENSED CONTRACiORS DECLARAiION {� i I hereby affirm fiat I am�icensed unde�provisians of Chap�er 9 ADORE55 WN�� �i)�\ NO. VALUATION . (commencing wiih Seciion 7000)of Division 3 of fhe Business ond • tK. � ^ ��F Professions Code,ond my license is in tul�forte ond effe[t � Giv ' CtA55 E �aV �e� 5�.Fi. NO.OF NO.�F CHECK LiCense Number LiC.Class SIZE STORIES FAMILIES ONE r�•• •• • 1 S Contracto� Date DESCRIWIONOF WORK N� ❑ �� . ��� F(� � I am exempi from fhe licensing reqoiremenfs as I om a N � M � ADD � � � a �_,� _�n; � licensed archiiect or a registered professionol engineer . • nt7ER FlNAI q p . � acfing in my professiona� capacity (Section �051, ./ TL.e �G D�5" REPAIft � OATE .} � /�pr D Q�'���i .. Busineas ond Professions Code). USE OF �Ma � fINAL E7(ISTING BLDG. , BY � y� . �Lic.or Reg.No. Date APPLIGANT� TEL /r-r,C �� OWNER-BUILDER DECLARATION PRINT) 71LWi/J A8 NO. rau-�� fJ.C 8���' I herehy affirm ihat I am eaempl from Ihe Coniractor's Litense �G��c— t/l_ R �/. Law for the following raoson(Section 7031.5,Business and /+�DRE55 7 W �27 01 �/�/ar/ Profassians Code): , pgESENi � 8V It�ING ��"1, os owner of Ihe property, or my employees with pooRE55 . wages as their sole compensatian,will do?he work and � the structure is nm imended or offered for sole�Section tOCnliiv . 7044,Business and Professions Code). MpwNG iei. � I,as awner of tha property,am exclusively coniracting CONTRAC70R NO. with licensed cantrociors io construct the project(Sec- pDoaE55 tion 7044,Business ond Profeuions Code). � - REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWV p{tpp.��NE ,WIDTH �hareby affirm that�here is a construction lending ogency for FRON7 �he performance of the work for which Ihis permit is issued P.L � (Sec.3097,Civ.C.). - SIDE '. . . .. P.l. . . Lender s Name . - Lendei 5 Address P���Fee 5 ���-� Permli Fee , O I rertify rhat I have read this applico�ion and state tha�rhe isso ce F�e •'�� abov infarmation is mrrect,I agree Io comply wilh a�l County Investigotion Fee �n � �� ordin nces and Sote lows rela�ing to building construction, ioial Fee ond er by au�horize representmives of this Counry to enrer �_ up 1 obove-mentione roperly for inspection purposes. , SEEREVERSEfORE%PtANATORYtANGUAGE �. . �.._�._..__"___' n..�e ' Oi j_^ [�2 r' rn � 7 O � O � � T � T O c 7' S O 0 O � y� 11 O � n N � 7 � t0 � � 5 a-G � � �Ly �n �i1 � T .� ' � p,2 z �� � n ° o D� g v � � � o 0 0 � '� o = -� � �3 m O F w ' �� 'C t4 Q � Q vt O � p Q c'p 0 O N " Q C � 4y� T. . 3 `�1 tG � m S 7 � � p" Q � � ` � 3� �? O BQ � p � 4? 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