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HomeMy WebLinkAbout1588A 1589A . . ....___ __.____.___.._..---_...__._�_.__. _.__. ... WORKERS'COMPENSATION UECIARATION � " - � � � I he.�eby a,{firm thal I have a certifim�e of consenf to self APPLICATION FOR .BUILDtNG� PERMIT insure,or o'�er�i4icate of Workers'Compensaiion Insurance, or a�certified copy thereof(Sec.3800,Lob.C.) � ��""� � - -�-�-� - � �- ��� _ _. _.__.... .... .._. COUNTY OF LOS ANGELES BUILDINCe AND SAfETY Po❑li[y No. Compony BUILDING � i� � Gertified mpy is hereby fumished. FOR APPLICANT TO FILI IN ADDRESS C .�.CJ � Certified topy is filed with fhe county building inspec- gUILDING ,� l iion deporimaM. � � � ADDRE55 - � � ��1.1/�c� ., . .. . . L ... . .. . ...... � .. '� .,'I � . . . . Do1e Applicant � CITY ,i zIP �OCALITY ��UCZ-L�(.T � CERTIflCATE OF EXEMPI'fON fROM WORKER$' NO.OF BtDGS. NEARESL.._.___.- . ._. _. . .__.. . -.. . � � � COMPENSATION INSUf2ANCE� � � S�ZE OF LOT NOW ON LOT CRO55 5T. (This sec�ion need not ba complefed if�he permit is for one �"`�R hondred dollprs(j100)or leu.) TRAQ� B�OCK LOT NO. �App gppK p,qGE PqR(FL L o (sT. ,��. ��ZONE �,P 3 3 � r . } I cerfify thal in�he performance of�he work for which�this awt�ER N . �� _ � permil is issued,1 sha�l noi empioy ony person in any manner �/ �! �-SaECIAI � - -� - � �- � -- � � so as fo 6ecome sobject io the Workers'Compensatiori tows. ADDRE55 p� ,L�L(. V� CON�ITIONS v j '_ c�rr� U.7 L. T zir m Dote�Applicanl ��°LL/ 0 i NOTI E TO APPLICANT: 1f;afler making is CeRific6ta of ARCHITECT OR ht� DISTRICT GRouP TYPE FIRE SSED 8Y .� ENGINEER �� CONy�! � ZpNE � Exemption, you should become subject to �the Workers' r'� 7 W i Compensntion provisions of rhe Lobor Code,you musr forth- A�R� �. ��' ✓/ . d wifh comply with such provisions or this permit sfiall be - y � deemed re�oked. - )TE�� � _ STATISTICAL CUSSIFiCAT10N AVT. COf�100. Z . CANTRACTOR NO. . . .. IICENSED CONTRACiORS DECtARATIOM � � �C p�, _ CLASS NU.��DwEU,UNITS � 1 hereby offirm thaf 1 om licensed under provisioas of Chapier 9 ADDRE55 3� .� �..0 �- S{WER MAP � � (commancing with Secfion 7000)of Division 3 of the Business and . ���_ � Professions COde,and my license is in fuli fo¢e ond effM. C7?Y CIASS G�'r � � � VALIOA710N p C-� Xi.R. NO.OF NO.OF CMECK � � � � � � LicenseNumbar�-7�33(1 .Lf�,Closs ���J SIZE SiDR1E5 FAMILIES ONE yA�UATION /�/.,./� � '�IY�IV._... ......._ . . _ . .. C❑ontractor ' C Oate�- ��IPfION OF WORK - A� ' ; J ► . � - I am exampt under Sec. s „ � �^ r - ALTER � q� = . B.BP.C.for this reoson . i REPAIR � ; USE pF �, a s �,� Dafe: E%ISTING&DG. UEMOI ❑ . . ' �- Signoturo APPLICANT TE�. FINAI / G j • "%" `'�,��. . �. OWNER-BUILDER DECIARATION ��M �" OATE *- p � lherebYaff'xmlhaFlamexempF#romtheConir«toisLicense ADDRESS ._..........���.... . FINAL . e . �.�.:�� � f.S law fOr fhe following reason(Section 7031.5,8usiness ond Profess�oro Code): . . . .. . . . vae-rm By- , ii._,�,c_r.;i � I, oa ownar of tha properry, or my employees with nUooeE5�5 � - � wages os thair sole aompensation,will do ehe work ond , `���� {�������� the shuctura is not intandad or offered for sale(Section ����TM � 7044,8usiness aad P�ofessions Coda). � - naOv�taG TK_ � . '�• ' '' ' � � � I,as owner of{he propeny,am exdvsively coniratting ��T�'�� �' C . wifh licensed coMractore to conetrvct the projact{Sec- - . � " '-f���� tion 7044,Buainese and Drofeuions Code�. nDoae55 T REqUIRED TO7AL SETnACK F20M E%I T. �• ` . ,. , ::�+ CONSTRUCTION IENDING AGfNCY ��-- SET BAIX VARD HWY pppP.LINE WiDTH I hereby offirm that�here is o constr�aion lending oge�cy for fRONi � " '� '- '<t �i,�.,::.-t:.,. fhe performanm of the work For wMth lhis permit is issued P.L � - � � (Sac.3097,Civ.C.). � SIDE � g P.L. = Lander'a Name �7,�- /� IDMq Ref.M ; � �� $ P.4 Fee S �^-7���v Permit Fee . . . , .-. ...... ... . - Lender's Address ' � I terlify thot I have reod this.applicotion.and state that 1he tuoan�e Fee �, LDMA P/C M � - - � - �� .� � above infarta�ion is corcect.I agree to comply with all Gounty In�es��pi�on Fee �-. ��,g ordinancea and S�ota laws relating to 6uilding consMuclion, Towl Fee �•�`� toMq Pa�m.M �- � � � and hereby o��horize reprezenratives of this County to ante� � uppn ihe obova-mentioned property for inspetfion purposes. , . 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