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HomeMy WebLinkAbout1816A 1817A n,r ■ ■ � v � WORKERS'COMPENSATION DECLARATION . ��������� I here6y oitirm thol I have a cenificote oF consent�o self �p���CA�t�N FQ� � � msure,o�o tenificafe of Workers'Compensalion Insurance, o�a mrtiYed copy ihe�eof�Sec.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Compony � Cer�if�ed mpy�s hereby 4umished. FOR APPLICANT TO FILL IN su����raG nooRess � � Cerfiffed wpy is filed wlrh the county b��lding inspec- BUIIOING - liondepor7meM. ADDRESS � �, �1}y{p Date ApplicoM � C�7Y L T ZIP 7 q� �p�q��Ty CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BlDGS. f�&AREST COMPENSATION INSURANCE SIZE OF lOT �vOW ON tOT CRO55 ST. (This section nead not be completed if tha permil i�far ane ASSESSOR" TFACT BIOCK lOT NO. hundred dollars(5100)or less.� . �80dc PAGE PARCEL � 7Et.� Z, U5E ZONE M1AP I ceni/y�ha�in ihe per/ormonce oi ihe work for which this � OwNER � � ) (_ � permit is issued,I shall nol employ any person in any monner v�� SPECIAL � t+ , O� so as to bemme Subje[t to fhe Workers'Compensatipn lows. ADDRE55 ' CONDITIONS J (� Date Applitant CITY ZIP , . � NOTICf TO APPLICAN7: If, after.making ihis Certificate of ARCHITECf OR TEL DiSTRI GROU PE flR PROCESSED BV � Exemption, you should become su6ject to the Workers' A GIMEER NO. � CON57� ZONE � a Compenso�ion provisione of Ihe Labor Code,you must forth- wilh comply with s�ch provisions or Ihis permif shall be � )� T[�, STATISTIGI C SIfICATlO APT. CO�O. � deemed revoked. cOWiRnCT /�J — LICENSED CONTRACTORS DECIARATION �� . �QASS NO.� tL UNITS � I hereby affirm thot I am licensed under provisions of Chop�er 9 ADORE55 (9 �. (rnmmenci,g wiih Section 70DD)of D�viaion 3 of rhe Bus�ness ond ��� SEWER MAP Rofeuions Code,and my license is in f�il force ond effe[t. CI7Y CLA55 YALIDATION SQ.Ff. NO.OF I.b.OF �HECK 8K. PG. Liceme Num6er Li�.Class SIZ OR1E5 FAMIilES ONE � . �ESCRIP71pN pF WpRK � ~Q� NEW V�UAT�ON � Conhacror Dale ADD = �� � : � ;' � (�.n ❑I am eaempf ondar Sec. ��� ❑ �_ _ . Y �__'_, 8.8P.C.fo�this roafpn REPAIR � s ^ . Dare: use oc I = = �.` ;.. existir�e�. oerna ❑ Signalure APP�ICANT TEL. flNAI • rs ° -.. �� .,-.. OWNER-BUILDER DECLARATION ��NT � ' � � • '''��r `��- 1 pA7��,� � I h reby affirm rhat 1 am exempr from ihe Controcror's License �_. � !;--?-� La for the following reawn(Sec�ion 7031.5, Business and ADORE55 FIN � fessioas Codel' aRe Nr eX�.. . -�'� n �,�l�. eunoiric • 1 I, oa owner of the property, or my employees wifh ADpRE55 ' � wages as Iheir so�e compensa�ion,will do�he work ond � , " � � ° the struc�ure ia nor inrended or offered for sale�Settion tOCAtiTY 70I4,Businees and Professions Code). nnpwn� � re�. ' n �_...�; � I,as owner of the property,om exclusively conMacling CONTRACTpR NO. � - with licansed controcrors to conatruc�ihe projatl(Sec- A�R� ' . e o ?,!,j-,':: lion 7W4,Business ond Profcnsions Code). �� REQUIRED IOTAI SETBAIX FR � ('�� '� i� CONSTRUCTION IENDiNG AGENCY �ARD �iwv - - -�" � SET BAGK PROP.tINE WIDiFi I here6y affirm fhot thme is a consh�ction lending ogency for FROM �ha performance of the work for which this permit is issuad p.�, � (Sec.3097,Civ.G.). s�oe P.t. lender's Name ' IDMA Ref.M Lender's AddreSs P.C.fea S / Pormit Fee D I certify thal I hnve read this appiicatian and sfata that the lu�once Fea � LDMA P/C k abore informotion is correcl.1 agee to comply with oll County lnreatigotion Fee ardinances and Stale lavn relating to building mnstruction, toro�p� �Dµq perm.� and heraby authorize representotives of ihis Co�nry�o enter � � upo�1 above-mentioned property 4or inspettio purposes. ♦ , �S ffE REVERSE FOR EXMANATORY UNGUAGE . lure of p ont en po�s —r-_ _ --- -.... _ �—--- - - - -- ---- — -- - —r �� z -� �� 0 � �� � �;-� �� � - I � r .,A 1 " �� __� .- _ ,q.. i� = 4 T 7 J (] D C ��" � ( .., I ( � Q. ry�� .1...� � 2 I C � �� � a ' n ,si ! w � + - , m I = R ! :-- - � � U �� �Y 7 � . fD � Q C L i �� � 7, � y--_' J R'z � •r n � O Y� � S1 � -, � � f;7 O � V � V r1 ' i } j n Q O 1 U- � � � � ( q � O'�J � � � ! �. ;'1 � .��'" t7 I i ( ' {!Y's < c •x � n � � �. cA � � G � y n � p '. a � � � �, o N1 M � ;c � @ � 3 c o j � , ' a R . � � f ., ��I _.n sc, 'm o �'• �a ? m � �._.. ,� Y'� . 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