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HomeMy WebLinkAbout0898A (4) WORKERS'COMPENSATION DECLARATION � � � - �. . here6y affirm that I hove o cerfificate of,consent to se�f � APPLICATION FQR BUIL�DItVG PERMIT � sure,or o certificote of Workers'Compenwtion Insuronce, r o cenitied copy rhereof(Set.3800,lob:C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY olicY No. ComP�^Y . BVILDING Ce�t�fied copy�s he�eby.4um�sl�ed....., .. _ . . FOR APPLICANT TO fILL IN qpo�� � / Certified copy�s fited wNh ihe caunfy 6uilding inspea BUILouvG � � ��-- -�- -"- - . - � tiondepartmem. : . . .. ADottess �d�ld�..GOC.It��+ Q..D _ _ . Oate � Appliccnt CiT� D1An,+oAtO�P ZIP IODUTY �'' -CfRAFICATE OF EXEMPTION��FROM WQRKERS' � � - � '�-�"'������-----�-''�-����+5. � • NEARE+1.._- � . ��` - -6QMPENSATION-IN$URANCE:... .. ... SIZE OF LOT NOW ON lOT - C1205S ST. .. -... . .. (This Setlion need not be comp�eted if.ihe.permit is for one TRAGT � BLOCK LO7 NO. ��R�,� . - . .... hyndrsd do4lors(SI00)or leas.) . . ��BOOK�`' .RAGE ARCEI . . ,�. TH ��ONE P ' . owr�e pti GoitP. . No. �'trj �( I certify�hat in the performance of the work�for whicF�this � w0. " � � permit is issued,I shall nof employ any pe�son in ony manner ADORE55 �l��� �(J �l d'- � �Q �� i �,� � �� 9 ,Q so as to become subjecf io Iha Workers'tampansafion laws. ....."� CONDITION _.. � � _. . . �......- ._,. . . . .._ , ^r�/ a �, . . - .:�. Gi.Y....O ��AJ ZIP �C18{O O ..' .- ..: ��: _. '' .� ' Ome � • `_ . . .APGlicant . .. .. . .. .. . . � ._.. ..� ARCNITEC7 TEt �`.O NOTICE TO APPLICANi: If, ohx making tbia Certitieate of �C,NLt � - � .,DISTRI�T GROua. 7YPE_. �. ., :FtRF ..,��ED.gy __� Exemption,-you ahould batome-subjeet-to�Ihe Workers' ����--- E INEER WRl�sr�0. _ �1 �p�T: 'ZONE Gompensotion prov�sions of the la6or Code,you must forth- �R� r�p ��� �A �. ^ pL. .-. � � 'Q with comply with such proyisions or fhis permit sholl be ...,.,_..__. .., . , .... .. . � y deemed revoked. .. . �... .... . . ...... ... � .� . .. . �� '. 5lATISTICAL LLA5$�FjCp�ON ' �: APT. WNW. '-a ' . �� CONTRHCTOR VAN UU�f3� U}ILIIRlalO � J )_ - � , LICENSEA CONTRACTORS DECLARATION_ ��.. . �- . ���CV SS�NO. �f0 OWEIL UNITS � � I hereby affirm ihet 1 om lic0nsed�nder provisions o4 CFwpter 9 Ap�RESS��O� ���11(-1/���.Np.�a7.1���. - (commenting with Seclioa7000)of Dibision 3 of lhe Business pnd . 1iC. ���� � i Professions Code,and my{icense is in fu�l force and effect. CITY V/SA! ' �! �4OlQp,55 C'Co r� - � � � - � 50.Ff. NO.OF NO.OF CHECK � �� , Vµ�DATION li[ense Number� � � � �-lic:CIOss�`' � � SIZE - �- S70RIE5 fAMltlES ONE �0 8 9.8 A� . . . . � . . .. . _ . __. NEW � _VAI.UATION . #� �• •Z.3 . . ... DESCRIPT�OIJ OF WORK.�_ ._...._ . ... �. Coatrattor � - ......Date . - �I am ezempt ondar Sec. . .. .. ' � �p L��� �- �/h A� � s , ` � •1 4 G.5�� AlIER B.&P.C.for ihis reoson REpq�Q_..� - Z/] rt /� •�� �L Qr 5�c�i� DOte: EX STING BLDG.R-�.S A�\Z.6.l.�T . DEMOL � oGS V�CJ � 211 -&6 Signature � -' aaPtiG4N7 •�. . .. ...--. _.iEL � .. FINAI PRINT �[�tOTY Q- . NO. �QO . OWNER-BUIlOER DECIARATION ,._ _.pq=g.-__.._._ . �I heraby-offkm tho�i am exempt 4romlhe Confractoi s License . . . . -...._-. .-.-..._ _.. - _......... . Law for the following.reasoa{Section 7031.5,Business and AOORE55 � ( �C1 EA1 T..I Cf"� < 'T R L/ ./3' FWAt� - � '-�-- " � � . _�.... . ...... .. Profassions Code): _.. .. R . . _ ..__._......---.._. ::. yY .... � . . .. . �. ._ . ....... ......._... � BUILDING '� - 1, as owner of ihe property, or my employees with qppRESS G'•'• '.. woges as thair sote compenso�ioa,wilt do the work and � �� � ��� � �/1�/�� ' fhe sirudure ia not in�ended or offered for sole(Sectian IOCAtRV � 7/�� . ,..� � ��7044;$vsiness and Professions Code). � MOVttJG��-� -���� �-���' � �� TEL � lyYE�l}, � I,as owner of fhe properry,am e:clusively coniracting CON7RACTOR NO. � a�l /�,i�-�iG,/_ � , with licensed contracton to consvuct�he project(Seo- - -- --� � �- � '� � '� �� f� ADDRf55 tion 7W�,Business and Professions Code). � _p/ i � . ....._ . REQUIRFD._ . TO7JLL SEiBA K . __... �r� � � �CONSTRUCTION LENDING AGENCY $E7 gq�K "(ARD MwY fy2pp��NE WIDTH � � � � I hereby affiim tho�ihere is o construction lending ogency for FRONT r^�{t �� � the performonce of the work for which-this�permit is issued -p.t. -- /� �� //� (Sec.3W7.Civ.C.). SI�E L p ��/� . m ._ .., .. . ._ . P.L. . . �I e Lender's Name � � � Q L�MA Ref.N �� � � .... ..� -_... P.C:fee S� - Permii fa� - . . lender's Address � � � � � J certify lhat I have raod this application and state thot the ....... ._ . �ssuance Fee � �� ---- LDMA ViC 1f � � � � ��� ¢ above informatinn is conect.I agree to compiy wilh all County Inrestiqa�ion Fce . � ordinances cnd Stata Iaws reloting to 6uilding conatrudion, __..._.._.__,..___ 7otal Fee - - �-� ! tDMq.Porm.Y � � and hereby authorize represento�ives of this County to enrer , � upon the above-mentioned property for inspecfion purpoaes. � , � _ .. _. . . . � . . � a -.......__ . n Gt,/�j �GG�e� ��/ SEE REVEiSE FOi E7f�lAHATORY LA!{GUAGE . .--..._ Sigewrure oi AppNwn�or Agenr - Gole . .-.-_-- . .. � � ���O� ' �'^ �'t d X � � ie."a.n`i �c c �b `o .� m w h a„e m � _ �,�, m � E`'�G„�� L u-N,� �� ' �� .e... � �U�i'° �„\'�0 3 °o �' �' o..� oV � x p O '] 0 p.y d� y O..,. tl O .N y�..�-0 d^O�T.r` G � C O y i. � .� , C^ w d t S .�a �O-:G M ..Ci� d O y� C � .Y M .�„ C� � d « 7.�.1� . . 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