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HomeMy WebLinkAbout1462A (8) � WORKERS'COMPENSATION DFCLARATION . � - ' � �, ! �ereby off ihat i.hove a certificate ol consent to self � � ure,oracerfifi<o�eofWorke�s'Compensotioninsyrance, aPPLICATI,�3.N„.F.QR....��.U.ILDI.NG PERMiT u o certified copy thereof(Sec.3800,Lob.C.) -� " �-� - '�� ��������� __ _,. C9UN7Y.OF..I,QS,ANGELES BUILDING.AND SA.FETY '-ty No, C6mpany �� � n ! � ± . 9UILDING I` � � Certified copy is hereby fumished. FOR�APPLICANT TO FILL IN qppRESS o�����7 c 't� w co�� 1 Certified copy is iiled with ihe county building Inspec- BUIiDiNG � ��� � � � tion deparimeni. ADDRE55 ;�e'aS� .o7"+�ra'" .�RN_ rte Appl�con, orv ��„i(��N� ziP �l�) ' �ocnuTv '�� r CERTIFIGATE OF EXEMPTION fRQM WORKERS' NO.OF BLDGS. NEAREST + COMPENSATION INSURANCE Si2E OF LOi NOw ON�OT CROSS S7. � IJ �is seclion need nat be mmpleted if Ihe permit is for one TRAQ•3 /�J� ASSESSOR � . rndred dollors($100)or less.) _ BLOCK L�TLNO. MAP BOOK E �PARCEI OWNER ,(U 3PiNt NO.'J% '�3 USE ZONE NaP ` I c-� ,�3 :eriify fhot in Ihe performonce of fhe work for which this � ;rm�t is issued,I shall no7 employ any person in any manner � SPECIAL _ � �os to become sobject to ihe Workers'Compensotion lows. ADDRE55 �/,�.SJ Q�7'TQ/V L�1r,''iJD �. h'E: CONDITIONS ' L'. �� �( Q CITV ��� ZIP J�� � �te ' 'APplitanf AR.CHITECT OR TEL � OTICE TO APPUCANT: If, after moking�this Ceriifimie of i.•.S$5--333' DISTRICT GROUP ttPE FIRE PROCESSEo Bv Q ' :empfion, you should become subjecf to tbe N�orkers' ENGINEER !U-- d�+ Z N����• CONST. ZONE � Dmpensotion provjsiong of ihe Labor Gode,you must forth- qDDRE55 � � � � � �-ith comply with such provisions ar this permif shall 6e � � TEL. STA715TICAL CLPSSIFlCATION AaT. CON00. C�i^�i �emed revoked. cowsRnncroa D�Nr�: �tu1�,Jr'P No. 5hn�t � J � LICENSED CONTRACTORS DECLARATION � - uC ClA$S,.N¢.t�L_.DWE.LI,UNITS hereby affirm lhat I am licensed under provisbn5 of Chopter 9 A�ORE55 NO. SEWER MAP �' - :ommencing with$eclion 7D00)of Division 3 of the Business and `µC. rofessions Code,and my lice�se is in full force ond eHect CITY ` COCSS BK p� �� , VAIIDATION SQ.FT. NO.OF r NO.OF CHECK �d- :�' i u.C�G r7 �cense Numbe� Lic.Class S�ZE S70RiE5 0� FAMILIES ONE �,y 6 0 o m j� � � � - �� � � VALUATION DESCRIVTION OF WORK NEW ❑ D()V { �oMractor �ate � � AD0 S �i , � ° �'G 1.O.� ��I om exemPt under Sec. ... X�X � If1Cr � Y2tl.G��H * i� �7JNG � o � o(%'/,'�5? ACiER 8.8P.C.for rhis reason � �� J-01=T. L E l/J .�-�y`k=^� ��RT�REPAIR ❑ ; ��3 j —s) Do1e: USE OF t9 r S� /�S- DEMIX EXIS7IN Signafure A CAN7 � � iEL FINAL OWNER-BUILDER DECLARATION PRINT) NC�'. �bhl�.� Na.�JJYy"A:-.4- DATE hereby.offirm rhaf i am exempt from the Contractai s License 55 .;1 J5�7 GCTTZ�n)caaoD�-./�� +�%�`1hN✓t` ow for the following reason(Seciion 7031.5, Business and FINAL 'rofessions Gode): PR N �� - � � - By � BUILDING I, as owner of Ihe property, or my employees with AQORE55 � � woges as�heir sole compensation,will do the work and , the strucrure is not intended or offered for sale(Section LOCAIITY �IO 7044,Bosiness ond Professions Code). MOVING tE�. � �'�r � CONTRACTOR ,/� yg' a• I,as owner of the property,am exdusively contracting No. '�J�P I M�A �� �v` ,� witfi licensed coniractors ta mnslru[t Ihe pro'lect(Sec- ADDRE55 � {��� J�� �.�, tian 7044,Business and Professions Code). �/j j � , REQUIRED iOTAL SET6ACK F /i � �� � � ' CONSTRUCTtON LENDING RGENCY SET BACK YARD NWY p{tpp,LINE WIDTFi �hereby affirm thot there is a consirucfion lending ogency for FRONT �he performonce of fhe work for which this permit is issued P.�. !Sec.3097,Civ.C.). SIDE . P.L. :ender's Name ) .=C � � IDMA Ref.# 7.0 Fee S Perm�i fea , Lendei s Address � cerfify 1hqiJ haye reod lhis opplimiion and state thai ihe bsuan<e Fee LDMA P/C 8 �bove informolion is mrrect I ogree to comply with oll Coumy Inves�iga�ion Fee � ardinances and Sra1e laws relating to b�ilding consiruction, Total fee LDMA Perm.# md hereby outhorize representatives of this Coumy to enfer , , ... . �pon the above-meMioned proparty for inspection purposes. .. . .. , .^.`.. ..":".... ...'........ . .... .. . . . 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