HomeMy WebLinkAbout1289A (6) � ______ _._.� \
WORKERS'COMPENSATIDN�ECLARATtON -� � � . - � �-°�
or�tertifcatte af WorkersrtC mpensotionensuron e�f APPLfCATI�ON� FOt� �tJ-IL�IN�� P�I��iii�'._. ...��. ��
• �rtiited mpy�thereof(Sec.380D,Lob.C.) � � " � - - ��
COUNTY OF LOS ANGELES BUILDINC.AND SA�ETY
No. �. .-Compaoy. -� . _ ... . .... .....
Cer�ified copy�s hereby furnished. POR APPLICANT TO FILL IN ����NG
ADDRESS � � �
Cerlified copy is filCd with th6�tounty building inspec- BUIIDING�(n^ �/ ��]A�'^+' .�7 �)
tion dapOrtment. ' • ' ADORESS "�f-L 5- �V� {(�/�7yN V I� . •��
t�ucarn arr �NV f3/4'� ziP � bs iocaim
��CERTIfICATE OF EXEMPTION'�ROM WORKERS' � � ���gloGs. nIEaRE57. -�� --- - -
COMPENSATION-INSURANCE�-- � � � SIZE OF LOT NOW ON L CRO55 5T.
D. 6 / nssessoa.. - .,
:3Action need noT 6e completed if Ihe�permil is for one TRACT ��7�� , �t NO. / MqP gpqC" - PAGE PAR[EL
jred dollurs(SI00)or less.) ' �" � �
TEL. p USE NE MAP ,,�ql....... .:
rtify�fiat in the performance of the work ior which this ��ER � � ����5 �. !'�_o�� � :�r �, �—" � �6
mit Is isaoed,I shail not amploy dny pe on in any manner ef �/ SPECtat � � � � -� � -
�s to become subjecl 7o the Workers' mpenwfion-Lows. ADDRE55 +t �6� 7�lVfi j) �pNp1TIONS U
i�-q/��-�}��' -App(icant � C�TY �tAAd � z�v �l?(os _ O
371LE"10 APPfICJ11VT: H,'6her king Ihis Cerfifi[efe of ARCHITECIOR iEL. �ISiRICT GRC7UP TYPE FIRE _ N20CFSSEDBY,_ F�
am tion, bu•�should 6ecom s E���R �" CONST.� ZONE V
p y vbjecr to-fha�Wonkers' - . W
e
impensption provisions of the labor Code,you musf foHh- A��� 'D _ _ 6
ifh compiy WNFt SUCF1-Q(OMi51pI15 or,lhia permit shall he �y
aemed revoked. . .... �._-t-'�-A TE�.� STATISnG4L C1A551F TION /PT. D�. Z
� � - CONTRACTOR ✓f(JNGl� NO.
LICENSED CONTRACTORS DECLARATION �- � �. L��. d.A55�N0. � DWELL VNtTS_
. heroby affirm thaf I am licensed under provisioro of Chap�er 9 ADDRESS Np.
:ommen[irg with Seciion 7W0)a4 Division 3 of Ihe 8utiness vod .1K. . `��R� . ......... .
kofe�ons�Cade,and my license is in full farce ond affect C�TY CtA55 BK. � '��-�:���� -� V�LIDATtON �
. . � . . ... . SQ.FT. NO.OF NO.OF CHEIX ..
License Numbei Lia Qnss -�-- S�ZE' � SiORIESC�, FAMIt1E5 � ONE-� - � .
' LNCLOf� P VAIUAiION ..... ...�..._..
Conmocfar Date � ����wORK � . f `/�.,.�'� . .
ADA �J V •�
❑I am exempt under Sec. [�" �1�ss1�'�f�'� �
����) n«a D , c1289A.
8.8P.C.for this repson �C/��7�I REPAIR � S - � - f�� � • •.� '� .
Date: � USE OF DEMOL
EXISTING BIOG. �
Signature . ._. � APftICANT � iet. FlN � ••J J�O
OWNER-BUILDER OEQARATION Ptt�Ni NO. - ....-bATE'�^�� .�... � . • r:�'�Q c=i-�
�!hereby affirm ihei i am ezempt from Ibe Connacro(s ticense - -' .
Law for the follawing�teason(Setlion 7031.5,Businese and a�� FlNAi ,z -'�� -��' ' - �Q���_8 7
Professions Code): ' � pRESENT dP � �
� BUILDING � _.. . ..
I, as owner of the�xoperty,or my employees with ADD2E55 �• .
wages os tfieir wle compensOtion,will do the wark ond � -. .
the sfrutfura is noi intended o�affared for sale(Section ��A��TM �� � ' - - '
--7044,Bosiness and Profenione Code). � � MOVING - � - tEL - - � -- - �� �
� 1,os owner of the property,om exdusively contratling CONTRACfOR ni0. . � � �
with iicensed<onhattors�to constntel ihe prajed(Sec- A�E� � -�� � �� �� - - --
tion 704I,Business and Prafessions Codei. � - ..
RE�UIRE� i07A1 SEiBACK fROM. T. �
- CONSTRUCfION LEN�ING AGENCY � � �T gq�K -YARD HWY pRpp.��NE WIUTN � � -- �
1 here6y affirm thof ihere is o construc�ion lending agency for FRONT - ' .
�fie performance of Ihe work fw which this permit is issued � p.�. -- � � � -- -
� (Sec.3097,Civ.C.�. SIDE -
P.t.
. . . . . ._. ... . . .. . _ . ... . .
Lender'e Name �
a LDAM Ref.M � �
� Lender's Address - '� � P.0 Fee S ve.m�i Fee �-�-�- � � . -- .
> ��j'�
I certify thot I hove read this application and sfate ihaf.the Issuance Fee d'"� "� IDMA P/C-M � -
aa6ove informalion is correct.I agree to comp�y with all County Investiyo�ion Fee � .
ordinances and S1ote lows relating fo 6uilding construcfion, � -iawl Fee� ��+� lDMq4erm.M -- �
u and hereby aufhorize�epresenta�ives of thin County to enter
� upon the a� e-memioned properry for inspection pu�poses. � . '
a SEE REVEASF FOR E%PLANATORY LANGUAGE
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