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Home My WebLink About1658A 1659A WORKERS'COMPENSATION DECLARATION � he,ebY aff�.m .�o� I hove d�e„�f��a,e af�o�=e�,,o=e�f APPLICA�'10�1 FOR BUILDING PERMIT � ��sure,or o<ertifi<ate of Workers'Compensalion Insuronw, or o certifled<opv thereof(Sec.3800,Lab C.� COUNTY OP LOS ANGELES BUILDING AND SAFETY Pol�<y No. Company BUILDING '` � Certified�opy is nereby f�r�ished. FOR APPLICANT TO FILL W �� qoDReSs �-�J'-Y�� e�� Cerhfied mpy Is filed with the wunly budding Inspec- BUILDING /� L L ,�o�deporimen�. ADDRESS2� �7 ^� ' � S i'I a'1 6� tis,,� ` �1 C �l Date Applicon! ❑Tv/ ��'li7Y! � L7Lr Z17 LOCAIITY y .�`lv�_@ �''-v`_ CERTIFICATE OF EXEMPTION.FROM WORKERS' NO OF B�DGS. NEAaeSi COMPENSATION WSURANCE SIZE OF LOT NOW ON LOT CRO55 ST. (This sr_ction need not be completed if the permit is for one TRACT�`-�� eLOCK LOT NO. �j� /•SSESSOR hundred dollars($100J or less.) MAP BOOK PAGE PARCEL TEI.C/!_/ USE ZONE NWP I certify rhot in fhe performonce of the work for which this OwNER "y'C �i,J NO �'v NO. ¢ permit is issued,1 shail no�employ any person in ony monner ADDRESS �G'�� (� 4`E'J(:�� CONDITIONS U so as to become subject to 1he�Norkers'Comp nsation Laws. � ~— C17Y ZIP O 0a/C Applican ARCHITECT O �- TE�. NOTICE TO APPLICRNT: If, ofler�m ing this Certificale of V_S�-` DiSTRIC7 GROU TYPE FIRE P CESSED BY � ENGINEER -'V`" " =ANO,� U NSY�- ZONE Exemption, yoo sho�ld become sub�ect to �he Workers' � n ,\ ^(`�\ � Compensafion provisions of Ihe Labor Code,you musf forth- qpDRE55 � t/��U� j� , ��= � � W!�_ with comply with such provisions or this permit sholl be deemed revoked. �E�� STATISTICAL CLASSIFICATION APT. CONDO. z CONTRACTOR 'U ', '� NO. LICENSE�CONTRACTORS DECLARATION f ,\ �� ' f � C�ASS NO. DWELL.UNITS I hereby affirm ihot I om licensed onder provisions of Chopter 9 AD�RESS � l�! .�.�1� �i��7 NO. �Ut7�J� . (commenang with Sedion 70001 of Division 3 of the Business and �� SEWER MAP P fessions Code,ond my license is in fuil force and effect. qTY � � � "� �� C1A55 BK � VALIDATION // //�/ SQ.FT. NO.OF NO.OF CHECK License Numb r �"'t .�+ Lic.Class�� SiZE SiORIES FAMILIES ONE . ❑ VAI,UATION Coniroctor ` Dale �ESC��RIPT�ON OF WORK � A D O s� ��"`.A�, , \lV I om exempf under Sec. � Al7ER B.BP.C.for�his reason � REaaiR ❑ s Dafe: USE OF DEMOI E%IS�iN6 BLDG ❑ 1 $ignOture APPLICANT � r TEL G"y�/_(��/ FINAI OWNER-BUILDER DECLARATION PRINT)4��7Se 'l� I��J''� NO. t �"� 1 DAT �� `j R� 1 I hereby affirm thal I am ezempt from the Controuor's Llcense / j / � Low for the following reasan (Section 7031.5, Business and AOORE55� 1 �- � I��-`7 f FIN �� e % I Professions Code�: PRE NT . . . gY -� �� fl�3 � I, os owner of the properry, or my employees wilh AD R SS � ° ��1� ly � wages as their sole compenwfion,wiil do Ihe work and ihe stru�ture is nor inrended or offered for sale(Section tOCntliv � . .. :��.�(j� f 7044,Business and Professions Code). MOVING TEL. I,as owner of Ihe property,am exclusively contracting CONTRACTOR Np. �9� C/-Sj� with licensed controctors ro construc�the prolect(Sec- tion 704G,Business and Professions Code}. ADORE55 �'� v�r�� CONSTRUCTION LENDING AGENCV ��Bq�K YARD HWY T�T'4p OTP.LICNE WI�TH y � G C 6 O I hereby offirm thal there is o conslru<tion lending ogency for FRONT � the performance of rhe work for whlch this permit is issued P.L. � ., 7 l.J�J (Sec.3097,Civ.C.). SIDE � P.L. lender's Name q D �� `4';i.'''. ��I (�(1} �`}�(�,/� LDMA Ref.N i '"v 4� � P.C.Fee E P�J�v v Permit Fee GW.UIJ ' O C7, �/ C,, ' Lender's Address g I certif that I have read this o licalion and s�me thot ihe Y PP Issuance Fee L�MA P/C 8 a6ove information is correcl.I ogree ro comply with all County In�es��gofion Fee ordinonces and Stote laws relating to 6uilding construction, Total Fee IDMA Perm.# and hereby outhorize representaiives of this Coun�y�a enter .upon fh ❑bove-m ntioned property for inspection purposes. � ' '� ' "� � 1 � r� �.�J S"� i ! J SEE REVERSE FOR E%PLANATORY LANGUAGEr� /� . �� nalure o Applicant or Agenl �o�e 7��,r _.._ .___.. .. ..___.._---.- - — -...._._,�___ .,_a_e.._.n....,_..___.. _ _�.. u. �e. ,...._...._.__......�_�__. . " - _ ='.YC^�',09:'rTE:`s .`S�s�' - ....�. ... . -,..i➢C:�. .. � ...� .,. .,.., . .:: e .. .. .�..-,. ... 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