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Home My WebLink About0800A WORKERS COMPENSATION DECLARATION �� I here6y affirm ihat I have a certifitate of consenf to self APPLICATI�ON FOR BUILDING PERMIT �insure.or o certificale of Workers'Campensotion Insurance, or o certified mpy ihereof(Sec.3800,La6.C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Compony �. � CeriRed copy is hereby furnished. FOR APPLICAN?TO FILL IN B��tQ�NG �3 . ADDRE55 � Cenified copy is filed with the counry building inspec- BUILDING /!.� ^""' j""7, „y. �a�„ «�+ „ tion depar�menL ADDRE55 /fP ��'t`.""�- w ) � ,�&� Date Applico�t� CITY P �P},.'.j�,>�,�.a�{ ,. ZIP LOCALITV CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BL�GS. NE,4RESi COMPENSATION INSURANCE � SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permil is for one 7RAC7 BLOCK lOT NO. MAp BOqC � PAGE PARCEL hundred dollars($100}or less.) � � �e TEL.,/' J U E E MAP I cerfify ihat in ihe performonce of fhe work for which this OWNERpT.. ^��_ l�`-? •�- . NO.�? ��'`"d �p� Np. -� 3 permit is Issued,I shall not empl y any person in ony monner � 7.� SPECLa� r � ��CONDITIONS so as to become subject to ihe orkers' m nsation Laws. ADDRE55 � '�.._ U� Q ` cirr ziP V Dote � �'" Appliconf � �� ARCHITECTOR TEL � NOTICE TO A PLICANT; If, ofter m� ing�ihis Certifimte of ENGINEER Np DISTRIQ GROUP TYPE fIRE PROCESSED BY � Exemption, you should become subjecf to the Workers' � �� CONST.� 2� �� U Compensation provisions of the Labor 6ode,you must forih- ADDRE55 '�'�� wi�h comply with such provisions or ihis permit sholl be �-' deemed revoked. CONTRACTOR i � .� �'i�( �.q4 TE,.�r��,.'��'� STATISTICAL C1A551FI.A710N APT. CONDO. (n z LICENSED CONTRACTORS�ECLARATION p �iC.� QASS NO. DWELL UNITS -'- I hereby afflrm tho�I am licensed under provisions of Chapter 9 ADDRES �� ,�{,t-/�. �V'�'.C"" NO: - � � {commencing with Section 7000J of Division 3 of the Business and �` $� �� SEWER MAP Professions Code,and my litense is in full force and effetL CITY�t��';R�A��+� P,�E{.W"' CLA55 � gK � VkLIDATION "'� .r�+ 5�.FT, q O.OF NO.OF CHECK !icense Number � � �+ lic.Class � SIZE J� STORIES FAMILIES ONE VALUATION Contrac�or.��'F�.�``'��Dafe � �a �� ESCRIPTIONOF�WORK N� s -✓�`. �"°d ��'��' �. �I om exempt u�der Sec. f �� ,�,'„.. �_�t� �e:� �.�g„.a ADD ❑ ., d � }�' ALTER :C'�.(�� B.&P.C.for t 'S reason �R�' C"s'�.P �'xf�. � �.. REPAIR = �� g � s..i Date: USE OF ' DEMOL s �y.��s E%ISTING BIOG. -I_ Si natur0 .l � �'�p �-�..-.. °"""1ii°'"�'�""i1^'�-�- APPtICANT �R TEL y e�y�yo�p� FINAL r ��C'i) 9 $ . a •, PRINT) - d'T'`' �'`cm.' NO. �:/o-�bw'd'/_"d e j �3'.�,'Q� O NER� ILDER DECIARATION g_ �p P �t DATE I here6y affirm thqf I am exempt from the Contractar's License qDDRF55F'� `l �"�:'" �-6�*'�li�°"" �yP`�� r� FINAL � r � f � r Low for the following reason($ection 7031.5, Business and Professions Code): PRE ENT ' - BY � QBUILDING I, ps owner oF fhe properfy, or my empioyees wilh ADDRESS woges as their sole compensation,will do ihe work and ihe strocture is r�ot intended or offere;for sole(Section LOCALITV ' ��Q S 7044,Business and Professions Code. MOVWG TFL. dn_; �� I,as owner of the properry,am exctusively cooiracting CONTRACTOR NO. with licensed controcbrs to construct the project(Seo- qppRE55 tion 7044,Business and Professions Ccde). - �'�a'�� CONSTRUCTION LENDING AGENCY �� SE�gp� VARD �HWY T�TAPROP LI�NEFR WIDTH I hereby affirm fhat there is a consiruction lending agancy for FRONT the performonce of ihe work for wMich this permit is issued P.L . (Sec.3097,Civ.C.). SiDE P.L. Lender's Name � .�7 �`� LDMA Re4.p P.C.Fea E Permit Fee i'� ✓ Lender's Address `/'} I rertify that I have read this applimtion and stote that the Issua�ce Fee 1 v• �� LDMA P/C# above information is correct.I agree to comply with all Counry Invesfigotion Fee or Ynantes and State laws relating to building construction, To�al Fee � � � IDMn Perm.k o d hereby aot orae represematives of this County to enter u o ihe ab e-meni oned property for inspection parpos�s. . � t� �� _f�p� ,�rv,v+��-�^'�w.A� �' ��,_.i.,!x r �' SEE REVERSE FOR EXPLANATORV LANGUAGE 5'g�re of Appl'onf ar Agent Dnt� �� tr�l4a�lS Sf3 ts,�%4*�l�ANT IP35PgCTC)R'S 5�C{ATES �WNf'.F2.63Lp[.I)ER t3r'€:].AP2A�['EFJN . Ih �.lya.t ��i t � r< � tu s �To¢ . , � � Re6arned� 4 .: ','. � ' . . , � i <�e . �..�. f I 5 .a :, �. 7�9, �, _�._� �.�� ..... ��-�� ----._..--- f3 . nd 1 f n.r( i 2+�4 zt} �untt u a�r� fi.g�penved � •A� Date �(No.��CmPe� � . � Pay r - Fc i �< n t e t �tt,r� nf de 1.�1. — ... �� . . . , - -� p x� t t� �_.pa �t� s � re{r .- . �. - 1 ` - � � .�. � -� � tl�a�rnt'urar1 '{p rrc�t ti� sh�-r a t I �..�___—__—� , thut L e s Z-n d p �uu t i.rF nr i :,uras uJ f1 f '€- � f � . . � . .- t t J� l.ire I,sa<�C."5 ytcrJ:,✓cnrnn:e+nc�n�v tf 4ns �"-q--..--�--�--._. __{____....�._.. _ . �--.. . . . .-•. t r 7(1!3„}r,f C3� asr n j r t5e Bu raf �s t'rr f.e� �� _ . . . � . - . , C�ctlnr3k=�zt1. u�rennjtdf rcf��m� �c�&t .a� f�r�f�d .��,.-;- . �. a/tc�..d xs»apt'nn.fl+sy ca Zatratt r�l tr�� /tJ3 ..S h�. } . � &�quir��d p�y4e 8eceiv��` �_.�� . ._ . .� . . ' - u Y PPbcant for�ys�vreit�s htr'ts 7f_ cypZ.nt t .'s�iD '�.. 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I _ . ., . � 1 c f<rt pt t m tF rt 8r r t!bna. tFi .__ . bura.n tPr cria,�iJ=�ar Ge ded n�c,t bmxdd�r zrrs,terar�e/nr _Gede r an P c�ecr�en- . i 3 . , ! urji xs•�(rain). . . -;fen� < .0 cPv 1 ' � �� . . .. - _. „ I I . � th 3�rce t �rr e I. �- ly c : f 3 ih I� n ed �,ac s� < r� c1 e p . (5-. (5pec �i �c.ec.f. � � - . � ?C1aA @ an r a�P f s a C cl Il .( ra c �!Ce .,Vrnsanr�l fVde��..d:rgl . � � � � . . .. � . I rce t�zi,d nr> npJrt t ,zs ru j Ar>nertt .t r �..,.____—.—...—_�__1_ � �— b Ert <rnpr E.-tf=vtoa zmd�a�-1. ntra�t lr �rch i�c'o a�-�a3�= ( . _ . .... _. _ . -�� q -t.� zz. a � trnst r(j tecens �pursz�..na t� rJe ,_ �._��, . . . . C antrn'Erar's Lacenne f,vkf. � . ' 1.P^;k",y.� � � . � � I :m rxempP under Sec.______Y_,�3.A:P.C.�Fo�rhis �. . . '_ .. . ' ° . r a�or , e i : . . ..' ______� �-_____.�__.__....�._...__.._i � . . . . �._ .�..... C�Ee O'��r„zr t_ __�___ . _ -.� � . � �. .. . - � � � . . , ..__.___ � �..... _. - . �F°}P o n9s ( Qes6� fnspec4or`s"sF�nature .. . . 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