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HomeMy WebLinkAbout0919A WORKERS'COMPENSATION DECLARATION � � � . - � � - � I hae6��.ofs:rm thot I hove o cerifcote of consenfto self � . .. �pp���q�IpIV .:F�R-�--�UIlDlIVC�. PERrAl19T � � s e,o�a certlfica�e oi Workzrs'Compen5at on Insurance, f or o cer�if'ed copy thereof(Sec.3800.Lab.C) � � *✓ . ��- � - - . � 4 COUNTY OP LOS AtdGELES BUILDlNG Ah'Q SAFETY Polity No. - Company ' . . . . �.� . � Certified mpy is hereby fumished... -. � � - FOR�RPPGCANT TO FICL�IN` ---� "���� euiioiNc, ��3 Z,���,���.y-.jA �� � ADDRESS � .Certi4ied copy is filed with the county 6uilding inspec- BW�DING��� � 0���c�T�' fion department. _ A�DRESS fi /� __ __ _ HI,¢�GsV� �ate Applicont CITV ��/f ZIP LOCALITV CER71fICATE OF EXEMPTION FROM WORKERS � . NO.OF Bl�GS. _ � NEAREST ' � - � COMPENSATION INSURANLE- ���- � � "- SiZE OF iOT N01N ON lO7 CROSS SL -�- �-��"'� (This sectio�need no7 be completed,.if the permit.is for one .. TRACT � �' BIOCK - LOT NO. ( MAG BOOK PAGE - PARCEL hundred dollars($100)or less.) � a• 'a- �r 7EL. �Y"-T� �s � OWNER �/�w�'M P��D�NO.4J/J�4��f U ZONE- MAP \ \ ���� ',,, 4� NO. � E I certify�hot in the performance of the work.for which)his - �(.,� �- -� ---- ri perm,it is issued,(shall not employ any person n any monner ADDRE55 �/°'y'/� SPKIAL � ` � F � so os to b co subleci to the Warkers'Compen t on Laws - . CONDITIONS �,y,Yy,� ,:� � �� �.���i. CIT7 Z�P ✓ � O Date Applica - ARCHITEQOR TEL. NOTICE TO.4PPLICANT� if, afrer making�1 is Ce tificate of DiSTRICT GROUP TYPE FIRE CESSED 8Y � ENGINEER NO. ExempPion you sho�ld become subject b the Wo�kers' � � . . - �- `�-, W CONSi. Z Compensat on provisions of flie Labor Code,you must forth- ADDRESS � ��(� �� •`s+f•�`"1 � wiih comply with such provisions or-ihis perm t shall be � �TEt STATISTICAL C1A551FICP,TION APT. CONDO. Z deemed revoked-: � � - -�� � -���� cONieACTO �� 4NfI��•rv033�ovG! � _ LICENSED CONTRACTORS DEC�RRATION �. � _/;� �) �iC /,.../ CLA55 NO. � DWEu.UNI75 I hereby affirm that I am licensed unde provisions of Chopier 9 - ADDRESS • �'�7 I'►'NO.y737��� �pyER�MAP� � (commencing with Section 7000�of D vrswn 3 of the Business ond ,�p(�,��� - � �i�. � ��/ � Professions Code,and my license is in full force ond.effect. CITY v,�•� . CLA55!r! BK � VALIDATION �/jfj � SQ.FT NO.Of NO.OF / CHEGX License NumberlT�•��- Lic.Class � SIZE ��� STORIES FAMIliES ONE , � �.' � e�e� Y'L�� VAL ATION Conira � Date �7 �ESCRIPTION OF WORK � AD ❑ S �3_ /,�.d ;' �� �, - 8 ❑I om ezempi under Sea . „ � � o� � - � -� � � / � . � - ALTER t � � ❑ 8.8P.C.for rhis reason � F - REPAiR f .- �;",����. - USE OF � . -„ ....... ..'. '- Dafe: . ... .. . . .._ EXISTING BL�/ �/ � DEMOL � ..r�. . APPLICANT- / TEL p '.�3 ��.. Signat�re -� vRIM7� [,�(f �'� N���d�a FINAL �i OWNER BUILDER DECLARATION - _ �r �,/� DATE ��� . I hereby affirM ihat I am exzmpt from ihe Coniracfor's License ADDRE55 �� �'•���+�� � � � Low for ihe fol(owing reason($eclion 7031.5, Business ond FINAL ����y� Profe55ion5 Code)'� � � . PRE ENt.. .. . ._... . ..... . _ .: �. BY ���+1 ❑ BUIIDMG� � � . � - I, as owner of the properly, or my employees with ADDRESS wages as iheir sole rompensation,will do the work and - �OCALiTY � ' - the siructure is nof intended or offe�ed for sale(Section . . 7044,B�Sing55 and Profes5ions Code). MOVING _ TEL. . . � I,as owner of ihe property,am exdusively conirocting CONTRACTOR NO: with licensed mniraciors to mnstruct ihe projen(Seo- qDDRE55� - - � � � - -�-� - -�� --� -� - - iion 7044,Business and Professions Code). . kEQUiREO TOTAL$ETSAIX FR CON57RUCTION LENDING AGENCV SET BACK YARD HWY p{tpp.pNE - -�- WIOTH - - .I hereby affirm that there is a canstruction lending agency for FRONT the performonce of the work for which this permit is issued a.i, � (Sec.3047,Civ.C.)... . .�.. ...... .... . .... . . SIDE� � . P_L. Lender's Ndme �. � � -� - � LDMA Ref.# s Lender's Address P.0 Fee 5 Permir Fee • � � I certify that 1 have read this applicafian and state that the issuance Fee V`� LDMA P/C# - above information is corretl.I ogree-to comply with all County � Investigation Fee � - ordinances and State I s relating to b�ilding consfruction, Toral fee - LDMA Perm.# £ ond here6 t ori pres ntatives o4 this Coumy to enter � Q upo e � property for inspection pur oses.. . . . -.. .. . ... . ......... ` ... ..� �`. ... . _ . . . � . - � SEE REVERSE FOR E%PLANATORY LANCUAGE Signa re of Appl�com or Agent � Date. .. . . .. . _ .. . . .. . � . ..�,_r,�...->..._....s.......�.,...� .... .- .._...-...-�.o..-�.�......_-.r...s.,.�j�.....�g,..,�...»�v - .��.«m...�..�..a..:m..a....,�o.a.��. !f}«�Z .[.'::: ��<.'..i. ,.'�,Sa[".. ; 3•�` C- ._ + :�4r:'.'^.L` aSR ;M=x-,-. . , �,�.......�. i G't L`b . v.-_...,r .�.,_.s____.�,.._..a.._ �.-�,- -.s_ .. . „_. .�_a...�__...,,m.�._, , __...__._,...�..�-.....-.._ . , � . .:_ c. � '_:..eu . . � . ., . i. _ , , .� . ,. , .:.,x .: . . n.,,�.. ,-_..___.�.._..___��_.___.____. ..__.�...,___._._.......,._._.._._ �_,_�_�e...�.�.:._�..� .. , ..._ —_.__—._.._.._..._...__._.._. s : .�.�u.. .. i is : :_ - - - - .. ... _...__,-�. � ; _ . ..�._ .'��_;.��. _ ._ . . ... .. ._ . .. . � , .._ . _'__ � t. : � .� I -. i � __ . _ .. � . � � -�, - ;: - . 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