HomeMy WebLinkAbout1638A WORKERS'COhIPENSATION DECLARATION � ��
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�rtsere�oraafcertifca�teof Workesr�Compensation Insuran elf � APPLIC��1T1 �IV �� O�R��BU�II� ��-�ING PERMIT
or o certified copy ihereof(Sec.3800,Lab.C.) �
COUNTY OF LOS ANGELES BUILDING AND SAFETY
P�ol�icyNo. Company � . . . . . .: �. . ..
Certified mpy is he�eby forn�shed. FOR APPLICANT TO FICLIN npoaEss '`/� � L.9 - ^
� Cerfified copy is filed with The county building inspeo BUILDING - �
tiondepariment. , AD�RE55 „2"?�,i�.`�f. �%j?�'il�% .��'��Y'��' �ocauTv t,,. �V-��_
1 !� �.t NEAREST
Date Applicant CITV �a� .�a3 t,J iJ 7'� ZIP /�f�_� CROSS SL
�CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF�O7 ,i��� ��� � NOW ON LOTS� r MAP BOOK PAGE PARCEL
COMPENSATION INSURANCE �
(This section need nof be camplefed if fhe permif is for one -� �i � USEZONE�--� MAP � �
hundred dollars($100)or less.) TRACT .,�. �'7 BLOCK LOT NO. � �-t NO.
,/ TEL �(', '/ � SPECIAL `s-
OWNER C%�i + %��I�i�Md� ciC/�4'rf°NO.r�� �EF'�7 CONDITIONS �L
I certify ihot in the performance of the work for which this n
ermit is issued,I shall nof em lo an erson in an manner _ ° DISTRICT GROUP TYPE . FIRE PROCESSED BY �
P P Y Y P Y ADDRE$$ . ��}S.S U --J' e'$-!'^i�4� 17/�' CONST ZONE �
so as to become sobject to the Workers'Compensation Laws.
[,�' / / crtr__i'i'�R ��s:✓d P'�.3 7/' z�P
e- �i.� !�`� �L. �'`
Dote-J�Y��� '"' Applicant��y�Gi��.'�Ct;,t,� F `��} S7ATISTICAL CLASSIFICATI APT. CONDO. �
NOTICE TO APPUCANT: If, aftar making this Ce� rtifitdfe of ARCHITEC70R TEL g,j
ENGINEER NO. CLA55 NO. DWELL.UNITS �+
�Exemptian, you should 6ecome subject to the Workers' � � � �
Compensafion provisions of ihe-Labor Code,you must forth- . qD�RE55 SEwER MAP� �
wi�h comply with such provisions or t.his permit shall be �
deemed revoked. F�: � � TE�� eK. 7G; YALIDATION
CONTRACTOR � ) ".�,j"' Np.
LICENSED CONTRACTORS DECLARAiION � uc.
I hereby affirm ihat I am licensed under provisions of Chapter 9 ADDRE55 NO. VpWATION�� �
(commencing with Section 7000)of Division 3 of Ihe Business and �IC. K•.�
Professions Code,and my license is in full force and effect. aiv - cu�ss S ,"��..��r
- � , SQ.P7. �,i NO.OF NO.OF � CHECK � ` � I ��,'��}�
LiCen58 NUmber LIC.C�O55 - $IZE /�� STORIES � FAMIUE$ � ONE
s ;;� o � oe�
Coniracfor pa�e DESCRtPTION OF WORK �.:j3 f'�"�C�t:� NEW � y�
ADD t e ���:1.V O
❑I am exempt under Sec ..... . . (.�:'�'�i^c�r, i''1)Ji� !).'�J -y . .
. ALiER � fINAL .� � e L',.���L. r
B.BP.C.for this reason � DATE ��l' �\ '�'
REPAIR
Date: USE OF ;S o�o� FINAL �� Fi`�1,.Q:—8 b.
. .- EXISTING BLOG. �0��z� o BY ti
Si nat�re :+PPLICANT,� - TEL �+�
9 OWNER-BUILDER DECLARATION - PRINT y,�1^'�`ri fl ��^,�;, . ��� NO. -- -E 5 � �
I hereby affirm ihaf I am exempt�from fhe Controcfor's License � qDDRE55•��.,°T 7 Pi .�`�r'���!t� r � � '� ,
Law for}he following reoson(Sectioq7031S, Business and ��^ ✓�`3�''`� g '•'�`
Pro eSsiOnS Code�: PR NT
I, as owner of the properfy, or my employees with ADDRESS
wages as iheir sole compensation,wil I do the work and �
ihe sirocture is not intended or offered for sale(Section IOCA�I7Y
7044,Business and Professions Cade). MOVING TEL.
� I,as owner of rhe property,om exclusively contractinq CONiRnCTOR IVo.
with licensed coniractors to construcf the project(Sec- pDORE55
�fion 7044,Business and Professions Code).
�-REQUIRED TOTAL SETOACK FROM EXIST.
CONSTRUCTION IENDING AGENCY �'$ET BACK YARD HWV PROP.LINE WIDTH ,
I here6y affirm that there is a construciion lending ogency for FRONT
ihe performance of the work for which ihis permit is issued RL.
(Sec.3097,Civ.C.). StDE
- P.L.
Lender's Name � �^—/? �
� P.C.Fee S Permit Fee 'Z,J d+
Lender's Addreu
� I certify that I have read ihis application and state thot the Issu ce Fee �L•.S
� above information is correct.I agree to comply with all County Investigolion Fee on -
$ ordinances and Sta�e laws relating to building consiruction, ioral Fee � �"
u
ond hereby authorize representatives of this County to enter
upon ihe above-mentioned properry for inspetlion purposes. � ���� --
.ry , a /� f
a '�'(L},.7yyy, Q�.. �LVLeye t(.o��7_. ^� v7• - . SEE REVERSE FOR"EXPCANATORY LANGUAGE _ �s
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Signafura of Applicont or Ageii�— Date
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