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HomeMy WebLinkAbout0861A (4) _ WORKERS'COMPENSA710N DECLARATION � � � � �-�� ���- ��` ` �---- �- - - - - - - � � . . . . , . .� _ _m„ . I hereby affirm tha[I have a certfcote of consen�to self _ .�ppLfCi4TlON -FOR� BU��-IL�IN��PE�RMIT- - msure,o a certificate of Workers'Compensafion Insuronce, or a ce�rfled copy+hereof(Sec:3eoo,�a6:C.) COUNTY OF LOS ANGELES BUILDING AND SAPETY UJC(-tqf-CL533�.1 -pR� Policy No Company - - � � - -� � . . . . . � Cert�fied copy s hereby fomtshed.:� �tiyty,�„�, FOR APPLICANT TO FILC IN su�to�NG � /_ y�2��� ADDRE55 lf� LJ O� �Cerrified copy is filed with the wuMy building insp BUiIDING iion deporiment. )/�, ADDRE55 �t ��,c.�r��0 Date �Q^I'�� Applimn�� U���� CITV ��i••.y f:,�j� ZIP 1�� LOCALITY 's���� l � CERTiFICATE OF EXEMPTION�FROM WORKERS � . NO.OF BtDGS. NEAREST � COMPENSATION INSURANCE - - SIZE OF LOt NOW ON LOT - ��� � -- CRQSS"SL � �� - (This seclion need nof 6e completed if the�permit is for one ASSESSOR- � � hundred tlollars($100)or less.) - TRACT 6LOCK LOT NO. MAp gpOK PAGE PARCEL - TEL�-'�C� �SEZONE MAP � OWNER I certify that in the performance of ihe work for which ihis 4 N�' NO. permit is issued,�I shall no�employ ony person-in ony manner � SPEQAL } so�as fo become subiect to the-Workers'Compensation Laws. ADDRE55 ✓�'1 . CONDITIONS � . . . .. - � . CITY ,Q6ylG �-�i ZIP !I� � . � Do�e Applicanf � �- � ,� NOTICE TO APPLICANT: If, after making this Cerfificote of P.RCHITECT OR TEL . DISTRICT GROUP NPE FIRE PROCESSED BV �i ENGINEER �— NO. Ezemp�ion, you should betome sobject to the Workers' . i COIy�������� ZONE U Compensation-provisions of the Lpbor Code,you must forih- qDDRESS � �� !� V �'� �, L•J with comply ith such provisions or ihis permit shall be deemed revoked. - � ?E� -�� STATISTIGAI CtAS IFICATION APT. CON00. G��9 - . . CONTRACTOR � NO. "CAtO{ LICENSEDCONTRACTORSDECLARATION� � i,, ��� � ClA55NO.��WELL.UNITS I hereby aRirm fhot I om licensed under provisions of Chopter 9 ADDRE55 - ,/�, ��,,. qL� NO. 7. �� Z. (commenting with$ectiod7000)of Division 3 of-the 8usiness and ��� � �SEWER MAP �� --- - Professions Cade,and my license is in full force and effect. Ciiv -�' i'� CLa55 BK � . YAI.IDATION i i'l?/y�� Q SQ.fT. NO. NO.OF CHECK License Number -��L7v� lia CIa55 � SIZE STORIES FAMILIES ONE � - ( QG �j ❑ VALUAiION� ��- CoMracfor��\�L pa�e ����I'(� 1 - DESCRIPTION OF WORK�'�`1`�� �.3� NEW s ���� , ❑I am exempt under Sec. . . �l3JlSJ� ��� -� .7 i� ���1 A�� s_ ALTER � B.&P.C.for fhis reason� ���� ����- • �°f'tl''C. REPAIR ❑ s Date: USE OF Kl - EXISTING Bt�G. � 1� OEMOL ❑ � . Sig�at�re �- .. . APPUCANT {- �',�y TEL.' 4 .�- � PRINT) r—�'� L.�S "y'C,� NO.R �'CtG�{- -DA E` `�?� - OWNER-BUILDER DECIARATION . � C� --- - � � � � � � I hereby affirm that I arti exempt from the Con}rottor's License �r"! R) ��G j,ti, - � - Law for the following reason(Section�7031.5, Business and - AO�RE55 d_l �V (�-'f1.1 FINAL Professions-Code):� � � � - - -� �� � � � � g � I, as owner of the property, or my employees with ADDRESS Y ��G�6:� A wages as iheir sole compensotion,will do ihe work and � � , � � � � �o, _ g a � ' � � the sfructure is not iMended or oftered for sale(Section IOCALiTv " 7044,Business and Professions Code). MO��NG TEL. � T� e e 4�,L��,� � I,as owner of the property,pm exclusively conira[ting CONTRACTOR - NO. . - - � : with litensed controtlo�s to cansiruct fbe project-(Sec- qDDRE55 � - - - - � ° e °C,j,��C'� tion 7044,Business and Profeseions Code). " CONSTRUCTION LENDING AGENCY - SET�BAGK YARD. HWY T�TApROP LMEF-M WIDTH ��-� �—�� � I hereby affirm ihat ifiere is a consvu<tion tending agenty for FRONT - ihe performonce of�he work for which this permit is issued p.L. (Sec.3097,Civ.C.). SI�E P.L. Lender's Name � - � � . - P1+,- -LDMA Ref.# $ -�'Lender'S Address P.C.Fee E Permir Fee i V . � I certify that I have read ihis application and state}hoi Ihe Issuan `(1, ce Fee `V r LOMA A/C�1 ' o6ove informotion is correcf.1 agree to comply wiih.oll Coumy Investigation Fee �� ocdinances and Sta1e laws relating to building construction, Totol Fee LDMA Perm.A R � ond hareby authorize represeniatives of this County to enter - " � ` � upon the above-men�ioned prop�(ry�f.or inspection purposes. -- --� � �-- - - � �^' o S�'� ,.g . _. ._.. ....: . �. .... . .�. - - . . � �(�'� L✓ ��) �' ^�2 J�� SEE REVERSE FOR EXPWNATORY EANGUAGE- - � �/$'9na}�re ot Applimnr or Agen� pofa . . . . . _ _ _ _ i_____�.d.,.�..__..,.._�. - ..�... . m..�,. ..,�.. ..� . `..._.. . . . . 3_.:;'*,i-H F} 1['3 h 1 f �h j s'ti � _�,.�. . ._. _. . ...,_....`....,..�.... = - �'LAE$t '�Py'bis�nE�i` � :idvSpTG"C$�"A_Pl��''2K . .-_ ... .... ., ����. v��^....,., 7 ..^r.� ...__� _._�__-.�-.,"�".:-r--""- .. ,. . .-, . .. _, . _ .;.> _ . . r �f . � t .,, ..-�....,�, .._. . _. ., �-i, . t� . � r . .. .. 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