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HomeMy WebLinkAbout1106A 1107A (5) WORKERS'COMPENSATION-DECLARATION �� � � �- - � � - - � � � I hereby affirm ihat I have a certifiwte of consent to self -� � _ e � insure,orpcertificateofWorkers'CompensahonlnsVrance, �.� /'"�P:F'LICATION FOR -.BU_.ILDING �ERM(T� or a certified copy thereof Sec.3800;Lob.C.J " -- � ' "-" �-- - " �� �"� - ' -�� ���-� ��-" -�--- p f�� COUNTY OF LOS ANGELES _ BUILDING AND SAFETY PolicyN�t7����J.•�ompany_�R�C. . . . . .. .. � Cert ' d co is hereb fornished.�� - - BUIL�wG �� ar v FOR APPiICANT TO FILL IN n�oa�ss ' �3 � �� Certified copy is filed with ihe county bmldmg inspec- BUILDING f - �/ y� / tion deparlmeni. � - - ' ADDRE55 � t? X �j/L �i �'C._ 'L1� ' IOCALITV � Date Applicant -CITY - /� Z�P /� --�"� NEAREST . � ! i � %/ CRO55 ST. � <<1�1�-'�> - CERTIFICATE OF EXEMPTION PROM WORKERS' � • NO.OF elDGS. . _ ASSESSOR �- � - COMPENSATION-INSURANCE � -� �" � - SIZE OF LOT ' - NOW ON LOT �� : - MnP BOOK PAGE PARCEL (This section need qoY be completed.i4 ihe�permit is for one J���.a� USE ZONE�---� MAP - � - - - - hundred dollars($100)or less.) � - T�ta.Ci s� aioa ioT No. . �s.� No. .2 3 — - .5' . � �+ '/ _ g TEL.� G SPECIAL� I certify ihat irt the performance of-the work for which}his OwNER r 4�G�/L-S 4/� . NO. d.�T'7� coND1710N5 . - E"�1 permif is isSUe 1,I Shal I not employ any person in any manner i/��� fe � DISTRICT .GROUP TVPE FIRE PR CESSED 8Y � � ADDRESS 1 L CON57,�� ZONE `� so as fo become subject to the Workers'Compensation Laws. . , _„ �_� i n �� � i�' �, !f Y f Dafe - � APPI Cani �. ... .. _ CI?Y��i��� dG� ZIP�: / .STA'ISTICAL CL4551FICATION . .. . AP7. CONDO. � NOTICE-TO APPLICANT: If, ofter making-this Certrficqte of �+RCH1TfCt0 :TEL /'�� . _. . _ �p � BNGINEER " � -� ,. r�1V0. . � D �-GLASSNO.�DWELL..WNI75 � -.Exemption, you-should become sub�ect��3o ihe Workers= �� .� y �- / �J � -- � � �-- y3, Compensation prqvisinns of fhe La6or Code;you musf forth-. - qp➢RESS .�j�/�,f-�C ��s..�.�f2�1.-��+ SEWER MAP�- � � - ``'� with comply wtlh such provisions or lhis permit-.shall�be � �-� -/'�j � / � = deemed revoked. - �- � - � � k«' � TE�� - . gK. PG, VALIDATION . . CONTRACTOR(G.- -//' � �NO C�l LICENSE�CONTRACTORS DECLARATION - � � . � - .���, - I hereby aHirm ihat I am licensed under prooisions of-Chapter 9 � ADDRESS NO: VAtUATION- � (commencing wiih Section 7000)of D vision 3 of the Business and . - - - uC. �f�..(J Profeuions Code,and my license isin full force and e�ct. Clrv CLA55 S , / SO.FT. NO.OF � - NO.OF CHECK Li[en5e Numbe�z� lic.Clas�� �ks� SIZE STORIES FAMIUES - ONE . . ... DESCRIPTION OF WORK . NEW � 5 $� � O b R Confractor Dqte� " � �I am exem t under Sec � .. . . ... . � � '�- �(��-�"L AD-�"`� � $'j e e • •`�,3 . P . . .�. A7ER FlNAL a �( r-� B.&P.C.for this reason . . � ���- EPAIR � DATE ....� '; �--�" � • °�7,b.Z, � . . .Ddte: � . . use aF � -� oEhn01. ❑ B1NA�n . .. .- e a a�7,(l'J c=i � - EXISTING BIDG. � Signature -- . APPLICANT � TEL- . . Y ��{r� ' `Z�'�- O'�.L�..8 4 OWNER-BUILDER DECLARATION PRINT) NO. /e�� 'y�,,..�p� I hereby affirm that I am exempi from ihe Controctor's License - Law for the following reason (Section 7031.5, Business.and � ADORESS ► �$�y� Profe55ion5 Code):� . . � - � PRE ENT . - - - � � � � I, os owner of the ro er � y P Y BUILDING . p p ry, or m em lo ees wifh ADDRESS - wages as their sole compensation,will do ihe work and - . � the sicu<ture is not iNended or offered for sale(Section. LOCAUTY 7044,Business and Professions Code). - MOVING . TEL _ �1 � �,'7 A .� I,as owner of fhe property,am�ezclusively coniracting COMRACTOR � NO. - �wifh licensed coniracfors to conslNcl-fhe proje[t(Sec- qDDRE55 � � �- - � �• 0 • • @ � -tion 7044,Business and Professions Code). - � - CONSTRUCTION LENOING AGENCY - - - - �REQUIRED -yARD HWY TOTAL SETBAIX FROM E%IST. ( e.o(j�j,Q O SET BACK � PROP.UNE- W1DTH I hereby affirm that ihere isq�consiroction lending agency for FRONi. � • ��!z.O O� the performante of the work for which ihis permit is issued . P.L - - . a (Sec.3097,Civ.C.J. � . �� - SIDE � _ P,�, - 01.20-84 - Lender's Name - ry . .. . _ - $ � P.C.Fee$ g� � ��'� Permi�Fee - �� Lender's Address - � I cenify tha�I have read this application dncl sfote fhal fhe Isso e Fee �•�' �� � ¢ obove information is correct.I agree.to comply wifh.all County Invesigo��on Fee � � an� � � < � ordinances and$tate laws relofing�a building construction, Toml Fee .� , � u ond he�eb authorize re n tive f this Cou ty to enter Q u n ihe ove-me d o for insp cti purposes: . �. ' .. . .. .. .--.. . . -.- � . ... . � . - . . � SEE REVERSE FOR EXPLANATORY LANGUAGE ^ . �-Signafu e ot PP ica Y r Ag t � Dala � . . . . . . .. . . . . . �s a�= --- ��TT_ �� ��ta�r .��� "tKaE�f "..: . , s.,, . . . ot�`P��5��3•�:��� -. . es%.Sr�s�-r3 �,.rEZ n,.�.ir�A'r£fa. ,: : ".'�.'"""„-'�'. .. � � .- . � ..I FiBr Fy c.itvc�{h�.r -rs»e rnpt:fr�rh rhe Cc�i a or.'s p�+: Re4�e1�d ' :cen z tavi or �`e-follo n� rcesor (Se 7J31-S) -�..- `A��e.^.^re� � ' c:• e-a�.,�g'ro�fe a,s tr� cYorer�..r,�uhicb Pdc. � � �i334a ..€,,. s?e , � - .. -e�.zsa.c�:,•r ��o c.r., t c? _ ..zmnlssEi, .� T : � � . .,: c-; r t r -r t.;� s erce a8su zegu:res ��__� . �. -.' � � , -. ,.. , ..,. � _.. - t?e e�}.s o 5 n t t .e a scgxc�a s6 eMeaa�t , r-a f r - t. - •�. .. � __ BC 3 t f .:JJB3 09t5 af� �032 . i � �..,�I _ ::� � ` - �I ���y �- . .�...� z. r df. ,c ��.sy 9!+conr esc�r�;s.sr cec . .�. ,- ;�� . ,: ., . .� . .. '� ._�. . ..:. - - � -�- . ' � -':f /G FiJ-o� ssez- �slt1-eb .n an�Pre�essxons � � l "`' ` '. 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