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HomeMy WebLinkAbout1468A WORKERS'COMPENSATIDN DECLARATION - �- � . - I here�y aff rm that�I have o cerr f cate of consent to_self � insure,oracertifiwleofWorkers'Compensononlnsuronce, � �PPLICATIOIN F.O�.�_�.BUI_LDING .PERMIT_ . o�a cectified copy tkereot(Sec.3800,�ab.C.) COUNTY QF_l05 ANGELES BUILDING_AND,SAFETY Policy No. Company . ... . .. . ... . . ,... - .. � Ceri;fied copy�s he�eby furnished. FOR APPLICA�T'TO�I[L IN nooaess I�� - � � � n„ � � Cerlified copy is'filed with ihe counfy building inspec- BUILOING��� �a `�' fion deparfinent. . ADDRE55. Date Applicam. � CITv � !?O`�7 ZIP- bJ . LOCALITY . - . . - � CERTIFICATE.OP EXEMPTION FROM WORKERS' - ��� SIZE OF LOT /. %> } NOW ON LO7 C OSSSST. D'�(,�,���� (t �y P,�. � COMPENSATfON�-fNSURANCE � Lo� o� 0 ""'"- "^� � �I`(�7�'4 N'�S� (This section need nof be-completed if ihe permit�is for one . TRAR ���J'Z„ gLOIX � lOT NO.�� y„�p,p gpp�( pq��� PARCEL hyndred doilor.s_($1W)or less.) / - ,, . . . � S $�'�� F�.� TEL. ���' I US IVE� OP ���� -3�-� - I certify thot in�he performon<e of the work fo�which�h's ��� OWNER NO. � � � i i ,�-pQ {^�- q� � SPECIAL pe�mit is issued,I shall-nat employ any persom in any manner qDDRE55 �J U I �> - V r ��%�'� CON�ITIONS � so�as to bemme-subject to the Workers'C mpensation Laws. -- - /� �j - Y- . . . O � r0 '� ��w��,� CITY � e9�4. BX�✓ ZIP L+�7�c�� � � � �Dote Appliconf ARCHITECT OR �+ - �7EL ��-` NOTICE TO APPLICANT: If, after making ihrs Certificpte of ENGWEER �U N� � DIb7RIC7 GROLIP NPE FIRE PROCESSED eV O Exemption you'ghould-beCome subject fo the Workers' � - � � � - - - .. . . . . .. �y CONS7. _ ZONE- U Compensahonprovisions of the La6or Code,you must forth- qDDRE55 �U +��3 --, � with comp�y with such proyisians or ihis permit shall be � --� 7EL �� �-� -�� STATISTICAL C:ASSIFICATION APT. CONDO. ( � ,, N deemed revoked. CONTRACTOR �� hJ-"'�--- NO . 7/ - � �ICENSED CONiRACTORS DECLARATION � -��-ij� -� -� � �� �---CL,4sS NO. <<'°'� DweLL.UNIrS — I hereby affirm tho7 I am licensed vnder provisions of Chopter 9 ADDRESS NO. . . . (commencing with Section 7000)01�ivision 3 of ihe Busness ond �-�-- --���- -� - --� SEWFR-MAP Professions�Code,and�my license is in full force and effett CITv CLA55 -BK- ��� � VALIDATION � - Sa.FT. e NO.OF NO.OF CHECK�� -� . . . . Litense Number Lic.CIa55 5RE C7� STORIES FAMILIES` ONE . . - . . .. .. VALUATION�� Cbniratlor - � � � Dote� � DESCRIPTION OF WORK � �d �D�� � s �, ❑I am exempt under Sec . . . q�rea ❑ � , �.I 4�.R r B.EP.C.for this reasOn REPA!R � s ---��m-e a�2 c f � �ate: USE OF- . . . . . DEMOI ❑ � �� EXIS7ING BLDG. Si nature � � - APP!ICANT "- y�� -' Q TEL � . . �� FINAL /� i "�,C G g OWNER-BUILDER�ECLARATION � -- PRIM) c�V� }��� NO DATE.�I � � .I here6y offirm that I arrt exempt from the�Contractor's License�-� - ( � 3 a b�v���� Low for the following reoson(Section 7031 5 Business and � ADDRE55 FINAL� �9 � � �7 � fe55ionsCode�' ' � � PRE EN � � ' -� - - -�� -� BY + BUILDING .. r. ` +rs I, as owner of fhe properfy, or my employees with ADDRESS� .. . ... _ . . __:_ _,�.��,,�. ^w.�,- "�� 4 x-,. -� ��cges ps iheir sole compenwtion,w II do the work and �� - '^ '-�� �`"' -;i � ihe structure is nof iMended or offered for sale(Section �a/+��TY , � -` < , �" � -� 7044,$�siness and Professions CodeJ. - MOVING - � � � -�TEL - _ -•-' � I,as owner of ihe property,am axdusively coMrocfing CONTRACTOR �NO. - . ,_... ._...... _. -with litensed<ontrodors to constroct tlie project(Seo- qDDRE55 tion 7044,8usiness and Professions Gade). � CONSTRUCTION LENDING AGENCY- - �SET�BACK Y�+RD HWY TOTAI��TPA NE -�� WIDTH � I hereoy affirm that Ihere is a construction lending agency for - FROM� � - � the performance of ihe work for which.this permit is issued P.t. � � ($ec.3097,Civ.C.). � SIDE . P.l. Lender's Name . .. . .. .... . .. . . . ...-. tAMA Ref.q _ - � - P.G Fee$ Perm t Fee._ � r ' � Lender's Address - - � � 1 ceriify ihot I hoye read fhis applimtion and state lhat the ,. . Iaeuonce Fae �`�� LDMA P/C k e� above information is conect.I agree to comply w th all Couny Invesiipation fee - � - � $ ardinonces and Stgle�pws reiating fo building tonsttuttion, ._ Toml Fae ��� � �� � I�MA Perm.�k �- and hereby outhorize representatrves of this County 10 emer�- _ . W upon�-ab e-mentioned pro �ty for inspectian purposes. . .. ... .... .. ..-.- .-.. :.._: . ...:, ._. ..,, . , . . . . . �. . . . . . . m � SfE!lEVERSE FOR E7fPLANATORY.LANGIIAGE �. _ _ � Signafure af Applicanf or Agem Dote ..._.._._.__,�..._ �� _ �K,�_:.�,.,����.,P�._a..�..�.�� .� �..�.�x_.a.�.�� � <t'_:-�.t._-i� ' 2..,Y°"�.v-..3i:1.. a�q �- i:k':!r 9- �I.:i�.0 .:}:,.'.. iL i.i`� ��t.*.,':5C: ' n ::. �- :E,�, � _ _ �--_-- . ._ , --- . .�. �:�.x� . 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