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HomeMy WebLinkAbout1590A (9) _ WORKERS'C MPENSATION DEGLARATION - - �� �� -���� � �--�� � . : . .� ,. �..._.. . : . . . �. I hereby affirm ihot I have a certifimte of consent to self ����'�A�'�� ��� ��I������ ��`�a a'� inwre,or a cerhfimte of Workers'Compensation Insuronce, h ` M or a cenified copy thereo`(Sec.3800,Lab.C.) - �'y,g'�y9 �.ta� �+�o�«.0 COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyN Company_ . . � Cernfied copy is hereby furnished.���— FOR APPLICANT TO FILLIN au��o�Nc �. �_ ADDRESS � CeFtified copy is filed with fhe counry building insper BUaDMG . fion department. ADDRESS � Date�D '�R �+� APPIimn�t�J -�� Ciiv r Zia '7!�T LOCAIITV � CERTIFICATE OF EXEMPTI ROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION I SURANCE SIZE OF LOT NOW ON LO7 CROSS 5T. d (This seciion need not be completed if the permit is for one TRAC7 BLOCK LOT NO. AUESSOR hundred dollars($100)or�ess.J .r�, (� / MAP BOOK PAGE PARCEL OWNER /� NO.O�L3 ll Zb USE ZONE MAP � I certify tha9 in the performance of ihe work for whic6 this � NO. permif is issued,I sholl not employ any person in any monner SPECIAL +�' so as to become subjecf fo the Workers'Campensatio�Laws. P.ODRE55 � _ CONDITIONS �� /�, p F � . Date Applicant . Ciiv oL'i.,.eG��.uv.� ,�e. 21P 7I��y V ARCH ITECT OR -TEL. � NOTICE TO APPLICANT: If, diter making ihis Certificafe of ENGINEER � � �~ � NO. DISTRI�T GROUP NPE FIRE PROCESSED BY Exemption, you should become subject to ihe Workers' CONSi. ZONE � Compensation provisions o4�he Labor Code,you must forth- qDDRESS ""--�"�-'��"-��"�"�- � � � � with comply with such provisions or this permit sholi be ` r � deemed revoked. CONTRACiO �,�. „� NQ SiA715TICAL CLASSIFICATION AP7. /CONDO. (,ry � ,� 1�'�' LICENSED CONTRACTORS DECLARATION � � CLASS NO.�DWELL UNI75 � a f3 •�n. 3d11Y,�'/ I hereby affirm ihat I am licensed under provisions of Cho ter 9 ADDRE55� (mmmencing wifh Secrion 7000)of Division 3 of ihe Business and ��� SEWER MAo - Professions Code,and my license is in full force and effect. CITV�..�'t.�,�.f..z.L . f7(4.2, CLASS e J� BK � YALI�ATION License IVumber .70"���'d Lic.Class C_�� SIZE�T 5 ORI�ES /v�� NO.OF ¢ CHEIX _ FAMIlIES / ONE /},, VALUATION dy,Q�Q fi DESCRIPTION OF WORK � NEW � �n( //� COnifO[IO �t�ate ����/ p ir ADD ❑ s _`" �� , �I am xempt�nder Sec. � AtTER � 0.&P.C.for fhis reason REPAIR s Dofe: USE OF � EXISTING BLDG. DEMOL ❑ SiJnatUl¢ APPLICANT� g TEt. FINAL� • �� OWNER-BUILDERDECLARATION � PR�NT� p �N yfJ A�� NO. s� �'2� DATE:`"'% I here6y affirm that I am exempt from ihe Coniroctor's license � �rl � �� Law for ihe following reason(Section 7031.5, Business and F+DDRE55 S�� yr� �A+qlb p� �Ti QjtJ�. FINAL Professions Code): PRE EN � /� B / � = � Jni,lnl� ❑ BUILDING - .��P -/�7(�ps� Y L/ #e a e z a � I, as owner of the properfy, or my employees with ADDRESS wages as iheir sole compensafion,will do the work and ' . � . � the structuie is not intended or offered for sale(Section �o�Aut� � m a� �,�.G 7044,Business and Professions Code). MOVING TEL, � I,as owner of fhe praperty,om exclusively coMrotling CONTRAQOR � e e�,;.j,[:U ci'. wiih licensed confrociors to construct the projed(Sec- qDDRE55 � tion 7044,Business and Professions Code). � - Q Q I �_�� CONSTRUCTIONLENDINGAGENCY SET�BACK �.4RD HWY TOTAPROPACNEFR M WIOTH I hereby affirm that ihere is a construc�ian lending agency for FRONT the performance of ihe work for which ihis permii is issued p.L. (Sea 3097,Civ.C.). SIDE � P.l. Lender's Name �. /� LDMA Ref.N ` Lender's Address � P.C.Fee S Permit Fee �7 ' � I certify ihat I hove read this applimtion and stofa that ihe iseuance Fee �b��`� IDMA P/C k obove information is correct I agree to comply with all Counfy Investigotlon Fee � ordinances and Slate lows relating to building construc�ion, 7otal fae ���o LDMA Perm.8 and here6y authorize representatives of�his County fo enter upon tha above-meMioned properly for inspedion purposes. � � ' - � . � L�a-B�4.Avr�.@� /7/�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signaf�re of Applimnl or Ageni �a � ,..»..................s.....,.....:... ,..,.,..«. . ,. .. ..<,.....,,....e.._..a,��<e,..,.. ..,...,,..,..�.._.....,.,,..,_..r..�.,.......,.....,._....�,. . . �.«.M...._..«»....e_..........�v.,.............,,,..._...,. ��ti€ ,-:.12?.is 2€ ..�,:.ia'J•��';dtY, � i p.;.;e.;i'tt Fi E-:57�7 ; iid�='�c. 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