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HomeMy WebLinkAbout0786A (4) WORKERS'COMPENSATION DECLARATION � I hereby affirm thar I have a cenlficafe of consent to self APPLiCATION F4R BUILDING PEItMIT insure,cr a certifimte of Workers'Compensation Insurance, o�o�e�r�fied copy�hereof(Sec.3800,Lab.C.) CpUNTY OF LOS ANGELES BUIIDING AND SAfETY Policy No. Company � �-� � CArlified co �s hereb furnished. - � eUiLDING av� v FOR APPLICANT TO Flll IN nooRess �.��� C� � Certified copy is filed with ihe county building inspe[- BUILDING �/ tion departmeM. ADDRE55 �Y � � Y Date Applimnt CITV yyy /?�.�,1v1 Y ."�- ZIP tOCAUTY \ � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS. NEAREST COMPENSATION INSURANCE SIZE OF LDT NOW ON LOT CROSS ST. (This section need m�be<ompleted if the permit is for ane X ASSESSOR hundred dollars($100)or less.) TRACT BLOIX LOT N J pJ�qP BOOK PAGE PARCEI ��k J . ��/ / TEL. �;y USE ZONE hU1P OWNER [_jf .-� A !B�Y+CY NO. f I cerfty fhai in the per4ormance of the or ffor which this J� NO. permit is issued,I shall not employ any` rso�in a y manner qODRESS ;���/ 77 �Y. SPK�A� O so os to become su6ject to 1he Workers Co pens ion Lows. / CONDITIONS � CITV�}� Y,/ s7lJ' ,. �l ZIP �J% ,j U Dafe Applimnt ��� ` � ARCHiTECT OR TEL. NOTICE TO APPLICANT: If, aifer ma 'ng this Certifi te o4 ENGiNEER NO. DISTRICT GROU7 NPE FIRE PROCESSE�BY O Exemprion, you should bacome subject ro th 'Wo ers' _ .._.. . . . . �OTNS7 20NE F� Compensa�ion provisions ot 1he labor Code,y must f rth- qODRE55 �� �, U � � wiih comply with such provisions or this ermit s I be F, 4 deemed revoked. TE�- SiATISTICAL CLASS CAnON APT. CONDp. (/; CONTRACTOR NO. Z LICENSED CONTRACTORS DECIARATION ���, C1A55 NO. DWELL.11NIT5 I hereby affirm thot I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 700�)of Division 3 of Ihe Business and ��� SEWEft MAP Professions Code,and my license is in full force and effect. CiTv CtASS BK � VALIDATION Sq.FT. NO.OF NO.OF CHECK �i[ense Number Lic.Class SIZE STORIES � FAMILIES ONE f� �EW YALUATION COnhaCiOr ��e DESCRIPTION OF WORK Y� " _ ` ADD �. s , �I am exempt under Sec. � t�1 ti7'� 1-'a t"> v (t� . AITER ❑ t�lJ�(J(13 B.BP.C.for this reason � REPAIR ❑ s Date: uSE oF EXISTING BLDG. �EMOI Signature APPUCAN7 �� �_'_ TEL. 7 . FINAL OWNER-BUI�DERDECLARATION PRWT) JJ' 7/ ['r'� N�.S�L^�"' �. OATE �" � 'f"�i� I hereby affirm that I am exempt fram the Contractor's License . � � A��j�, �sl.�5� F�NA� � Law for 9he following reason(Section 7031.5,6usiness and ADDRES� f'7�!'3 � Professions Code): PR EN � BY { QBURDING I, as owner of the property, or my employees with A�DRE55 wages as their sole compensation,will do the work and � z(',`]�,�,g the structure is not intended or offered for sale($ection IOCAIITv 7044,Business and Professions CodeJ. MOvinlG TEL. � �:�o w o c m j Q I,as owner of ihe property,am exclusively confrocfing CONTRACTOR NO. wifh licensed contrpttors to consirucf fhe project(Sec- ADDRESS � C j o o?j,j� tion 7044,Bus�ness and Professions Code). j � �'�� r y _ z REQUIRED TOTAL SETBAIX M � � �"�l,C>%;c CONSTRUCTION LENDING AGENCY SET BACK �AR� NWV pROP.LINE WIDTH � A.-=� I hereby effirm ihat there is a consiruGion lending agency for fRONT . �.�^'`,y-""'��� �1`S� j_,�7 1he performonce of�he work for which this permit is issued P.L, i^``��J (Sec.3097,Civ.C.). SIDE P.L. `�--.Y.'._.--"_ Lendei s Nome _ P�lq L�MA Ref.N 'T P.G Fee$ 7ermi�Fee �Y`��8 ' Lender's Address � I certify t at I ave reod this applim�ion ond state ehat the iasuonce Fea IDMA P/G M obove in rma on is correct.I agree ro comply with all County Invesrigmion Fee ordinanc s o d Sta7e laws relating to building construtlion, To1al Fee � LDMA Perm.# n and her y���QQQuthorizqt representatives of rhis Counry fo enrer a upon th a�tOve-me }ioned properfy for inspectio p� . .. _... .... ., � : . _. . . � ' � J SEE REYERSE ipR FXPLANATORY LANGUAGE Signolure at Appl�c t or Agenf DWe -�ataa:s.�:�.:�,.,«-,.,.:�.�m.�:�v.w.^xw.._r.:rm:�;.�n:�.as:s.:<:cx�.:,�.:c:::.z:..:.�.�.::s..:-::x,�:�-� ._...._,..:._....."":_:'_...<.-,....,_F,�_...._..-...n....�.z...............�:_,:,.. ...._.-......,_....-:.., .,._ .- , -...,,....-. .,�.._.,-.,«........,,....,,.,._-,..-.�P.,._...-r_..,,,.._...a� ...�_ . _ _...�_..d ___.._.__a.e. _. . _ _.�_.,_.._._,.._�_.�_. . _. e.. .._ ._ _..._ _�..�^.._ _._ ._ .� ___. . ... . . � .. � _ � � . • � . 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