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HomeMy WebLinkAbout1206A WORKERS COMPENSATION DECLARATION � - � I hereby affirm �ha, � h��e a cerfifitote ar�on5e��,o self � App��CATION FOR:: BUILDING PERMIT insure,or a certifimte of Workers"Compenstion Insurance,or a ce�rifi�d� �y r e e,of_I�Se)_3epo,�ab. .) r.j; COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. . �� dCompany C+ ' [l�/�""� � BUILUIN(G ' t Certified copy is hereby furnished. FOR APPLICANT TO fILL IN noosess ��r d'v�ies^! C•i /t``�° Certified wpy is filed wiih ihe cR unty building inspec- BUILDWG O✓ uo�dopa�rme��r. W,.,,,{, nooRess � �3 � jCl� Cr! �L �ocnurv �4!'W7�!✓/ C.•� �n��-- f�t�������� Date�_.A licanf �S.ra�+T'^�u'S��ih �a CITY �� ) �+. NEAREST pp -�r,'i� r L C� zIP � CROS55T. 4�y G � CERiIFlCATE OF EXEMPTION FI�OM WORKERS' NO.OF BLDGS. A55ESSOR COMPENSATION INSURANCE SIZE OF LOi NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permif is for one USE 7pNE MAP 'r � �� � hu�d�ed dolla�s($lDo)o�less.) . rkncr stocK �or No. rva. ,� TEL. n� SPECIAL � I certify thaf in ihe performnnce of ihe work for which fhis ���'�'NhR� /��P`' NO. ^ CONDI7lON5 � � � permit is issued,I shall not employ ony person in any manner - / / ) UISTRIC7 GROU4' TYPE FlRE PROCESSED BY � sa ns to hecom2 subject to ihe Workers'Compensotion Laws. ADDRE55 ((;oRlj�n�5& � -*�y�/G 1� CONSi. ZONe �,�n ('\ . � / �`��l � Dote Applicant � CITY f T19�yVJ ` CY 7�P SIATISTICALCIA551FI ATION � APT. CONDO. � ARCHITECi OR T[L. . NOTICE TO APPLICANT: If, after making ihis Certificate of �� � � Exemption, you should beconie subjecl to �he Workers' ENGWE[R NO. CIASS NO. DwFLL.UNIiS_ p, Compensation provisions of the Labor Code,yau must torth� `� wilh comply with such provisions or this permil sholl be AnoRE55 ` Sf.wFRMnP � deemed reVoked. l �E`,�J� �� 6K. PG, VALIDATION CONTRAC7'U I '{A NO. LICENSED CONiRACTORS DECLARATION y - iiC. ty 2 I hereby nffirm�hnt I nm licensed under provisions of Chapter 9 ADDRCSS �� ��/ `L NO. 0����e VALUATION (commencinc�with Seclion 7(%�)of Divisiori 3 of ihe Business ond w�l LIC. /' r (�q�, Professions Code,and my license is in full torm and ette<t. U7Y �' ��'•[��'j C1A55 L��. � J� V C� - "'� � Sq.FT. NO OF NO OF CI-IECK �12Q6A License Number � '��� Lic.Class� SIZE STORI(S FAMILIES ONE ��•.�,• ��3 � �� DESCRIPTIpN OF WORK Pt9�'. P PC. ; NEW g con��a�m, C�vl►9a 5','?�Yi r o�f� Gr �-. 7t�'C, nvo f • 0 1 3,6 0 � I am exempt from-ihe licensinc�requirements as I am o )�- licensed archilect or a regisrered professional engineer ALTER � FINAI P d a:1 3,6 p c=.i acting in my professional c pacity (Section 7051, � DATE � 8usiness and Professions Code). USE Of REPAIR . EXISiING BLDG. �A DEMOL � FINAL 0 7.0-5—8 2 Llc.or Re No.�__. Date APPLICANT TFt. p y BY 9 OWNER-BUILDER DECLARATION � PRWI 1 � j��1(' NO. J�=(��1 I hereby affinn t4iai I am ezempt from ihe Coniractor's Licensa /" p,�rA. [q_' ��J Law for the followinq reason(Se.dion 7031.5, Business and ADDRESS - (7 ^"CIICCi �[����[7%+ � Professions Code): � PRESENT 6UILDING � 1, as owner ol ihe property, or my employees wifh ADDRE55. �.,� wages as their sole compensation,will do Ihe work and � ',�� , Ihe s .... - - --;{e�ed for soie(Secrion ���"�I'' � �� � r�������.e,�„cf;nten.,�d� � ' 7044,8usiness nnd Professions Codo). MOVWG � . fEL ,7 "'& � � I,as owner of�he properly,am exdusively contracting CONTRACTOR NO. �s�-/J •a� with licensed contracfors lo conslruU Ihe project(Seo ���� . . tion 704q 6usiness ond Professions Code�. ADDRE55 RF.QUIRED� TniA�SF.IBACKFRnM EXIST. � CONSTRUCTION LENDING AGENCY SET BACK �ARD HWY PR[�V.LNE W�D1H I hereby ufFirm thoh Ihere is a cons�ruction lendinq agency for FRONI , the perfannance of rhe work for which ihis permit is isaued p i. (Sec.3(�7.Civ.C.). . SipE - i�.�. Lender's Name � Lender's Address P.C.Fee 5 �� Pcrmif Fee I certify ihot I have rend this applimtion and sta�e ihat ihe iss� ce Fee above informaiion is mrred.I agree to comply wiih oll Counly Invesiigoticn Fee � ordinances nnd State lows relatinq to buildiny conslruction, � Toiol Fee - and hereby outhori�e representatives of fhis Co�nly to enter upo the ab�e tion{p d pwperry for inspection purposes. � ��.�'�JC.[�/; :J Q'�� J.- SEE REVEkSE FOR EXPtANATORY LANGUAGE S�gnc��ure af Appllcnnt ar Ageni Do�e ._ �s IZ � x S: 3 � T � G, � � � x-��� �_' 3 � ^r ,: �..�_�__... --.�., - —"'__�--..4._�.e........�� cP Q r_ r —._ _ _. � .— . '__ ^ _' ___"." � ,', . .,-_ ' �' � � �Lq T � i �'.. �__._..__�'__��-___ 9 � �...,� C� _ � � � � � � �` � m-n�(1�_ --'�_p_............`^C ❑ O.' �'6 � ���� I � i f q ! y� -5 � j O �^—� i. ��.t� j �'J Q ! 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