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HomeMy WebLinkAbout0707A 0786A WORKERS'COMPENSATION DECLARATION � . �I insureborafclertifiwtelafWorkerseCompen�lonlnsurancesalf ,�pPLICATION FOR BUILDI�NG PERMIT LS a certified mpy thereof(Sec.3800,lab.C.) ' COUNTY OF LOS ANGELES BUIL�ING AND SAPETY PolicyNo. Company ❑ BUILDING � � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AD�RESS l .� .f/ ❑ Certified copy is filed with the county building inspec- gUILDING , tion deparimenL � � ADDRESS ✓��(j..�/�9r»dx��A/'�` ' iocnSrv �/iP-vrt �.� . � � - ,� �J NEARES7 Date Applicpnt CITY,_,_,// pjp /J.S�/' ZIP CROSS ST. ��9'�Ti' " CERTIFICATE OF EXf.MPTION FROM WORKERS' NO.OF BLDGS. .a5SE550R COMPENSATION INSURANCE - SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL � (This section need noi be completed if the permit is for one u5e zoNe MAP h��d�ed douors(S�ao)or less.� rencr a�ocK �or No No ,.,. TEL. SPECIAL �}�,,, I cerlify Ihat in fhe performon<e of Ihe work for which fhis OWNFR ���/f � NO. CONDITIONS �j ermit is issued,I shall no}em lo an erson in an manner DISTRICT GROUP TYPE FIRE PROCESSED BY tJ P P Y Y P Y AUDRE55 CONS�"� .ZANE- �� so as to become subjec�fo the Workers'Compensation Lows. : � ��;� ,i� �'..� /,!/, •k-�-� � Date /l%Applicanf��'_ / CITY ZIP STATI51'ICALCLASSIFICATION APT. CONDO- � NOTICE T AP LICAN7� If, after making this Ce tifitate of ENG NEERT OR NO � sj Exemption, you should betome subjeci fo the Workers' CLA55 NU. .-� .�` DWELL UNITS_ �� Compensation pravisions of Iho Lnbor Code,you must forfh- i ifh comply wilh s�ch provisions or this permit shall be �nURESS ; ,� SEWf�R MAP �= deemed revoked. � TE�� -' ,VAUDATION CONTRl�CTOR ��,_ NO. I I V )`f�h�� BK. PG, LICENSED CONTRACTCRS QECLARATIOiJ tIC. � �C'�b,'7� � I hereby affirm�hat I om Ilcensed under provisinns of Chapter 9 �D�RESS - NO. ypLUATION (commencing with Section 7000)of Division 3 of�he.8usiness ond LIC. ;�Er % �m 8 �L 3 ProFessions Code,and my license Is in full force and efFect. GTY CLASS � ��,J� �l� . � SQ FTy/ NO.OF / NO.OF CHECK J 8 9�n�n LiCense Number Li[.Class SRE/,_7� 510RIE5 ! FAMILIES ONE � V. 1; Coniractor Date DF.SCRIVTION OF WORK NEW � � m�s s�j��,�5��� +❑ .1 . AOD I am exempt from the licensing reqoirements as I am a / N r!J/ h' qLTER O FINAL /y �y f �'' ���, licensed architecf or a regislered profes5ional engineer � DATE /oK �� q acting in my professional capacity (Secfion 7051, � � Business and Professions Code). u5e OF /� REPniR EXISTING6LDG. !"gI� .S�i�«�� DEMOL � FINAL . � Lic.or Reg.Na. Date APPLICAN7���J ,1 ��y.� „""`� 7EL. BYt--" ry � OWNER-BUILDERDECLARATION (PRINi)EC[1L�(flY! /�!� /P/ry�V(J N0.7�N7�U`�yaj I hereby affirm�hat I am exemot from the Con±ractoi s License / Low for ihe fallowing reason(Section 7031.5, Business and ao0RE55 � ��s.� �C�'�C�v't�i���!�J1. s� �' ��f• � Professions Code�: PRE ENT � BUIL�ING _._ ... .___ , �(1�]�(]A I, as owner of the property, or my employees with A�DRfS$ waya;os Il�iei�aoie compensarion,wiii do ihe work and . ihe siructure is not intended or offered for sale(Section LOCauiY �.o a r,:a • � .:7044,Business ond Rofessions Code). - MOVWG TFL � O'�,I,as owner of the property,am exdusively mniracting CONTRACTOR - No. � • 1 Q 9,5 0 with li<ensed conirocrors to construd Ihe project(Sec- pD�kE55 m'�o � (��'j,��� tion 7044.Business nnd Professions Code). � . RE(;UIREO T07AL SFT6ACK FROM EXIST_ �� CONSTRUCTION IFNDING AGENCY 5[T RACK YARD HWY vROP.I.INt WIDT41 � ' � I ��L�"H.�I I hereby affirm Ihot fhere is a mnsiruction lending agency for FkONI . . the performance of ihe work for which�hls penni�is lssued p_� (Sec 3U97,Civ.C.). � Sioe - � � r.i Lender's Narne lendar's Address_ .. _._ P.C,Fr.c S ����'�. u���� Per nii Fea f C���• L��� I cerlify ihat I have read Ihis applicolion and state thot the � issu ce Fee �.:.i �) � abave informafion is r.orrect.I agree to cornply with all County invest�i9m�ion Fze - a � ordlnonces and Stale laws rel�ting to building construction, imol Fae �(,� ��7 and herekiy outhorize represenintives of.this County to enter . upon pbore��rnentioned properly for inspedion purposes. � _ r� . 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