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HomeMy WebLinkAbout0923A 1056A (9) WORKERS'COMPENSATION DECLARATION � � � � I hereby affirm that I hqve a cerlificole of conseni to se�f � � qpp��CAT10N FOR BUI.LDING PERMIT ins�re,or a�certificate of Workers'Compensiion Insurance,or � . a certified copy rhe.�eoF(Sec.3800,�ab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY PolicyNo�,-z.,�/�:;��1`�ompan��t;.���i'U✓1%�{��'�'�1��� . Y ,e��— 3 Cer�ified ca is hereb furnished. BUILDING ❑ PY Y FOR APPLICANT TO FILL IN ADDRESS �� O �' Certitied copy is filed with the county building inspeo BUILDWG d --a _— �"/ tion deparfinenf. � AUDRE55�°��'�.� ,-, £,'.� ,J's [y,�,� LOCALITY NEAR[S? Date�g'`� '`i Applicanl��✓l�!%�t,!/V_�"�'�f�'.,L���� CiTv :.✓� y� Jd�'�'� � LIP CROSS Si. - CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF 6LDG5. ASSESSOR . COMPENSATION INSURANCE SI7[OF LOT NOW ON LOT MAP 600K PAGE PARCEL (This section need not be mmpleted if thc permit is far one _ USE ZONE MAV � hundred dollars($100)or le,ss.) 1KACT BIOCK LOT NO. Np, � - 7EI,7 �s�^j - SPECIAL � I cerlify ihat in 7he performance o(the work for which ihis OWNER �����,,f�� r .,� . ���� NO�`��"P,3'�� CONDIT!ONS � permii is issued,I shall nol employ any person in ony monner ,t UISfRICT GROUP IYPE fIRE PROCESSED BY �p so as to become subjeci to ihe Worke�s�Compensation Laws. AD�RE55����? ���y�,?f(�jfJ?� �° ,��•f�. /� CONST, IONE � D,ate Applicant ' Ci1v,YR����-eCiJa1;:: ,�����' zia . � ST�TISTICAI CI.ASSIf TIUN- . ANi. CONDO. NOTICF TO APPLICANT: If, o(ter making �his Certificate af- ANCHIIECI Ok TEL � Exempt'ion, you should becnme subjeci fo the Warkers' ENGINEER NO. CL�55 NO. DWELI..UNITS ,y� Compensalion p�ovisions of ihe Labnr Code,you must forfh- �D�R[55 SEWEN MAP � ith comply wilh such provisions or this,permit shall he � � deemed revoked. � � l y T�� � � VALIDATION CONTRACTOR-� ;P `�'�/'11 !'"� ND. �i" ��,e>r� BK. PCi, LICENSED CONTRACTORS DEC!ARATICN - i.�c. . �C I hereby c�ffirrn fho}I am licensed under provisions of Chc.ipter 9 ADDRESS j�j�,� ;.�j!�'�� '�,�� NO.,�lg'�'�.7xJ.�1 VALUATION (tommencing wifh Seciion 7000)of Uivlsfon 3 of ihe Business and � � Protessions Code,and iny license is in Full force and etfeU. Ciiy ``�fi��� �p�J�, ��ASS£`¢!�•-�°'� S �G'}��T�.,. .�qa� T �Y SC�.I I.- NO.OF NO.Of CHFCK LicenSe Numb•��T���l �iC.Class�-" � SILE STORIES FAMILIES ONE ' co�o-ac�o���•�i.*�/J.``sdr�,�.�,L� -r' �are�`<�-' � ,�� oFsceimiorv oF woRK ,r'r�'4 ,�='"f' - � Nrtiv � � �0 9?.�3�: ❑ I am exempY from ihe licensing requirernents as I qm a m=.� .:s �� ADD ' . ���. /�/�=���. - 'i�. ❑ �Y O �.o a e o L j � ' licensed architect or�registered professlonal engineer � � AtTFR � FINAL . � acting in my professional capacity (SeUion 7051, RFPAIR � DA7E . �i ' � a 'f°g,4 O dusiness and Professions Code). U5E oF . F�NA - � . exisiiNc a�oc_���.'.�" �..'�/ o�nno� ❑ _ a �, j ts.4�:� Lic.or Reg.No._ Date APPLICANT � 7E� y {��7 �� OWNER-BUILDER DECLARATION (PRMT) � ' �� %.�,J 9 �NO,��'p.�yYl � , �.r 7��1 I hereby atfirm ihat I am exempt from the Contrqctor's License qpDRESS �/! .:i�• /���Y� �r'I�2`�/�f�' Law for the following reason (Secrion 7031.5, Business ond �-� i�' � r«'�ii,/� . Professions Code)� pRESENi �� ❑ aUILDING � . I; as owner of}he property, or my emplayees with A�DRESS .�.,, __-Y�' ��__ "_ - the siructure is not intended�or offered for�sale(Seciion IOCALITY � � 7044,Business and Professians Code). � MDVING TEI.. - � I,as owner of ihe property,am exclusively contracting CONTRAC70R Np, � wifh licensed confrpclors to construct the project(Se[- AOUR[55 tion 7044,Business and Professions Code). / REC7UIREU TOTAL SETfiACK FROM EXISi. .��1.�,��'� CONSiRUQION LENDING AGENCY SET BAIX YARD HWV pRDP.uNP WIDTH I hereby affirm ihat there is a cqnstruction lendiny ayency for� Fgn�q . -°-• �,5� the performance of the work for wf�ich this permit is issued p,t. . � �se�.sov�,r,, c,), s�oe :. . .3 i.5 0� ,,.� �e���rs N�,m� �2.7 7�8 1 'Lendcr's Address P.C.Fee S l fe mir rc� -.,��..�� I crrtify Ihat I have re�d ihis npplimtion and stote ihat the Isso ce Fee . '� above information is correct.I agree io comply with all County Invesri9ntion Fee an ordinances and State laws relaling to 6uilding construction, -� � .and hereby authori�e representalives of this County to enier Tnrol Fee ,�/',S� upon the nbove-mentioned.property for inspecfion purposes. � �� ��a�� .� ,/� � (''�f.9v°;s?J;,�/��� f'.�y�� �j' SEE REVERSE FOR EXPLANATORV LANGl1AGE - Siynaiure a!Ap. plic<y�� ur A�e Daie ns �,f �. �r�;��:�� I ` �,�-��,,�k-�-7; �Q . � � o � �\. � � ...�,.,y� ,r,� :;c Q� �n :k � . �=n� �', �� t3' � `t� � � ` l�� '�/�- (\'� c, a '' � � ` � , `i-u ' c;. � o � � � '�%� '� � 9 � '',\ � `E \ � 'g' . p � � �• ��, � :.� O c ° \ t' �„�-��' � :, p J n � a �;, � � � � � � '` \ \ �� n7 � � \ n� .�� t o� .. �� � tl ` � �.� r��v t as Q i �� � � c I� =' i ° " °� �: N �, v �; � � `� �'�, s T. 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