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��� .
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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�� .�
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