HomeMy WebLinkAbout1689A 1808A (10) WORKERS'COMPENSATION DECLARAiION - ' - .. . . �f
I hereby affirm fha! I have a cerfifimfe of consenf fo self - 5��'V�`,' '�NJ�FO�R �BUILDING PERMIT LS
insure,or a certificate of Workers'Campensiicn Insurance,or �� '�
a ce�vfied�co�py�t/here�[o�f{SQ)c 3800,iab.�C^./� .¢ NTY OF LOS ANGELES BUILDING AND SAFETY
P❑ollcy No.��Bmpany JT�G2/ �LZ'1'�-� ��
Ce�tifiad copy is here6y furn'ished. FOR APPLICANT TO FILL IN Aooaess �1 �✓W � �'�'�`��.- ��•
� Certified copy is filed with rhe caun.ry buil i insper gUItDING / l � �
tion departmenl. r, .j ADDRESS�.'$p U//;�/�{ON,��.�C-�L�✓I�' LCCA�ITY � 't� ��
oa,e_�Applicont �/ � o1v�.gr✓iu/✓-1� 13,q� C3l, n,eaaesr �.
Zip .,RO55 ST.
RTIFICATE OF EXEMPTIO FROM WORKERS' NO.OF elCGS. /+SSESSOR
COMPENSATION INSURANCE � SiZE OF LO? NOW ON�OT M.4a BOOK a/aGE PazCEL
(This section need not be completed if ihe permit is for one USE ZONE MAP
i
hundred dollars(51001 or less.� TRACT . 6LOCK LOT NO. No. t���`�`f'^� }
TE.. 7/5° sFeaai a
own.R✓%Y+N�lG�r'i�/�C w�EJ���. ho. 772£�Z-7o c �� _oNoiliorvs
I certify thar in the perfarmance of the work for which ihls ..,. ,_,..._ ,,.._,,,,,,,,,,,,,,,,.,, �
permif is issued,(sholl nat empicy any person in any manner DISTRICT GROUP TVPE FIRE PROCESSED BY
ADDRE55 Zj10 S-CLFJI/0/ S'j ���"'
so as to 6ecame subject to the Workers'Compensation Laws. ^ � �,� � CONS� /`j � �
CIiY/'r/1iO!�„�.rl� �f i� ZIF `7�S�5 �• -..�1 .L..4/t' '�
Dote Applicont STATISTICALCLASSIFICATION APT. CONDO. �
ARCH:TECTO � TEL'�Fi� �
NOTICE TO APPLICANT: If, af�er making this Certiflcate of Gh�INEER �r'NRLO rY�.. y��x(;p� NO. 3-1Z01` CLa55 NO. �� �WELL UNi75_ p,
Exemption, you should become subjecl to Ihe Workers' �/ 7 . �
Compensa�ion provlsions of ihe Labor Code,you must fcrth- qpDRE55 x�7"�•[�.�/Ylif'9/� /1N.�f/�'sTMI �H'�• SEWER MAP �
with comply w'ih su<h prcvlsicns or ?hls permit shall be .
deemed revoked. COMRaCiOR(�A/✓�Gs�'�-E�t1�w '7�:�: NO.�� 2-yZ7� gK� �. VALIDATION
� � - LICENSED CONTRACTORS DECLARATION LI[BE!/N- .
I here6y offirm thot 1 am ficensed under provisions of Chapter 9 ADDRE55��/'G S� _ L�W�+�S� NO. 6 VAWATION
(mmmencing wiih Sectlon 7000)of Division 3 of the Business ond n - � �i� F'r"—� f7 8,9 A
Professions Cade,and my license Is in full force and effect. aTv,7/✓✓t/i�E//b( �fj-L. CLA55 S �� t�y�
SG!.FT fv0.Of NO.OF . CHECK i�• • • •2 3
Li�ense Number Lic.Class SIZE ��S 0 5'ORIES � FAMILIES ONE
. _ . . NEW 5 � ° °&�,��
Cont�a[for Dqte DESCRiPTION OF WORK ❑ s ry� _
� I am ezem t from the licensin e uirements os I om a TP.s�''d`� > A�D � °���U U
P 9� 9 ��0�'� r � ��� A'.TER FINAL
licensed architect ar a registered professional engineer ❑ ��,C� .—�?
acting In my professlonal copad+y (Seciion 7051, F � DATE �/F ��
Business dnd Professions Code). b5E OF , RE AiR
EXISTI�G dLDG. ' � j'rJ�2E �EIAOL ❑ FINAL �
Llc.or Reg.No._ �ote APPLICANT 'EL Y By
OWNER-BUILDER DECLARATION '� :PRiNT;T�Ybs=LG��T�7Lt N0.77d�'3'yo
I here6y affirm lhat I am exempt from the Comrac�or's License p 5'-� f6�2/.Cl �✓9�//bl
Low for ihe following reason (Seciion 7031.5, Business and ADDRe55 /Z*f
Professions Codelr 7 E � � � � • � ���
❑ BUI_DING
I, as owner of the propeny, or my employees wiYn ADDRE55
woges as their scle compensatlon,wlll do rhe work and
the structure�s not intended ar offered fo�sale(Secrian �O�.Aui�
7044,Business and Professicns Code). �ViOVMG TEt , _� ��i',�A
� I,as owner o*ihe properry,am ez<luslvely contrccling CONTRACTOR ��� fi c a a
wlth licensed con+ractors te<cnslruct�he project;Se<- *' • �' �
ticn 7044,Business and Professlans Code1. ADDRE55
COf�STRUC�'ON LENDING AGENCV SET�dACK� YaRC HW" T�T°`pROBACNEFROM� �X�I�SH j t � C�,�O
" I here6y affirm Ih��Ihere is a mnstructior le�ding agency for �gpN7 �e e j (1 Q��.�
�he performance oi tne work for wh�ch this perm�t is issued P.
(Sec.3097.Civ.C;. Sioe �J,� �_�2
a
Lender's Name p
P C.Fee 5 ; J/4� r-.i�Fee �`! . L�
_
Lender's Addres>
I cert�f rha�I have read Ihis applimtlon and state iho��he x Fee ��:S�l�
x o6ove Infennotion is correct.I agree to compiy with all Coun�y ,es���ga:�on Fee �ssoor �
m ordlnances and State lows relovng Ia building mnstruction, Tmol Fee r f`�J L�
and hereby out represen�otives of this Couniy tc enter
� upcn t�bo rer.�lon � per!y�or InsoeUion purposes. • :. ...�.. .. ..- .- .��.. .... � . - , . . . - - _... . . .. ,
' fiO y SEE REVERSE FOR EXPLANATORV LANGUAGE
^ S�gneture ef Aop'iccnt or Agenl D�,e �s
_
__�._.�._.M.� �_�. �_��...�.�
� . ?L/adJS T°,9 6aNF.L"s�AfdT _ . ' . OTBSPECTOce�s....... .__, , � I herebyoaff m�ihc�l am�x��empLAom ih�eO cntroctor's
M .c.a�.- �� � � �ta�ia�re�su., . . � F� .. . � � � License Law ior the following reason. (Sac. 7031.5)
j�,_, _ __ _ h"v:�"�*�^-d ! . Bresinessar.dProJessior.sC�tle:t:r.ycitti�opmssnty:�$dcfi
'Pip, �c�te Fdu,� Ipcpe i � ' regsi;�a e perr.zit to coratruct,aker,as:prove,davr.ol(sh,
��_ — or ra�uir any strucdure,�rior to ets issuaMce,ako ra,au:res
J� � � � � dhc uaplica na jor sarcb permit to fdle a sz„tted sta:esxer.E
�— I . --�—� tbrst be is licensed¢ar.cuant to tbe provisions o°tbe Cor.-
; ' tractnr'.;Licem.se Law(Chapter 9J(commencdng uith.Tec-
tion 7�00/nf Drvisiosa 3 of tbe Business and Profassions
I �N Cou�eJ o:16at ie zs exempt therefrom and the b�sisfor t5e
�.�..�.�..,.�_�� alle�ed e:ceraptron.Any veolution jSection 7031.5 by
���quir.C ar.y applirar.S fn?�a fie�mit subjacts SFe applicant io a cfvil
�� C9a3c @Pocc:�dec�
� �'Rp�D�°€� ar� evc+d yereZty cf-.o!nanre abaxi,f'vc�uxdred dnllars($50CJ•1:
i Yex Ro �'�" .
��—.`_._.w.�-._____
C I,os owner of the properiy,or my employees wiPh
;V<<oPer CertificaPe � � �` wages as their sole compensrnion,will do the work,and
�� ihe structure is noi inoended or offered forsole(Sec.7044)
�usirsess�r.d.F'sro essions L'odc:T'ha Contrruror's L(rense
Hecith Depariment � ` � � � � . .�
�._._ __.—_ � Lcw does+eaa appdy to aaa awra�r o,`pro�erty wba&uil`ls
� or iatc r-,ve.c tbareon,and mh�dc¢s sucb wcrk fi&nsed r
f;reD2pdrtmsr4 , � `1� f�
�-T— thrnugfi bis nwn empinyees, pmvi�ed tb¢:sucb i -
I Crading � f . . prnr:ements are xnt lnter.3er[or offered for sale. Ij,
� �.,___�_�, however,tb¢Suf;dfng crl.verroven±ent rssold wiebir one
�Geeloci^ol �^ �� � ysar of complatien, �be ou�ner-builder weFB hsve tGe
� � �� _I_, i §us'�'e;s sf)iroci::c tbQt Ge d.ed.eo*builsf or irrt,rnve for
�� -���-�T— . the f::+pc e ef sule/.
�Padea3'iar.'�Protecti�n I�Y i .
1(`enccJ(Ccncpy) � C� ;,as owner oi the property,am exdusively contrac-
I lirtg wifh licensed con;;Qctors fo construc}9he project(Sec.
Special InspacPion ��! 704A)Burinnss erd Pro,fess{oras Cnde:Tbe CoxSracPar's
'�Coic.j tPliesbnry;(Nielding) � i --- I,rcer.se]nx�does net upply tn an owner rsjfrr�pert1,rc•hn
�.— � E�url_s or:�ro��e�aFereon,a�d�.�bo cnnPracts fo:su.b
�{a' �p����pg�� - � projectr widb 2 contracfor/sf licer.sed pursu¢r.t to tbe
��, � � � � � Con;rac8or`s Licexse 7,¢wf,
1 norM.ing . : ,, �� . . . '
❑ 1 am exempf underSec ,B.&P.C.forthis
J I
� � - - r�ason_
` ..-Dafe.. .. .. .. . � � Owner
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� EEp,�.+.e�a'�aPa ; .s-ta�agee��ar`a S:x,;a�Su-___o ,.� � . � ..m.�..r.�.,. .�...,....,..� . . . . .
� ' !S'lSPECPOR'S P3OTE5
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�(Sef:eck&Ycres) i,� � . . . � �
s Pounda�ior,s �
� lab � � � { _ �
�e I 5L;,�q�E2�� 4`_ �
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iH�::�e num5�;-- i
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