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HomeMy WebLinkAbout0865A 0866A WORNER$'COMPENSATION DECLARATION � �� � ' ' � � V�./`�( ��� I hereby aitirm ihat 1 hove a certiFicare o1 consene to self ' PERMIT �� LJ insure,oracertificaleofWO�kers'Compenso��on��,�.o��e, APPLICATION FOR BUILD NG or a cerr�Red tapy�th/em� af(Sec.7800,lab.c.)(� i � COUNTY OF LOS ANGELES BUILDING AND SAFETY Pollcy No'�,{=,�Company �'��•� BUILDING /20o S �(�Q� �,� � Certified copy is hereby(vrni:fied. FOR APPLICANT TO FILL IN ADDRESS � Certii�ed capy��a(iled wilh Ihe county bUilding insp2c� BViIDWG�OO •�(�Q/'I'D J p, y L� tion deportme / ADDRESS /1 /� Oale��Applitant��/!I WlO�I�C `O ClTY LOS C� ZtP VdfO LOUIITY ti'I (V1N� ..D� RTIF CATE OF EXEMPTION FROM WORKERS' ' �- ' � NO.OF BlDGS. NFAREST, �' .. .. . � COMPfN5ATI0N INSURANCE � . SI2E OF LOT NOW ON tOT CRO55 ST. (ihis section nead not be mmpleled if the permit Is for one - � /+55ESSOR , hvndred dollan(5100)ar Ins.� , iRA[T � BIOCK �l01T NO.` MAP BOqC PAGE PARCEI tl�.7� �1 �LCOG�i1�N E�' USE 20NE� �P 1 I 1 .�? OWNER NO. � I ) I certify ihat�in the per(ormance of the work for which lhle ,�/�y7^ �.. /� ✓ //�7 C' . SPECIAI � permft ie hsu0d,I sholl not employ any pe�son in ony monner ., qODRE55�bZ3 C JI ri<<"�S� �f U CONDITIONS so os to 6ecome iubjetf to the Workers'Compensafion Laws. tl � � ,�, CITY CO £IP � � � � � Da1e AppllcoM � � ARCHITER OR TE�� p15iRICT GROUP NPE FIRE OCESSEO BY O NOiICE TO APPLICANT: If, ofler moking ihin CertifVco�e of NGMEER N�� CONST. ZONE � V Ezempfion, you should become�sub(etl fo 1he�Workers' - � W Compensafton provifions�af the lahor Code,you mwt iarth- poflaE55 t �� ��� 0. with Comply wifh such proviffons or Ihls permil sholl be TEL. SiATISTICAt QASSIFICATION APT. CONDO. c!) deemad revoked. � •� - GONTRA[TOR Q � �/ NO.27 � 3 . . Z LICENSED CONTRACTORS DECLARATION � � � � ^,qO / /?�l� UG� S MSS NO. DwEIL UNITS� - � I here6y affirm�hat�am Iicensed under provislons o(Chopter 9 ADDaESS lA� !7 � NO. . (commeneing with Secrion 7000)of Division 3 of iha 8ueineu ond /�q� . �b� uC' �R�P Praiesslons Code,and my license is in full forca and effect. Gltt `�I CU55 �� --�---BK------p�,-- ��� � � � VAl1�AT10N � �7/{� 50.FT. O NO.OF NO.OF CHFCK � License Nomber�.—LL Lic.CIa3s� SRE STORIES - � FAMILIES � � ONE - �� �. • � n/�� /����p �� � �ES�RIPTIONOFWORK' T ��Q� . J'tf fhlU !ON . _�D/ CoMra�t��dlC(TJ/� �EYY�(lL Da�q���... e a D�O , . � . . . �j dP�• ` noo �I QYm exampt under SeC 5 � �" I � � AUER � f 3P.C.for�his roason . � � '' � �• REPAIR.❑ _ - - � � � -� USE Of Da�p, EXISTING BIDG. �) /�J� � � � h 0 8 d 5 A Slgnature�•��.!y��/ APP�pRIMT��7T H-///� NO. flNAL �WNfR•BUIIDER DEC[ARATION' � OATE _ p��j7 �• •�• •2 3 I hereby affirm thot 1 am e�emp�irom fhe Con�racfor's License � A�� �7 � �� � FINAL^ � � Law for Ihe(ollawing reasoa(Sectian 7031.5,Businese ond e /'� . � a'3�.9 a Professions Coda): � - � gu lpiniG y �� i d •3 2 9 4 c=a � 1,as owaer of the prope�ty, or my�mployees wi�h n�OtiE55 wages as their sole tomoensation,will do�he work and ����iY � ��� 8—a'� the strucwra Is no�iniended or oifcred for sale(Settion 70ea,Business and Profeesions Code). � �- � -�� � MOv�NG � - � TEt. � I,as awner of the property,am e•clusively canlmeNng CONTRACTOR �� with Ilcensed comroctors ro construct�he project(Sec- nooaesS � ' lion 70<E,Business and Professions Code). - � � ' �n$�6 A REQUiBED TOiALSETBACK � . � . - CONSTRUCTION IENDING AGENCY � SET a.aCK YARD NWY DRpP.LINE W�DTH � ' . I hereby effirm Iha�Ihere is a const��Uion lendinq ogency for fRUNT � � �� � �� �� ��he peAo�mance oi�he work for which�his permi�is issued P.L � - . ' � (5ec.��,Civ.C.)• SIDE I • •4 9.2 5 v.i. , . . .49.25� Lender's Nome G �1 �DMA Ref.M P.C.Fee S ZI Vermit Fee 1 r � � 0 Q 1 8`8 7 lender's Address � l certify fhot I hove reod thii applimtion ond stote ihot tfie . . Issoon<e Fee �(�. LDMA v/C N � � obove Informefion is correct.I agrea to comply with all Co�nty inves�iga�ion fee q q f . ordinances and StO�e laws reloting 10 6uiiding construttion, . �mat iee I •f"'J LDMA Germ.N and hereby outhorize rep�esenta�ivas of thie County to enter upon Ihe above-�P�erfy for inspe fion P/Q oses. .. . . . . �,� SEE REVERSF FOR[II�tAHATORY IANGUAGE � Si8^mvre of Applico�t or Agenr po+ - � � � � � �, T N -� � � ;.�. -c�, -c._ T. ._s t - -- - -+ �_ � p � a o a ° �. o o ° m ° o � a a, o e p �� � - m o 7. - 3 a _ 50 � p � ., � m _ _ �c - o ^ � T ' o � � c ^ o. -D � o �� � � �°c : �? � s in ' � : �+ �'?: o o`f � - ° w? 'O o �� n� o : .1-.• o b _ D� � �:. - 0 0" � ' ° c '" � < n °n °:t' i t 3 � = � � � i- �.. ] ,n :7' C �` p O C � j _ �O p. fi •. .� .O � O fj �' � '1 : p N I, (_ ,� p� �C.^ n �.9 �D� , � O . 7 � � � � . � , . �. V p � » "_n _' . i � . � . --- - ' • ' • ' f� I ( 1 � . . , O � - ---I � i _- I ' ' ` ry _ 1. D � ,� � ;, 'C o --�' O �` . ` ; o � _ - �� . . 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