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HomeMy WebLinkAbout1272A 1897A �Y \ WORKERS'COMPENSATION DECLARATION ' �n I herehy affirm that I have a cerrificale af consenl to salf - f �S ,�,�.�,oraeertificaieo(Warkers'Compensation,�=��a�«, APPLIC.AT�ON FOR BUILDING PERMIT or a certified topy thereof(Sec.3800,Lab.C.� � i ' ��p 5 COUNTY OF LOS ANGELES BUILDING AND SAFETY�� A Poli o. ompany_ ��1 �..���/� � � CerriFled copy is hereby fumtshed. FOR APPLICANj TO FIIL IN ADDRESS � .7 Q ,�. �-C .�/,�� - � Certitied copy is filed with rhe covnty building inspec- BUiIDwG � tion deporfinent. � ADDRE55 � �j /Iti/hp ( IOCAUTY »+�.Isc�L. � 1 NEAREST Dale •�Z� -� pplicant Cltt D ZIP CROSS ST, CERTIF�CATE OF EXEMPTI FROM WORKERS' � NO.OF BLOGS. ASSESSOR � COMPENSATION SURANCE SIZE OF lOT NOW ON LOT AMP BOOK PAGE PARCFL � (This setlion need not be compleled ff fhe permlt Is for one USE ZONE MAF � hundred dollors(5100)or less.) TRACT BLOGK tOT NO. NO. � �`>� �� OWNER � S� TEt. �-� SPECIAL • I tertify thal fn Ihe pe�formonca of the work for which lhis NO. �ONDITIONS 6}. p2lmit ii i51u@d,I shall not employ any penon In any manner � 4 DiSieKT GROUP TYPE FIRE PR fSSFD BV � so as lo betome subject to the Workers'CompensoNon laws. AODRE55 e� \ �LFi ��� CONST. ZONF V /O ' C Dafa � ..' � APPIitOnf . .. .� . . . CIN ��� ZIP.. STATISTICAI ClP.SSIFI TION AVT. CONOp. �F NOTICE TO APP(ICANT: If, after making this Certificole'af � bRCHITE OR •�.:7 l,� � - ... . .. � J� V �Exempfion, �yoo shoold 6ecome subjetl��lo fhe Worker5' - ENGINEER��� � �.� NO. �. ��CLASSNO.,�sLDWELL UNITS � ��i Compensotion provisions of the Lobor Coda,you mvsl forth- noDaE55��� �(,pt SEWER MAP '� wllh camply wi�h such provisions er this permit shcll bo � �TE� � � ? deemed�evOked. � CONTRACTOR �- NO. . BK. PG, VALIDATION � LICENSED CONTRACTORS DECLARATION C � � I hereby affirm thot I am licensed under provisions of Chopter 9 ADDeE55 j O. Z - VALUATION (mmmenting with Section 7000)of Division 3 of the Business and ,� LIC. �� 2 7�2 A Professions Code,and my license is in full force and effect. ci7Y '�� CtA55 C' E .8j� •��--- � �/ /��� Sq.Fi. Np.pf NO.OF CHEIX , it• • • •2�J Licensa Nom6er_j�^ ,l _Lit.dass C;4S SIZE STORIES PAMILIES ONE � �q-..{/ u.�. � � DESCRIPTION OF WORK NEV'! S� � � �2 S.O O Con}raCto�w+'� 1�� Date ��� �N � .��, � A�� � � •�• •2.rl d Q U ❑I am ezempt�nder Sec. � � B.&P.C.for this reason ( S RE ARQ� � DA EL � f -0�.2 7—8 4 USEOF ��.C.r.t ?b�o/► EMOL ❑ gY I4'lL�.lae��� DO1e' ExiSnNG BIDG FINAL � � � , Signafura � Ava M .J u� NO. d � ... - OWNER-BUILDER DECLARATION . - I here6y nf(irm thar I am exempt from the Conrroctorb Ltcensa ADDRFSS�t S �Ir 1� A � ► � law for ihe following reason(Setlion 7031.5,Business and --' � � � Professions Code): . . . veESeNt ❑ BUILDING , � I,as owner of rhe p�operry, or�my amployees with aooaE55 wages as fheir sole compensa�ion,will do tha work and � . , � .. tha slrutlure is not infended or offered for svla(Section ��`��TY 7044,Business and Professions Code). MOVING TEL. ' � 1,as owner of Iha ro erf am e�clusivel contratfin C NTRACfOR NO. f� P P v, r s 189,7A - �. with licensed contracton to consnuU the project(Sec- aoDRe55 �. . . . . � � tian 7044,Business and Professfons Code). . � , � • � REOUIRED TOTAL SETBACK FROM E%IST, CONSTRUCTION LEN�ING AGENCY SET BACK �ARD HwV PROP.LINE wioiH I • •3 b 7 5 I hereby offirm�hot there ie a mnsrrvc�ion lending ogency for FgpNi � �he parformonca of the work for whith thie permit is issued r.t. .• • ��(z 7 5� t5ec.3097.Civ.C.). SIDE . v.`. 0305-84 Lander's Name � - u) / � P.C.Fea S �`�v Permit Fee �S�•�� Lander's Address � - I certif that I haJe read this a lication and stote Ihat the � � � ��O• .�U � - - - � � Y PP � Issuonce Fee above information is carrect.I agree fo comply wilh all Counry Inveseiqot�on Fee o�dinances and State laws re�ating fo b�ilding consrrucfion, Totol Fee .3C• �.�� � ond hereby authorfza represanratives of thls Counry�o enter � , , opon 1he obova•meM"oned opert (or Inspection parposes. � - � � - � � � � Z �$ � SEE REVERSE FOR EXPLANATORY LANGUAGE � SignaNr ol App icant or Agen Dme � . .�� Z o ' ..� -- �o .. : � -T � Q _ -- - - N T� m Q m R . � ��1 '�' ; .p � .(1'D m 4 O d� U ?� � . p � �O � �,�' O 7 .T .�: O �' t r^ .C�" '7 J �. til G G. .. 17 �� N 'e NO � �� p' n� .V . �.� V �i ' C .,, � r*� '� p c p C � �.�. 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