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Home My WebLink About1759A 1760A (19) ; � WORKERS'COMPENSATION DECLARATION ' � � insureboraafcertifca'teofWorkes'iCompens lioolnsurancelf ' �P!'LICATION -F�OR- BUILDING �PERMIT or o certified copy thereof(Sec:3800,lab.C.) COUNTY OF LOS ANGELES _. BUILDING AND SAFETY : P❑ol�icyNo. Company . . . . . __ __' .. . BUILDING � Cer�itied copy�s hereby furnished. FOR APPLICANT TO FILL IN - nooaess �� 3 t�. .�� Certified copy is filed with the counly buildin9 inspec- BUaDiNG �+ � tion department. � ADORESS -J• LOULItY� Ls's>c �� . � NEAREST ; � Date Applicant � Citv AJD � Ziv � �S CR055 ST. CERTIF�CATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. a55E550R� COMPENSATION INSURANCE � SRE OF lOT NOW ON lOT MAP BOON � PAGE 7ARCEl (This section need not be compleied if Ihe permit is(or one USE ZONE� MAP hundred dollars(5100)or less.) � TRACT BLOCK LOT NO. � . .�. NO. /��.� � . . . . ___.TEL.' � . SPECIAI � .Y OWNER ',u5c - El. O. —� �ONDITIONS - a I cartify Ihot in the performance of ihe work for which this ., DISiRICT GRouP rvPE FlRE PROCESSEDBY 0 , . ...'._'...__.__ ___ . ..._.._.. permit is i55�ed,1 sholl not employ ony person in any manner CONST. ZONE so as to become subject to�he Wo�kers'C mpensation Laws. ADDtie55 �C• _ `� � � O � �I� CIiY (L� b GrF ZIP Date Applican «��'� � �,/J STATISTICAL¢ASSIFlfAT10N ,. . APT. CONDO. � / ARCHIiECf OR � TE�• W . NOTICE TO APPIICANT: If, after making this Cartificofe of fN�iNccq �' R n ��LASk i'�-ND. � � �-�- CIASS NO.�DWELL.UNITS_ �Exemption, you should become subjecr to the Workers' - N Compensation provisions of the Labor Code,yo�musl forlh- qpppEu . ..-_ . .. .._- .. - � SEWER h1AP �, wilh comply with such provisions or this permil shall be TEt. . deafllBd fBYOkC[J. ' ' CONTRAROR � NO. - -�BK. PG, - VALIDATION IICENSED CONTRACTORS DECIARATION IIC. 1 hereby affirm that I am licensad under provisians o(Chapter 9 a�oRESS NO. yqIUATION � (commencing wiih Setlion 7000)of Division 3 of the Business ond LiC. � � . Professions Code,ond my license is in full force and eHect. CiTY Cv 55 S � � . � $p.R, NO.OF � �� NO.OF CHECK � � �� Licensa Number � lia Closs � SIZE � STORiES I FAMNES ONE . . � / a �175.9R OESCRIPTION OF WORK O N NEW ' Contra[tor Dala . . .. .. . . ... .. . _._ ApD - � �• • •-•2 3 � ❑I am azempf under Sac. qiTEg � FINAL-. ,` .._. I • �z�� . ... . .. _._ ... . .. DATE'T�'.�'�M`�1 . B.&P.C.�of this feP50n (J p REPAIR ❑ � � � � �2�O O� , Date: . .. -. EX Si�G BIDG.� �\CCTA1�- -V EH�T � DEMOI ❑ BINAL1 \\ � • p p APPLICANT T L Y �1�''.� 1\ � O Z 2 V—V� . Signatura PRINT -LC � -� -.. - . . OWNER•BUIIDER DEClAR.4TION ^�, � , 1 hereby affirm ihat I am eaempi from tha CoNractor's License qDDaE55 � 1!!�I� F-�C.�r �� "" � - ''��'�� -� � � Law for the following reoson(SeUion 70.31.5,B�siness and . . . Professions Codef. � - PRE N -' - � ' , ❑ B�ILDING _ . . . . ... . I, us owner of Iha property, or my employees wilh qpDRE55 wcges as Iheir sole compensation,will do the work and ��A��TY . �1.7 C,0 A� .- �he strucwra is not imended or offered far sale(Section � �- ' - � 7044,Busineu and Professions CodeJ. MOVING TEL. Yi.� • • • •i� � I,as owner of the property,am ezclusively toNwUing CONTRACTOR NO. _ , _ . _ .. wilh licensed wntroctors to construct the project(Sec- qDDREss � �,• •L 2 5 Q� �tion 7044,Business and Professions Cada). � - -� �� - - � 2�2 5 Q x . � - REQUIRED TOTAI SETBACK FROM E%I57. • • • � . YARD HWY , CONSTRUCTION IENDING AGENCY - SET BACK PROP.LIN W�DTH � � I hereby affirm ihat Ihera is a conslrottion leodin9 cgency fot � FROM� - . , � �- �- - -- �- � - � Q'L 2$-$[� . . tha performance of�he work.(or which this permit is issoed ' v.l.�' - � . . � • ' iSec.3097,Civ.C.)... . . , • _ . .. ..SIDE�. . � , . . � . � .. . . . - . . � � . . . .�P.L . - . . . . . : lender's Name - ' -. . . �: .'. . . � � � y ._ . ._-..� ' /,y• � ----� --.... � ._ . � ' . .. . ..� . � ' - . P.C.Fee S �' �'� Permi�Fea ' if ' . — Lender's Address . � . - , ...... :✓�U _ -._ . ... --- � � _ . . . .. .._ ..... .. . . . ... a I ter�ify thot I have reod this opplitalion and state Ihat ihe Isa�ance Fee� ' � a6ove information is correcl.I agree lo comply with all County Investigalion Fee _ . .. . .. . - � ordinances and State laws relating to building construciion, Taial Fae ✓!��✓D Y'i dnd haroby aulhorize reprosamalives of this County to emer _ . . � -u/pon the above me tione properry for inspettion purposes. (� - - � - --� � --� �- �"" �" � - . < x ��/ . SEE REVERSE FOR EXPLAHATORY LANGUAGE._,,_, ... . . � � � - - . � /�iq owre o}Appliw ar Agent Dale . � �.�s I ' � , . . . ... _ ... . . . _. __ ... . . � � i: .. . . .... ..,...;�O 'O� '� � Cl/� j,' 1n \' �' � � �-.CrC,y:p��0�'•`•'\ L� afi� CL`�C��- '��Cd:C� Y� ' S �1 I� '. 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