HomeMy WebLinkAbout1406A 1885A (11) WORKERS'COMPENSATION DECL4RATION ' � ��- '
;�,�;borofcerlifcaleolWoken''Compenso 0�°��5��o��e` APPLICATIO�1 F,OR BUILDING PERMII` - ---
oAr(a-certified copy thereof(Sec.3800,Jlab.C.� / � COUNTY OP LOS ANGELES � � BUILDING ANO SAFETY �
/�d�d�cyNo.�Campany S7R�G�C'
�� � Certified topy+e hereby forniehed. FOR APPLICANT TO FILL 1N ADDRESS �7� ' � I C P+ !1 �(ic�
� Certified copy t:filed with the county bui�ding inspec- eua�iHc �
fion department. . - AODRESS ����1 Q�7��+�(.5���S� iocnuTv U�'�4Ua ,�3d
NEAREST
Dale � ��F� Applicont-S!.N C✓1 T< �Itt �Q:h�na � - � 21P CROSS ST. ��
�CERTIFICATE OF EXEMPiION FROM WORKERS' ' NO.OF BIDGS. � A55ESSOR �
� WMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP BOOK PAGE PARCEL
(This section need not be tompleted if the permit is for one TRAM BtOCK LOT NO. �SE ZONE oP
handred dollars(E��)or lees.) I - TE� - Sa�Ciat �
I'certif that in the erfo�manca of the work for whith this ��ER� G�+�d�i�CJ"��V'� Np' CON�ITIONS
y p ! D�STRICi GCOUP TYPE FIRE VROCESSE�BY O
permit if issved,1 shall not empl0y any person in any monnCr pDDRE55 :���� ��t✓1 f /I��vL• �ONST. ZONE .f V
so as to bacome subjed to Iha Workers'Compensotfon Laws.
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pro.��>:,�� « � ��P Q .,.��,�,�� o
. an ��
STATISTICAL Cl/�SSIFI TION � APT. CONDO, I-�
Dale .. APPlicanT . .' . � . . ARCtii7EC70R. •�.:TE4 �- _�.... � w
NOTICE TQ APPIICANT: If, aft2r makieg thls Ce�tiiica�e'of ENGiNEER:� � .� NO. � ��ClASS�NO.�DWELL.UNITS a
�Exemption, �you should-betome�subjecl��to�tha Worker5' � - . : ., ..
Compensolion pravisions of ihe labor Code;you must forth- - � qppaE�� � SewER nWP �
with comply with svch�provisians or this permi� shall be , . . i � TEL.�' . 'BK � . VAUDATION �� �
deemed revoked. - CONTRACfOR I� � ��'�Z� �e �k- No54 Y4 3• �
LICENSED CONTRACTOR5 DECtARATION - � . � /' uc. . .
I here6y affirm thot I om licensed under provisions of Chapfer 9 ADDRE55�I(f�Ut(d)U�'✓�if �NO. �GYa VAWATION .
(commencing with Settion 7000)of Divisio�3 oi�ha 8�siness and !� LiC. C � '�['t� .,
Professions Code,and my Ikense is in full(orce ond effect. CITV �.(!�'I�'l�f CaS.,`�Y 7 S , ' 7� U Q b A '
Sq.FT. NO.OF NO.Of CHECK
Licensa Number���� Lic.Class ��� SIZE� STORiES FAMILIES ONE �;� •.• •Z 3
S
coovo�tor�'1 G J(�P.��rn II'�r pote «6 F �ESCRIPTION OF WORK C �nr� k N�sr� A� a ' � �2`�a�Q�
�I am eMempt under See. q��g � FINAL 0 2 0 7—8 4� �
8.8P.C.for ihis reoson � RFPAIR � DATE � M�� U '
.. . Do�e: USE OF DEMOL ❑ FINAL �/ �� �
E%ISTING BIOG. gy
SignatUfa APPLICANT - TEL �.
OWNER•BUII�ER DECLARATION PRIM ( �(.�t"�e� r � No. �1
I hereby aifirm thaf I am exempt from tha Contrattor's littnsa ADoaE55 ' � � � � �
law for iho fallowing reason(Secfian 7031.5,Business and
Profentons Code): FRE Ni
❑ BUILDING
I, as awner of the property, or my employees with nODkESS
wogee as their sole compensation,will do tha work and
fhe s�ructura is no1 imended or offered(or sale(Sectfon ��`��TM
7044,Business and Professlons Code). MOVING *�t• . �1 8 fl 5 A -
� i,os owner of the praperty,am extivsively conlracting C NiRACTOR N�� . .
wlfh litensed conlracfors to mnstruct the project(Sec- ADDRE55 #'� • • • • 1
tion 7044,B�sine3s and Profes:ions Code). �
� REOUIGED TOTAL$fIBACK FROM EXIST. � • •3 6 7 5. �
CONSTRUGTION LENDING AGENCY SET BACK YARD HwY PROP.uNE WIDTH . �
I hereby affirm lhat there is o tonstruction lending agency(or FRONi � •3 4�5=
the periormance of Iha'work for which this permit is issued P.t. ��� "
Zse�.3oa�.Civ.C.). SIDE O�J.O P-8 4 �
v.i,
Lender's Noma ,,� �1 . . . �� '
P.C.Fee 3 �`y '` � GermO Fea �olG. � -�� � � �
Lender's Addrcss . -- ���
��
1 certify that 1 have reod this opplication and stata ihat Ihe luuonce Fee �O. �S v
obove iniormmion is conecl.I ogrea to comply with all Counry invev�gaiion Fee � . _ . . -
ordinaaces and'State laws rela�ing to building tonefrocfion, Toroi F�e j�v• 7tj
dnd hereby outhorize representa�ives of this CouMy to enter � .
upan tl bove•m n ioned property(or Inspection purposes. � _
/ �vG�E"� "L�j�
s SEEREVERSEFORf%PLANATORYLANGUACE
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