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HomeMy WebLinkAbout1406A 1885A (13) 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. (L' 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 S�gn rore of pplicom or AgeM Dote , � . �, i_� ,z � Q. o _ . . � ' - i y _� -- . O ' ro � Ci�1 p p � 1 �- (1 V m p. �0,� �(i- fl S. (1� ,,� , . , p � O cv , 'n � O 7 .S �f7 cD � ,� . . , f .�� :.�� y". �' � y 'U ::.' 'b ' � '� -rt Np �' Q �� O pl �P �" . 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