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HomeMy WebLinkAbout1725A � WORKERS'COMPENSATION DECIARATiON � ;�s��ebo�a`�e,,f�a,eo°wokes,'�om'Pe�sa,o���s�:o��a` APPLICATION FOR 8�111LDING PERMIT � or o certif�ed copy thereof(Seo 3800,lab.C.) � ' COUNTY OF LOS ANGELES... ' . BUILDING AND SAFETY � - I_ j P❑olicyNa. 4?6 CompanyS7R��H/ BUIIDING � r Certiiied copy is hereby furnished. FOR APPLICANT TO FILL IN - aooaess 3'Q ��G/ � Certified capy is filed wilh the taunty building inspeo- ' BUIIDMG � tion department. � ADDRE55 �' T�n'ldK LOG4LITY�� ^a�V� q NEAREST Date Applicanl CITY � � Or Zlv 6 CROSSST. ' �d'�L CERTIFICATE OF EXEMPTION FROM WORKERS � NO.OF BLDGS. ASSESSOR � � . . COMPENSATION INSURANCE . SIZE OF LOT NOW ON lOT hwP BOOK PAGE PARCEL (This section need not 6e campleted if ihe permit is for one � USE ZONE MAP , hvndred dollars(E100)or less.) . � TRACT BLOCK LOT NO. � . NO. ... . C IEL. ' '� .. . SPECIAI . Y 1 certify thal In the performance of the work for which this OWNER � a'G„ ' YNO. CONDRION$ a . �1 �y.... .. .... . ... .... .. DISTRICT GROUP TYPE FIRE ROCE O permit i3 i55ued,I Sholl not employ any person in any manner - ADDRESS`� I-��1��'1@� �/' j T. ZONE � � V eo as to bemme subjecl lo ihe Workers'Compensatian Laws. I�.. .. R . �-a � — — _ _ . _ tiJ �G-1.� Date � ApPII[on� - CITY Q Z�P STAi15TICAL CLASSIFICATION APT. C . O NOTICE TO APPLICANT: If, affer making-lhis Certificata of - � ARCHITER OR . _ TEt. _ ^�''"1 � .� � w �Ezemption, you should become s�bjee fo the Workers' ENGINEER � NO. QHS$NO.�`DWELL UNI75 � Compensation provisions of ihe La6or Code,yau must forth- . ADDRE55 - � - -- �-- - SEWER hWP �+ with compiy wilh s�ch provisions or this permil sholl be = TEL. deemed revoked. � CONiRACTOR (iJI P- rypS9 C�� � �-BK.'�� �PG, � � VAIIDATION� . LICENSED CONTRACTORS DECLARATION �J i��. �j,� � �� I hereby aTfirm tha�I am licensed under provistons of Chap�er 9 ADDRE5537 e� dnr�� NO. ��1 J ypt pTION� (3oJ � � (mmmencing with Section 7000)of DivisioM1 3 of the Busineu and I- J ��� L ���' C D .Professions Code,ond my license is in full force and ef(ect. dtt �/"'MM M55� S �� ,�Z 5{� n�y�', SQ.FT. NO.OF NO.OF CHECK . license Number ���J Lic.Class� SIZE STORIES FAMILIES ONE �1,� s . #. . . .23 Contmctor pa�e DESCRIPfION OF WORK C�QM����[kT� N� ❑ � ADD . 0 I • •2�00 �I am exempl under Sec. � � � . � � ALTER � FINAL . . •.• •2 S O O= . U B.BP.C.for lhis reason � � � � � ' -� � REPAIR DATE ' � . . Date: USE OF . .. ... DEMOL ❑ ��F�N^�.- .. - - . .�. 0 2 2 4�8 4 .� � EXISTINCa BIDG. - BY . $Ignature � APPIICANT TEI. " "' .._ _ ._ . . . . _. PRINT NO. .. OWNER•BUILDER DECLARATION � - - . , I hereby affirm thet I um exempl from Ihe Conlractor's ticense . Law for ihe following reason(Section 7031.5,Business ond . /oortE55 � � ��� � � � Professlons Code): PrtES�NT � - � ❑ BWLDING . .. . . I, os owner of tha praperty, or my employees w(Ih - ADDRE55 � - ------- wages as their sole tompenwlion,will do the work and � the str�ct�re is not intended or offered for sale(Secfion ��4L1TY - �-�� � ' 7044,Business ond Pro(essions Coda). MOVING TEL . � I,as owner of the property,am extlusively tontracting NTRACTOR No. .... .. ,,��' I f�� wilh licensed coNractors to conslruct the proiect(Sec- ADDRE55 � � ` � ' tion 7044,Business and Professions Coda). - __._ .,_ _.. � �. . . . RE�UIRED TOTAL SEiBAIX FROM EXIST., CONSTRUCTION IENDING AGENCY� ser encK YARD Hwv PROP.LWE wiorH , � �': .1 here6y affirm lhat there is a cons�ruclion lending agancy for . FeONT � •� � - � - � � ��- the performance of the work for whith this permit ii isiued ' P.L� � � � � � 2$CC.3097.CiV.C.J.... . , : SIOE ' . • .' • . � . .� .. . .�. . .... .'P.L. '..... ._ ,.• . ::_' . . .__..; :-.��. ..�-� _._ .. , . . . . . ... Lender's Neme � . ��. .. . � � . � .. . . . ;. : . . . . . /7 _... ._- �.ts-�7. Lender's Address � - - - P.C.Fee E L� � � Permit Fee � - . I tertify that I have read this applicalion and stale that the �- � I:suonce Fee � . obove information is mrrect.I agrea to comply with oll Coonty Invesrqaron fee � . ordinonces and Slate laws relming fo building construction, � � � � � ���'' � �� � �-' �� - - Toral Fee � �� e rapresantmives of this Counry to enter - . upo hereb�aurhor',y'.Q ed propeny for inspaction pvrposes. - � - � � -- - � - -� �� ���- --�- - -� � �� � �� � Y I . y{- ��� SEE REYERSE FOR EXPLANATORY LANGUAGE _ __ _�_ _ . , . . , , Signalure of AppllMnl or Agenl pole - ' . . . ..�t � � _ - - � ° � ^._. _ . ' , r" C� P �' � I ,' N ,n�p m � l9 ..- `.O.. 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