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HomeMy WebLinkAbout1318A WORKERS'COMPENSATION DECIARATION . 5j ` insurebor�a{certifcatteofWorken'rCompensatonlnsurane'f : APPLICATION FOR BUILDING �PERMIT �s or a cerrif�ed copy thereof(Sec.3800,La6.C.) COUNTY_OF LOS ANGELES _ BUILDING AND SAFETY PolicyNo. Company BUIIDiNG_. D�� , � Certified copy is herehy farnished. FOR APPLICANT TO FILL IN aooae55 �� .� lJ p� � Certified copy is filed wi�h�ha co�nty building inspec• BUitDiNG �J zG �� �_ . / tion department. . ADDRE55 N� ,/J j� - LOCALIN .U�•� Da1e Applicant _ CiN J . � Ziv �r C O55 9i. - � -'-'�� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BloGS. ASSESSOR COMPENSATION INSURANCE SRE OF LOT NOW ON l0T MAP BOOK PAGE PARCEt (ihis section need not be completed if the permit is Tor one u5e ZOrvE �+P hundred dollars(SI00)or less.) TRACT BLOCK LOT NO. . �� NO. -� ' - - TEt.` � . . . SPECIAL Y I certify thot in the performonce of�he work for which this OWNER Qy� O NCY' �� CONDITIONS d . .� , 1 , . . .... ..... DISTRIC7 GBOUP 7YPE FIRE PROCESSED BY O permil is issued,I shall not employ ony person in any monner ADDRE55 �)�� W a��r�+ J�� 1 CONSi. ZONE V so os to bemme sub�ect to the Worken'Compense�ion tows. . . � �,n � � z�P `laa 3 tn /� 6 � o Db10 ' Appli[ant ' STATISTI[ALClA551FICATION APi. CONDO. F� NOTICE TO APPLICANTi If, after moking Ihis Certificafe of ARC iTEROR TEL. _ . V • �E.emplion, you should become su6je[t to the Worken' ENGir�IEER � � � � -NO. C1A55 NO.�DWEII.UNiTS a Compensation provisians of the Lobor Code,you must forth- ' qpDeE55 --�� � �- - � � SEwert l.u+P � with comply with such provisions or this permil shall be = F iE�' � VAtIDATION deemed revoked. � . CONTRAC70R C NO. BK. � PG, LICENSEDCONTRACTORSDECLARATION � �� ' "� {QNO. y�D���7 I hereby aHirm that I am Iicensed under provisians oi Chapter 9 ADDkESS VALUATION � (commencing with Setlion 7000)of Division 3 of the Business and LIC. � Professions Code,and my license is in full force and effetl. CitY �.a { Ctq55 E , . � � � 50.Ff. NO.OF NO.OF CHECK License Number lic.Class � SIZE STORIES FAMILIES ONE ' . . . _. . N� O S . DES[RIPTION OF WORK ; Controttor Date � . Q I am eaempt under See. - . �111 f�.� ADD � � . AITER � FINAL . B.BP.C.for fhis reason � 1+ I al� REPAIR ❑ D NAL - � - R� 3�.$'A USE OF ` Data: E%ISTING BtDG. G�� �76� �, ._ . DEMOI ❑ B , . Sfgnature . . AVRI�UMT Cl h�+ lhl� [l. h '`/.,•.,� y �• • • •2�J OWNER-BUILDER DECLARATION f,� ) �`r� � _ f� ' I here6y affirm thot I om exempt irom tha Contractor's licensa pDDRE55 ✓v r � L.�i�v ( • •3 Q D 0 law for the fol�owing reason(Seclion 7031.5,Business and � �� � , � � f1' • ' _ /' • • •3Q00� PfoTBS3i0I13 COdBJ: PRE ENT n , ❑ � � � 9UILDING (/�y� ,1 ' � I, os owner of fhe proper}y:or my employees-with ADDRE55 - - --...---�-----�-----.___._.__._.___ l' �E�� 0 1.3 1 —a-4 � woges as their sole tompensation,will do the work and �1� �� � . Iha sirocWre is not iMended or ofiered for sale(Section . ��`��TY . . V. .✓- . 7044,Buziness and Professions Code). MOViNG TEL _ �� � 1,os owner of the property,am exdusively confratting . C NTRA�TOR NO. _ wilh Iicensed conlrocfon fo construct the pro�ecf(Sec- qDDRE55 tlon 70A4,Business and Profassfons Code). � .. „, _ . � �I REOUIRED TOTAL SETeAIX FROM EXIST. � �• � CONSTRUCTION IENDING AGENCY - , sei enCK YARD HVJY pROP.LINE wiDTti , . .._,I i�^• ' Iherebyaffirmthotthereisaconstruttionlending�6gentyfor _ppONt � � -� - � "' ' � � - - - the performante bf tha work.(or which this permit ii issoed - P.L - - t5ec.3097,G�.C.)..� � � . � � , �sioe � � , � .� . . . ' � f _ . ' - . � . �P.L. � ' - . i�. . m Lender's Nama � . . . . � � � � � ��•.� � . . . .,. _ �.. � i -� ; � . � .. ._..... ......._. .._.. _. -�_ . _. _.� . $ - � � � � P.G Fee S �a. � � Permit Fee `� Lender's Address , � 1 certify Ihot I have read Ihis appiication ond s�ota thot iha � � issuance F�e . a above information is mrrect.I agree ro comply with all County � i�„�si�qanon Fee � ordinances and Stafe laws relating to building construction, -- - - -' �-� �� � �- "�-� �� -" � � � �� ' � � ond heraby outhoriza represamatives of this Counry ro enter � . Toral Fee � upon 1he above-meMioned property for inspection purposee. i � - �- - � . , � ! SEE REVERSE FOR EXPIANATORY LANGUAGE . _ .. . . . . . . . . .. _ . . � Slgnorure of Appliconl or Agem . � puee � . . . ..�� � mT (�= r r m -n (n T NO ... 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