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HomeMy WebLinkAbout1053A 1543A (9) WORKER$'COMPENSATION DECLARATION I V Y��� �\�`�( � � I he�eby af(irm thot I have a cerfificate of�o�se�„e se�f � APPLICATION �FOR BUILDING- PERMIT insure,or a certifico�e of Workers'Compensation Insurance, i � or a certified copy thereof(Set.3800,Lob.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY PolicyNo. Comp�ny - BWLDING � Certified copy Is hereby f�rnished. FOR APPLICANT•TO FILL IN ADDRESS 7 � Certified topy Is fited wilh tha monry bollding inspec- BUiL�ING - ^- tion departmenl. . . ADDRESS ��.. ��• LOCALITV l�� �J6.1C . � NEAREST , Dota Applicant „ Cltt �4..v�^•O ZIP CROSSST. � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF etDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF l0T NOw ON�OT M.4P BOOK PAGE PARCEL (This setlion need not be comple�ed if�ha permit is for one u5E ZONe /�+v+P _! hundred dollars(SI00)or Iess.J TRAR 8�0[K LOT NO. NO. III�" �+�' / \ � TEL SPECIAL 0. �certif that in the performance of tha work for which this OWNER }(� NO. �� CONDITIONS y DISTRICT GROUP TYPE FIRE PROCESSED BY O permil is issued,I shvll not employ any person in any manner ' CONST. 20NE� . so as to become subject lo the Workers'Ca ens6tion Laws. a��RESS L. � � � � / � � CITY Z�P Daie - APPII[an� ' l � '. � . � , .. . STATISTICAlCLlSSIFICATION , _ - APT. CONDO. O NOTICE TO APPLIGINT: If, ofrer� king thls Cefti{i[a1B'OI � ARCHITECT OR'� -�- \ ` ' �TE�1 � ��' - � � W Exemption, you shouid-become� �ecl�do the Worken' � ENGMEER':.�'C ' � �OV�'. ��- ��NO. �•OZ. � :�L4$5 NO. `�a�- DWEII.LNITS_ a Compensation provisions of the Labor Code,you must forth- �, ADDRE55��-\ � ' - �� \ � SEwER MAP � with comply with such provisions or this permit sholl be ._. E�, � = deemed revoked. � � � tONTanCTOR ' ,r.t�1 C� -1. � NO. � � � BK•� --�. � VAIIDATION LICENSED CONTRACTORS DECtARATION � uC. I hereby affirm that I am licensed under pravisioni oi Chapter 9 t AD�RE55 NO. VAWATION ' . (commendng with Seclion 7000)of Divislon 3 of the 8usiness ond LIC. � �. Professions Code,and my license is in foll force and effect. . QTV C1A55 s Q� S . �1 0 5 3 A . ' - - � SO.FT, NO.OF NO.OF CHECK . ' Licensa Number� � Lit.Class ' S12E STORIES FAMILIES ONE �_� � • •2.3 � DESCRIPTION OF WORK N� ❑ 5 I • � � I�9�1 Contractar Dala ADD � � �i am ezempi under Set. , ALTER � FINAL � �•.• � � �'9 4� �����i.� DATE - B.BP.C.for this reason � REPAIR ❑ � � �.� 7�8 4� - Da1e: i USE OF `(� p��� � FINAL � � - � � E%ISTING BLDG. �F�l'iL ���' By F� � � Signature �-`1 . ' APPIICANT TEL.-��L\ . . O N R•BUILDER DECLARATION . �, PRiM NO. -pZ �`�;� ,lLf�, 4\ ��K. � � �.�. A�.. I heraby aifirm tha am ezempl from�he Contractor's Ucensa i � �.�+ .. Law for tha following reason(Section 7031.5,Busfness and ADDRESS w � �/ n�1`���� � ProfesslansCode): . � " � �i� �hUF_C- `�I3S�4Y• °� _ Q . � BUILDING Q i, as owner of�ha properry, or my employees with , no�RE55 wages as iheir sole tompensation,will do the work and tha structure is nol imended or offered for sale(Section ����TY - - 70E4,Business and Professions Code). i MOVING TE�• - � � I,as owner of the properly,am ezduslvely conlracting C NTRACTOR No. .. . �� 5 4.3 A- with litensed con�ractors to constrvd the projett(Sec- I ADDRE55 • •�, tlon 70<4,Business ond Professions Cade). -- -� ��� � � REOUIRED TOTAL SETBACK FkOM EXIST. CONSTRUCTION LENDING AGENCV � i SET BnCK �AR� FN�Y PROP.IINE WIDTH , . . .� •1 4 9.2 5 I here6y affirm thof fhere is a cons�r�ction lending ogency for I FRONT ' � �� I �tha performance of tha work for which this permit is issued � P.L • 1 4 9.2 5� (Sec.3097,Civ.C.). SIDF . � � ' � P.�. , 0214-84 m Lender's Nome� �1'n L ( � � � � � � P.C.Fea f' Permi�Fee ��Jy IJ� ' � lender's Address .. . � I certify�hat I have read this opplica�ion and state that�ha - tssuo ro Fee � � ✓�� � obove informaFlon is correct.1 agree to tomply with all Covny Investlgo�ion Fea . .. . . ordinonces and Stata lows relating fo bvflding consfruclian, Torol F�e 9. zr � ty ond hereby outharize representarives of this County to enter � � upon he above-menPone roperty for Inspection pvrposes. � . � � � - � � �,� � - SEE REVERSE FOR EXPLANATORY LANGUAGE . � Signature of AOPlicont or Agent Do�e � � ' �� m T (�= r r rn �t y -� > > o o ° o �� o a � m o n o na �T m � � '-' �- -� --r-- ---- - ...i o` o �o ' c �- T .3 �. ..7 0 .Jc" ° te � [L 0 � o p � i I � � • .. I n f�7 � � � � •R fl C�] ' `J' '0 i n 7.�•1 .��'U n- t� I ° Z r^ m� �� , . .� n � �' ,o o., p ° J � 7- I � ' � x ,� _ �'� r, L'l. . 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