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HomeMy WebLinkAbout1405A 1887A WORKERS'COMPENSATION DECLARATION �rGY insureborafcertifcateofWorkes'��Compensationlnsurancef � /"����'�Y1�i-�N FOR BUILDING PERMIT �S or a certified copy ihereof(Sec.3800,Lab.�C.) PolicyNo���ry3� Company5�'�f�f v� COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified co is hareb fumished. L 6UILDING ❑ Pv' v POR APPLICANT TO FILL IN ADDRESS 'S 4��»Km(�u�l �� � Certified copy is filed with.the county building inspec- BUILDING r y r ,,) / tion deparfinent. ADDRE55 �-j 1�C�O✓:/� 3��'��c LOCALITY � I�r"��✓'�n �9�% F^ " NEAREST / Dote��f`"I���� APPlicant���(�k��� : CITv rQ�Y - �� �G�� ZIP CROSSST. G"r�.✓!�l CERTIFICATE OF EXEMPTlON fROM WORKERS' NO.OF B�CGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if ihe permit is for one USE ZONE MAP hundred dolla�s($100)or less.) � TRAC7 aLOCK �Oi NO. NO. TEL SPEGAL ;m I certify ihat in the performance of the work for which ihis OWNER ' = F ` NO. CONDITIONS C} permit is issued,I shdll not employ any person in any manner / 1 DISTRICT GROUP TYPE FIRE PROCESSED BY 1,.. 1 AD�RESS � �� �0�!�^�� �5�� �JI L'?� CON3f. ZONE � so as to become s�bjeci lo fhe Workers'Compensofion Lows. � 1` f/� �„ . � . - CITY �.1j k-r�l(k. , q-C/� ZIP . (` .� c<.I..Gi � OaPe Appliwnt - . � � � . SiA715TICAL CLASSIFICATION APT. CONDO. im NOTICE i0 APPLICANT: If, after-moking��fhis Certificate�of ' PRCNiTECT oR�� � � � . TEI: _ ..:.. . - :i empiiun, you snouici oecome subject�fo the Worker5� _, -CLA55 KO. �'� DWELL.�UNIiS_ " _.:... _. �5. Compensation provisions of Ihe Labor Code,you must forth- ,. qDORE55 � - � - � SEWER MAP �'� with comply wi�h such prvvisions or this permit shall be � � � � �� � deemed revoked. � J�J t� TE�"J p� � BK. PG, VALIDATION ": CONTRACTOR . G-%4,17�E' I'/ .t�//r NO. / '�Yj - - IICENSED CONTRACTORS DECLARATION �i�J) �ff�`�✓'� �uc �- I hereby affirm ihot I am licensed u der provisions of Chapter 9 � ��� ADDRES r 7 f NO. ,� VALUATION (commencing with Secfion 700�)oi D vision 3 of the Business and . ��� t� / Professions Cade,and my license is in full force and effetl. C�7Y �'�����A�-� Cta,SS �7 C 5 �`7 (� , 4� r=f L CL J�(� „[._J t y�' �L%[ ^; SG1.Fi. NO.OF NO.OF CHECK }.� o 0 0'�`� License Num6er r � � �J� Lic.Class �� F SIZE STORIES FAMILIE$ ONE � n ,2 5,0 0 S� � J � �-rC�"� �� DESCRIPTION OF WORK C�(ii�✓��f I. t'(%�1 S// NEW � b Confractor����!7��r'C) fT/ Dafe�� � � r•c:�J,G(j�� �I am eXem f under$ec. ADD O p A�TER � FINALr ��.C ����d ❑ DATE d ��e B.BP.C.for ihis reason 2EPAIR Dafe: : USE OF DEMOL FINAL - � EXISTMG BLOG. ❑ BY ,.,� . Signature . . APPL�CANT�y q� TEL. OWNER-BUILDERDECLARATION PRINT ) Cv�7�: '+"�d/�yC No. 1 hereby affirm Iho�I om ezempt from ihe Contraclor's License , Law for fha Following reoson(Section 7031.5,8usiness and ADDRE55 Professions Cade): NT Q �BUILDING I, as owner of the property, or my employees with q�oRess wages as their sole compensation,will do the work and � � �� �g,�p ihe structure is not intended or offered for sale(Secfion LOCALI7Y 7044,Business and Professions Code). MOVING TEL 'fi7 a e m e m� � I,as owner of the-properfy,am exclusively contracting CONiRAc7oR NO, with licensed mntroctors to mnstrud the project(Sec- qpoRESS � � g`�V'�O fion 7044,Business and Professions Code�. REQUIRED TOTAL SETBACK FROM EXIST. o re CONSTRUCTION IENDING AGENCY - SET BACK YARD HWv PROP.LME W��TH , "�J C•J�O o I hereby aFfirm fhaf there is a construc�ion lending agenq for FRONT O 7Z O 2�8� the performance of the work for whith ihis permit is issued P.i. (Sec.3097,Civ.C.). SIDE v.�. Lender's Name - � � ca�t� $ Lender's Address � P.C.fee$ �.5 ^ �� Permii Fee d�/ I certify that I hove read�his opplicotion and state thai ihe issu ce Fee f C�• J ✓ � obove informmion is correa.I agree b comply with,all Coumy Iovesrgouon Fee an , ordinonces and State laws relating to building mnstruction, taal cee �S'�'� �a and hereby au�horize represen�atives of�his CouMy to enter � m upon the a.o e- entioned property for inspection purposes. � a f ,'E�` ����t, /��� t" SEE REVERSE FOR EXPLANATORY LANGUAGE .�� . Signalore of Applicant or Agent Date . � � �s i; �, � � � E � I � �. N'+n V� W : " � S�`..^�,1''^��'1 L C V' y�3 O �W�"� ^ L. `S: �^ -•�- I �' I S � . ` �. O._ ;; :„ C..,. CN w °�"y O p �. �•e. :C'.�`1 V.. � � I i ' �' I � � � " �! 0 0 ��'°'a� ,;�;'" }"��v n 3 X i.�,� y W� �= � � � <- � �, a. ,. ° � �� y'� a"� y u''-1 C � u � . "c> � u a� i•'� . i i ! � I�. a, i � .M�. ��„ "''`� �: cu o U � a � a� C, i . .. o � 'ao :r,� �: ca - � 3c�• r �� ��oo �w �: i�'. 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