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HomeMy WebLinkAbout1327A 2191A WORKERS'COMPENSATION DEC�ARATION 11 incure6or7ifcertifhmtteofWorkersrtCompensaion��5�:a�a'f APPLICATION F4R BUILDING PEitMIT L� or a cerlified mpy ihereof(Sec.3800,La6.C.) ;i �� COUNTY OF LOS ANGELES BUILDING AN�SAFETY P❑olicyNo. Company .� J �Q p Certified co F�R APPLICANT TO FILL IN ADDRESS py is hereby fumished. / � .�'��^+-�^'�f u'"`•�• � Cerfified copy is filed with the counly building inspec- �} BUiLDING :.- /�� �M �9y7 � tion depafimeni. ��� ADDRE55 '�1r1.. [.YP.�•,' /o LOCAi1TY ` '-�� j; �' ,Y� NEAREST Date Applimnt :��, CITY ��/�i ZIP CRO55 57. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF s�o�5. ASSESSOR COMPENSATION INSURANCE ' SIZE OF LOT NOW ON LOT MAP BOQK PAGE PARCEL (This section need not be completed it ihe petmit is for one t USE ZONE MAP ) ;� hundred dollars($100)or less.) �, TRA�T B���K �OT NO. NO. /�'��� ��Jr(„Ej" TEL �"� SFECIAL ?^ I certif that in the erformance of the work for which this - �wNER 7P NO. CONDiTIONS � y p p14RICT GROIJP TVPE FlRE PROCESSED BV G permit is issued,I shall not empby y person in ony anner - / � CONST. Zqq� � � ADDRESS �7� so as to heg6me s ject to the W ers'Comp w� aws. . .7 (� •�! u � � ' :' CITY � ' ZIP [;.�� , d � Date App�iC TEL STATISTICP.L CLASSIFICATION APT. CO O. � ARCNITECT OR NOTIC TO A L ANT: If, , te making this Certificale of ; FNr.iNEca ' S5 J"v. o��) uweu.uNnS_ - n� °��g;p;;ary yov ciiuu u ' �come suojeci ro �ne riorKerS � - �- � Compensation provisions of the Labor Code,you must forth- �� qDDRE55 SEWee rnaa � with comply with s�ch provisions or this permit sholl be TE� "' deemed revoked. ' CONTRACT � � .(l�NO. BK. PG, VAUDA710N LICENSED CONTRACTORS DECLARATION `. }� ,,q' uC. I hereby affirm ihat I am licensed under provisions of Chapter 9 �� ADDRE55� � �.C.�' `,✓� �7n-�NO. VALUATION t'� ?,�7� (commencing wiih Section 7000)of Divisiod 3 of�he Business and i ' . p�,I�� uc. - Professions Code,and my license is in full force and effetl. � CITV . r ✓� CLA5S 5 � , �p �, i; o�i. � - SQ.f7. NO.OF� NO.Oi CHECK f�0%1 License Number Liu Class SIZE � STORIES FAMILIES ONE g � o a.�9,�G �r DESCRIPTION OF WORK ���9 NEW � � � a � 1 Confracfor Date � ADD �:$ �`'�'�.':l:` �I am exempt under Sec. � �� � ALTER � FINAL � . ' / ,� O DATE . i�r !� U i��t"'t�cS B.&P.C.for this reason � REPAIR Date: � ' U5e oF � - �� oEMOt � FINAL � � , ' EXISTMG BIDG. \ BY � Signafure � APPLICANT.� .. - TEL � . � ' � OWNER-BUILOER DECLARATION PRINi No. _ I hereby affirm that I am exzmpt from the ConPracPor's License �� qDDRE55 /r/ � '�, Law for fhe following reason(Setlion 7031.5, Business and -�� � i � P fessiOns Code): � . PRESENT- � -BUILDING j , .,,� 'j/� a'",2f'� pd� I, as owner of fhe�property, or my employees with A9DRE55 j7 a e u o � � wages as their sale compensation,will do the work and the structure is no�fntended or offered for wle(Section �OCAIITY J � ti fi U,�r� 7044,Business ond Professions Code). MOVING TEL. � I,as owner of the property,am exclusively confracting CONTRACTOR NO. ti �, t�,�r�l�` with licensed tonirociors io mnstruct the project(Seo- qpDRESS fion 7044,Business and Professions Code). ��i S':i J-"�J REOUIREO YARD HWY TOTAL SETBAGK FROM EXIST. CONSTRUCTION LENDING AGENCY SET eaCK PROe.uNE WiDTH , I hereby afFirm ihat ihere is a consiruction lending agency for FpON7 fhe performance of Ihe work for whicb ihis permit is issued P.�. ZSec.3097,Civ.C.). 51DE P.L. � Lender's Name �—^�� /^� � P.C.Fee$ a� r�l (J Permit Fee /�-Uy Lender's Address � 1 cenify�hot I fiave read this application ond state that ihe Ism ce Fee �4',� ¢ above information is correct.I agree to mmply wiih all County Invesiigo+ion Pee an g ordinonces aad Stafe laws relating to building construction, Total Fee ��"�� i"i and reby authorize iep sentatives.of ihis Co roy to enter � up ihe above-m tiQn roperty for inspazJ' n pur oses. � � I ,�y SEE REVERSE FOR EXPLANATORY LANGUAGE 9s Signaiure ot Appiican�or Agenr � ate ' _ �' �n w..� G s ��,p�'',-� s� w;Z;� � j..�.',c: ?"w-i��s s 1 : tI r . . .� � �.�u o o � ^ a ro . I . .... , .� .. � w � - � � . ! � f , V i-` ,-.-,; w ^U`'`''n z 'n C 3 1� u �e.',�..�;.�' y `. c` ,� y-,U o I + - � I . j . 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