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HomeMy WebLinkAbout1726A 1883A (17) � WORKERS'COMPENSATION DECLARATION insurebaraafcertifcatteofWakersr'Compensatioolnsurancef �� APPLICATION� FOR BUILDING PERMIT � or a certified copy thereof(Sec 3800,tab.C.) - '� ` CpUNTY OF LOS ANGELES BUILDING AND SAFETY V�olicy No. .c+7.J 6 Company ��� � � Certiiied copy is here6y furnished. � FOR APPLICANT TO FILL IN noosess � Cenified copy is filed with the county building inspeo- BUILDING � fion dBpartmeht. - ADDRE55 �� �� LOCALITY /'QN1(J �.�l lA�.�. NEAREST Date ApplicaM .� CITY f�f�7��/�C� ZIP CRO55 ST. � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. A55ESSOR COMPENSATION INSURANCE `� SIZE OF LOT NOW ON LOT MAP e00K PAGE PARCEL (This section need not be-compleied if the permit is for one use ZONe MAP hundred dollars($ioo)or less.) rencr aiocK LO?NO. NO. - /+ �" �y�� TEL SPECIAL - I rerfify fhat in ihe performance of the work for which fhis � OWNER e,`.p (TQi �W/�t'� NO. CON�ITIONS �- � `� �� fj � �iSTRIC7 P TYPE FIRE PROCESSF � permit is issued,I shall not employ any person in any manner i AODRE55 S ` 0( �,/ ST. ZONE � 1 4-i so as ro become subject to the Workers Compensation Laws. / ZiP `� � ���� U t ' arr �Q+�Jsta��Gr Date Applicani STATISTICAL CLASS�FIG4TION APT. C N . t� NOTICE TO APPLICANT: If, after making this Certifiwte Of ; FNRNIFFpTOR �E^. .-�.-1 Ex.e.mp!?o.^. .. ---- uje me Workers' — CIASS NO. (,��DWELL.UN775_ ^ Com ensation rovisions of ihe�Lobor Code,�ou must forth- �'Z �` /� �3 P P y �� A�DRE55 V(w 'es� Pc CT SEWERMAP winc �omply with such provisions or this permit shall ba �} � deemed revoked. . rq�j st7y✓d NO..lff (t gK. p�, VRLIDATION �� CONTRAQOR LICENSED CONTRACiORS DECLARATION i ���. I hereby affirm ihat I am licensed under provisions of Chapter 9 A�DRE55 Qt�9t-'f" NO. ' yAj.0 TION (commencing ith Section 7000)of Divisio�t 3 of the Business and LIC. j /1� � Professions Code,and my license is in full force and effect. �� ciiv CLa55 c� § 1 t< ,F� ��L�h A C� ' Sq.FT. NO.OF NO.OF CHECK ► License Num6er ��� Lia Closs � SIZE STORIES FAMILIES ONE � �e o� u 2� ConifOc�ol Dofe � � OESCRIPTION OF WORK � Q Q . (• A D � � m �C�.�:C �I am exempf under Sec. ALTER � FINAL � `�t��,(i� DATE B.&P.C.for ihis reason REPAIR � �2�G s��� � USE OF fINAL � Dafe: � EXISTING gLD6. �EMOL ❑ �� Signatore �� APPUCANT TEL. BY ""' OWNER-OUILDER DECLARATION PRINT) NO. I hereby offirm that I am exempf from ihe Confracfor's License Law for the�following reason(Section 7031.5,Business ond ' ADDRESS � ProfessiOns Cod9): � PRESENT ❑ . �BUILDING I, as owner of ihe property, or my employees with � ADDRE55 °1 8 3,3 A wages as their sole compensation,will do the work ond - the strucfure is not in�ended or offered for sale(Section � LOCALITY �,� a o�� �,� 7044,Business and Professions Code). - MOVING TEL � . ❑ C NTRACTOR NO. I,as owner of fhe properfy,am exclusively rontracting �( � a j(a'�5 with licensed coniraUors 10 consiruct the project(Seo- qDDRf55 tion 7044,Business ond Professions Code). • • e J t�7 J cai CONSTRUCTION LENDING AGENCY . RE4uikED SOTAL SfTeACK FROM exisi. � SET BACK YARD HWY PROP.LINE W�D7H I hereby affirm fhaf thare is a consiruction lending ogenty for. � � FRONT � , �3,�2�8� the performance�of the work for which this permit is issued � P.L. (Sec.3097,Civ.C.).. � . . ' � . SIOE � � � � . - � � . . . . , . . . � P:l . - ' � . ' '. . . m Lender's Name � � - � � Lender's Address P.C.Fee S ���� Permit Fee �� .(.fj � I certify that I hove read this applicalian and stafe}haf the � Isauance Fee �( -...S��� � a6ove information is correct.I agree to mmply wifh oll County Inves�iga�ion Fee $ ordinances and State laws relating-to building construction, Totai Fee „� , �,.j� and hereby au�horize r presentatives of this CovMy�o enter . m upon�h above- e ti ed operty for inspection purposes. � a � . .� . SEE REVERSE FOR EXPIANATORY LANGUACsE . � � ign ure of Appli<anl or Agent� Oore , - --�� � i }- `, ' � � '► � � ; � .�:� � � s , ► ° � � . ��: � �� y�� M� o �:: w.� � � ,F � � I , , � ��,. = .n;;-. ,`� x w ci � ,s.�'6' »,�,-� �� �� N��� c G � O � ¢°. `q,� U �. � I � I �� ^ y . G r;fP. . '_'l J� J .i n. w�N V � V � . 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