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HomeMy WebLinkAbout1818A 1819A (19) I � WORKERS'COMPENSATION DECLARATION �� . I hereby affirm ihat I have a certifiwte o,consent,0 5a�f � APPLICATION FOR BUILDING PERMIT insure,or a certificate of Workers'Compensation Insurante, or a certifed copy thereof(Sec 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolityNo. Company � Ui��T' M� �`3� � Certified mpy is hereby fu�nished. FOR APPLICANT TO FILL IN gUILDING t q. :� ._ ,�`�L, ,�` ADDRESS ��� � Certified copy is filed with fhe county�building inspec- BUILDING y . tion deparfinent. ADDRESS � ry,r� / LOCALITY y�i(yirv�,C;��:y7�. Dafe_��,"tl T' A li[ant - CITY Z�P ` NEAREST �"� PP I a CRO55 ST. c:a�v�cvyrc' CERTIFICATE OF EXEMPTIO FR M WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON lOT MAP BOOK PAGE PARCEL (This section need not be completed if ihe permi}is for one USE ZONE MAP hundred dO�lprs($100)or less.) TRACT eLOIX LOT NO. NO. �L� "'�; TEL. SPECIAL I certify ihat in the performance of the work for which this � OwNER � � �'J�+ �'�� CONDI710NS FL. permit is issued,I shall not employ ony person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY '+.d -so as to become subject to the Workers'Com ensmion Laws - ADDRE55 ° �� CONST. ZONE F� Dafe�• �.� 1"�� A licanf �r� ` .% CI7V � ../ � ZIP �.: G� `'Q � � PP �� ARCHITEC70R TEL STATISTICALCLASSIFICATION • qp7. CONDD. �% NOTICE TO-APPIICANT: If, after ing this Certificate of� � ,� �� FN(.INFFR Ntl �7_ �'el1)NiiUil, yUu SnOUiO OECOTE SIID�ECI IO �i12 WOfkQ�S' - — ����—� Compensation provisions of the Labor Code,you must for�h- , AODRE55 �IVv - '��� SEWER MAP with comply with such provisions or ihis permit sholl be `X; deemed revoked. rEL.�; VALIDATION � 1 COMRAQOR Np. . � _ BK. PG, LICENSED CONTRACTORS DECLARATION i�� I hereby affirm thm I am licensed under pro�visions of Chapter 9 ; ADDRES � NO. VALUATION � �'1 8 1.H A (commencing wifh Se[Iion 7000)of Division 3 of fhe Business and �� �_ •� - Professions Code,and.my license is in full force and effect � QTY C A55 S���j.��' �� � o n J?,. License Number Lic.Class ' �"FT. NO.OF NO.OF CHECK , � �L 9 4 � SIZE STORIES FAMIUES ONE � ¢ a��", CoMfatto� � Date OESCRIPTION OF WORK - � NEW � $ b W v/,9��U ❑I am exempt onder Sec. ,O )"'' • 6qJ Ao� � j c AITER � FINAL ,�; � 'D� -�� B.&P.C.for fhis reason REPAIR � DATE M1���1�� Date: � USE Of FINAL � � E%ISTING BLOG. � �EMOL ❑ '/� Signafure - APPLICANT TEL. J �l BY �y i`. Z�'"��� OWNER-BUILDER DECLARATION PRINi) /�(,� NO. � ' p� � I here6y cffirm ihat I am ezempt from the Cororactor's License A,n C , Law for the following reason(Section 7031.5,Bosiness and ADDRE55 ,� /F� ✓� Professions Code): NT - ❑ BUILDING q � �� o� �n I, os owner of ihe property, or my employees wi�h ADDRESS / � �� wages as their sole compensation,will do the wo�k and , J ihe structure is not iMended or offered far sale(Section ����TY �' P �m � � o m`� 7044,Business and Professions Code). � MOVING TEL. � I,as owner of the ro ert am exclusivel contmctin CONTRACTOR NO. P P Y, Y 9 � a '�t!1,2�j wifh litensed contracfors ro consirucf fhe project(Seo- qDDRE55 tion 7044,Business�and Professions Code). , �, E �4 y,G cJ� �REQUIRED TO7AL SETBACK PROM EXIST. CONSTRUCTION LENDING AGENCY �SET BnCK YARD HWY pgoP.LWE wIDTH , ��U� ,,,8� I hereby affirm that there is a consiruction lending agency for peONi �the performance of the work for which this permit is issued � p.L. � tSec.3097,Civ.C.).. � - � . - , . � . . �SIDE � . .. .. � . . - � � . - . � � � - P.L. . . . . . . . . lender's Name - - - � `� P.C:Fee$ ���.-x (� Permit Fee � a Lender's Address `.�a E%c �� i I ceNify that I have read this applicafion and state ihat the Issuance Fee j 1;,,,�G � above informafion is<orrect.I agree to comply with all County Inves�igaiion Fee ordinances and State laws relating to building consirut�ion, To�al Fee .�� - - � ond hereby authorize representatives of this Co�nty to enfer a upon th abov mentione propeny for inspection purposes. . a SEE REVERSE FOR EXPLANATORY LANGUAGE j n ignature of Applicanr ar Age s'� . , �s '"uy .: � "' ' G �.:" . s U C 4 �`ti � � ^ �ti J :^ .� f � � _.. . ` � �';, � . 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