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HomeMy WebLinkAbout1208A 1209A (22) WORKERS'COMPENSATION DECLARATION � ! hereby pffirm that I hove a cerfifiwte of consent to self APPLICATION FOR BUILDING PERMIT �� ir„ure,ti,'��certificate of Workers'Compensotion Insuronce, Li � J c�a certified mpy theieof(Sec.3800,�ob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � PolicyNo. Company � Certified copy is he�eby furnished. POR APPLICANT TO FILL IN euuowG 1� ST ��•���. �� ADDRE55 r � Certified copy is filed wilh ihe couNy 6uilding insper BUILDING �7 nw, �J/ S / tiondepartmanf. ADDRE55 �j�� �. /`yi�J�j1 � '7l.,� � ,�J✓`•� Dote Applicnnt CITY �_ �a�A �� ZIP ��C� LOCAtITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS Si. (This section need not be compleled if fhe permif is for one 7Rn[T eLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars�$100)or less.) TEL C`7(�y) USE ZONE �P / ' I cenify tho�in the performonce of�he work for which this o`�'�NER �—C 0`� �,�� NO. NO. I{�—�. permit is issued,I sholl not employ any person in ony manner � ss fn SPECIAL � so as fo 6e ome subject to the Workers'C�ompensalio Lows. ADDRESS !Bl S"v rr���(( �r � `�'P� CONDITIONS Cj ':� .� �a. .� .. arv d%t Ni � zia )�',I� � �ate Applican NOTIC TO APPLICANT: If, a `makp(g Ihis erfificate of ARCHITEGTOR TEL DISTRICT GROUP NPE FIRE PROCESSED BY C7 ENGINEER NO. Ezemption, you should beco (iject to the Workers' ) CANST; ZONE � Compensation provisions of ihe La6or Code,you must forth• qODRE55�� U � , l��� G•` � �'�� I� iv �'"'� with comply wiih such pravisions or this permit shall 6e TEL. STATISTICAL C1A551FICATI APT. ONDO. a deemed revoked. CONTRACTOR - $� S� M NO. .� � LICENSED CON7RACTORS DECLARATION _���,�'._. _ CLA55 NO. DWELL UMITS � I hereby affirm thal I om licensed under provisions of Chapter 9 aDDRE55 "�. /Cr'J n10. (tommencing with Seclion 700D)of�ivision 3 of fhe Businessand � ��� SEWER MAP Professions Coda,and my license is in full force and effect. CITY L. G�i .��'of 'QP,SS BK � VALIDA7ION � ¢ (/,� !�c� SO.fT.ry�i� NO.OF NO.OF CHECK License Number � �'Zo/ Lic.Class `^� `"t � SIZE 04 STORIES FAMIUES ONE � �1 VALUATIQ N [�e,1���'�� GantmUor. �" ate � OESCRIPTION OF WORK NEW � �(J A--..M � / O s as�' G/ :'� �C,LSH � �r7(.�t I �.Q.�'� S ADD � I am exempt under Sec. AITER � �{o ;� e �� 8.8P.C.for this reason REPAIR � S ` Dale: USE OF �EMOL I a m�5,V i`'; EXISTING BLDG. � SignaPure APPLICANT TEL FINAI o.� `��=:�L��,u: OWNER-BUILDER DECLARATION PRiNi� NO. DATE �—�_�� �,�_ ,� . I hereby affiem that I am exempt from the Cantracror's License �'���� t;�:� Low for the following reason($ettion 7031.5,Business and ADDRE55 FINAL ,�1 ' � Professions Code): E eNi � BY "��+� BUILDING � I, os owner of Ihe property, or my employees with . ADORE55^ ' wages as iheir sole compensption,wiii ao rne work and ► rhe siructure is not intended or offered for sale(Section LOCALiTv 7044,6usiness and Pro4essions Code). MOVING TE�� . �1 �{�-C�� pI,as owner of the property,am exclusively coNracling CONTRACTOR _NO. �f y , , with litensed contractors to construtt the project(Ser qDDRE55 tion 7044,Business and Professions Code). � .� s����;� CONSTRUCTION IENDING AGENCY SE�BACR �ARO HWY T�TApROPA1�NEFR WIDTH I hereby affirm that there is o construction lending ogenq for FRONT a a�- �-��= �:h i.,,- fhe performance of the work for which this pe�mit is issued P.L. (Sec 3097,Civ.C.). SIDE Q�,��j���F. P.L. Lender's Name ✓J�.,, ^l q� LDMA Ref.# Lender's Address � P�C.Fee g t�:7.L"'p Permit Fee �(o{ , I certify ihat I have read ihis applimtion and state that ihe Isswnce Fee �V*�l V LDMA P/C p above information is torrect.1 agree to comply with all County Invas�igation fee ;p� ordinantes and Stote lows relating to building consiroction, Totol Fee :�47^ �DMA Perm.N ond here6y outhorize representatives of this Co�nty to enter upon ihe above-mentio ed�y�perty for inspecfion pu oses. � {�J¢— � ,� �� SEE REVERSE fOR EXPLANATORY IANGUAGE /��� ature ot Applimnv dr Agent � Date •— — � - ^ i i _ � $ . . . __ _ �. _ � ; � , - � : ' , ( , . ' . w � : : ; ... ; , , . � ; � � � r � _ � � : ,. � . <: .. ; � ._. „ � ' '� ,, . -� ; : , ; : , � _ � ; ' ' � � i.., � l � . ; , .. , . - � � � � - s 1 � � .. , . � -- • �; .. • � �� •, ,.. „ ; � � , . - �- , I � i ( t � i � I i ; � , � � i � � � ; , � �� ,� : ; ' � : � � , ' � j � � j ; � ( � i j i -'��' j ; � �'� � t , � i i , � : , � T--... 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