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HomeMy WebLinkAbout1208A WORKERS'COMPENSATION UECLARATION '} I hereby affirm Ihot I hove o certificate of consent to 5e�t . qppLICATION FQR BIJILDING PERMIT �� insure,or a cerlificate of Workers'Compensation Insurance, or n certi(ied copy the�eof(Sec.3800,lab.C.) � COUN7Y OF LOS ANGELES BUILDING AND SAFETY PolicyNo.����-3�Yi.� Compnny_5�.� �t)'Ywt.7 � Ceriified copy is hereby lurnished. � FOR APPLICANT TO FILL IN d'���u�N" � � ` � ���„ �ry,v�(p �DDRE55 �.a��a:3�, �. Y-'1 Certified copy is filed with the county building inspec- � yUIiUING ,• d r' LJ tion deparlmenl. ADDRE55�..�._-�3L� �. �/[tJ•Y�r�nt� 712i��. LOCAII�Y ��S;,�ij, � �'� ��/�� NEAREST 9ate �, l " � /�PPlicaniG��.�,N��/�( y,sLo� (.'I�Y f.2J�'tbrll�. 71P _�_ CROSSSI. W.W CERTIFICATE OF EXEMPTION FROM WORKERS No.Or uLUGS. As5E55oR COMPEMSATION INSURANCE SILE OF LOT ___ ___ NOW UN LOT MAP BOOiC PAGF PANCEL (This section nend not be completed if fho pennit is for one 7NAC:T BLOCK Ipl NO. USE 70�E OF � � hundred dollars(5100)or less.) l IEL. �) SYICiAL ;s. I certify thot in the pertormance uf the work for which this UWNFR L�.� �^ NO. ��G-�C�.��j � � <T CUNDITIONS � permif is issued,I sholl not employ any person in any manner ,. � .., DISIItICT (,ROl1P iYPE FIRI PROCESSED BY �:,1 so os to becomn subjeci�o the Workeri Compensofion Lows. �CDRE55 ; ��j,.' 1�L.� �J r�� �- . �� CONSi. 'L(� (� �4 ��° /1 \\ �.,: �ate .—A �iCaP� CIIY CiC�(:(�Pn.. 4�slLur_. _ZIP C a��r �O t�li �ms PP -- . -" �-`---L-- STAI�STIC:AI CiA551FICA710N ANT. CONUU. q-. NOTICE TO APPLICANT: If, ofler makiny this Certificate of ARCIIITECT UR � . TEL. . R� Exemption, you shoUld beCome SubjeCt to the WOrkers' ��'yGINEFR. � _ NC. CLASSNC�. DWELL.UNI1S tu .1_ Compensation provisions of the Lqbor Code,you musf forlh- qpDRESS ' � SEWbR MP.P ;°� with tornply with such pro�isions or this permit shnll be :` �E� yq��DATION deerned revoked. CONTRACipR � j� � (t/:i NO��, C �, BK. PG. •.�• LICENSED CONTRACTORS DECLARATION � i�� I hereby affirm 7hoi I nm licensed under provisions of Chnptnr 9 ADDRE55,� �• �� � � NO.��.��, �'1 O%2- VAlUAT�ON (tommencing with Seci�on 7ppp�of Division 3 of�he Business nnd ` y� ��� � 1 /`I�. Professions Code,ond my license is in full force and effecl. f.ITY`..)LL��, cr-� �-I�.�� �,��C� CLA55'�-�,l� S� �vtJ 1 , 3� � [I SCd.FT. � • • �O.C1F NU.Uh CIIE.'.K r� Liconse Number �������r Lic.Uass- ���-� SITE STORIES FMhltlES O�F /� �j p ' � NFW � S I Contracfor �(l`.`•>S f� /�'i!lOi��S riF]ate �'.)�/•t�� � UESCKIP110N OF WORK //'�'' /'i�t ❑ r�.�'I' AI)f) `y . ❑I am exempt under Sec. ��• C�" � � ��� �'ZFl � �-� q�7EN � FINAL � .,��� B.8P.C.for this reason REPAIR .� DATE �!;.i. �%, � USE OF Date: �' / ,,�..,�� DEMOL ❑ �NAL '�. EXISTING BLDG. .:t • : ,-..r�J� y Signalure AVPLICANI � � 11'7. ;. OWNER-BUILDER DECLARATION PRtNII L7.YC5'�c -� � s�/,cl/l•�n•�..S.>I"J�/�/G� �Il.�.'� � ,. �`�'. I hereby allirm inat I am exempf from iho Contractor's License ) 'L J �' �,a�'"�� �(1 �``� ,r'f Law for ihe following remon(Sectian 7031.5, Business ond AUDRE55 r>C :G' E" ���/O;t•' �Cd.n.�(2,- �'7"�� � � � aP�'�, '.11:�°�«'`*u. ProEessions Cedc): pKF-ryT . ;,a �r ❑ BUILDIN(i — .S .�1a1� I, as owner of ihe praperty, w my employees wilh ADDHESS �!f� 1����� �'� wages as iheir sole compensation,will do the work and �+f ,���•��1.`�`�,j'� •r' ; � ihe siructure is not intended or offered for sale(SeUion LUCALITY }{+� / � 1 �s `! .'�i G lj,C)!�1 7044,Business and Professi0ns Code). MOVING TEL ( �r P'y � i"'�� � I,os owner of 1he propeny,am exdusively mntraUiny CONTNACTOR Np. � `� , A'�' y` j(° u ° ° e � 1' t �p with licensed coniractors to constrvct the p�ojeci(Sec- � �� j. f d �,�, �;� � ADDRE55 J ��v�J tion 7044,Business and Professions Cade). f'�7 l �' �� � REE.�UIRED TnTAI$FTi�ACK FRUh� 1'XIST. �f CONSTRUCTION LENDING AGENCY SF.7 BACK YAND HwY PROV.LI�E �N�DTH 1`'�✓ � � �� �2:U 5 fi�; I hereby affirm ihot there is a construclion lending agency for �k���� �� the performnnce of tl�e work for which ih�s pe.m�t�s issucd v.i. , �;� 1/4_Zj� �Sec.3097,Ci�.C.�. SIDf P.L. Lender's IVame Lender's Addrr.ss P.C.Fa�$ f'ermit Fee ��`� I certify that I have rzad Ihis opplir.ntion and state Ihot fhe Is.wa ce Fae `��C above inlorrnation is correr.t.I ogree to comply wifh oll Counfy Invesi�gni�on Fnn �� ordinances and State laws rr.laiing io building consiruction, �Q C� und he.reby authorize representatives of this Covnty to enter �otnl Fee upon ihe above-mentioned proper�y for inspec�ion purposes. L.i 7i ' ��r�,if�,L,�,,ry��/;,.,(. ���•l�� SEE REVERSE FOR EXPLANATORV LANGUAGE ` Slgnn����o o�A� icaM or Agen� Date Pis r--�'----- --- r '---E---- ------ -•- �--1--- ---- ---- -- —._.�_.�_.I_.�---�..��---�—•----T—Y:—�--r , � „-.p� �"�� � 1� `! � � ' ,,� i.--�_�_.�-; �" .� - „ ,- � � �� : i r,� i � j : -j�;�rj J ' ? j � � i � :�� ! I i a° � = ; :l� I �� ! V � i Q ! �� �! e i f Q � C i r:Q' c � � � �� � _ i .S � i��.� I � � 7 � n j � i � ' i ! �--`--O"'-_�,.�1�� � � `p �n�° : ,y� J C i �G 2 I � a j O� O;� 7'a � 1 � � ,: I �O. I :C i `� - d I ?_ '` �� i. 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