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HomeMy WebLinkAbout1457A 1458A (13) WORKERS'COMPENSAT�ON DECLARAiION � � � � � - � � 1 hereby affirm that I have a certificare o,�a�,e�,�e 5e�� - APPLICATI4N FOR BUILDING PERMIT �insore,or a cerrifico�e of Workers'Compensatlon Insuronce, or o�/r�t�'(i d o y the eqo( Sec.3800,Lab(C.) ^� ( CpUNTY OP LOS ANGElES BUILDING AND SAFETY Po�I'�"No.��Q�I�m���if d4���'CA J .lh Q�l•I1� BUIIDING �p���t4�� '7qr'(z � �y �fn�fied mpy�s hereby tum�shed. FOR APPUCANT 70 FILL 1N ADDRE55 0 17 � � Cerlified mpy is filed wilh Ihe coonly building insp� �� BW��ING 2�5��a��� f�r'�,i lion deporfineni. ADDRESS Dofe � ApplitaM QSY �10."hc1Y�C1 1JQ'✓. ZIP LOCALiTY (��� Qf -7 C RTIFI ATE OF EXEMPT N F O ORKERS' y Sa� NO.OF slDGS. � NEAREST 1 J�f� COMP£NSAiION INSURANCE SIZE OP lOT D^ I MOW ON lOi CRO55 ST. � (This seciion need not be tompleted if tha permil is for one .. - ASSESSOR 7RpCT BtOCK lOT NO MA7 BOOK PAGE PARCEL hundred dollars(5��)or less.) /� / TEi . �y} . pWNER (N(� 0'} W���ICA NO. Z-1$"✓J �20NE �P . - I ce�ti(y�hal in ihe per(ormance of�he work for which this J �- permit is issved,I sholi nol employ ony person in any manner A�bRE55�S.j �/��P�r 67� F( SPE�iA� O(� q� so as to become subjett to the Workers'Compensalion Lows. � t CONDITIONS �.L 0 aTr ti �p S zir g�n�! U a Dafe � � AppllcaM ARLHITEGT OR TE�• OISTRICT GROUP ttCE FIRE PROCESSED BY O fdOTICE TO APPLICANT: If, ofler moking Ihis Certificofe of ENGiNEER Na� � CONST. ZONE "(�n U Exemption, you should become subjed.�o Ihe Workers' - -- ! (�: ^��— �``\ Campensa�lon provisions af the Labor Code,you muse for�h- qppqqu J ` W with comply with such provisions or this permit sholl be T �+ �-i�L, q STATISTICAL QASSIFI ATION � APT. CON00. (n deemed revoked. . �ONTRaCTOR �Wi^!►�P J �M�O. � ��2/2' � Z IICENSED CONTRACTORS DECIARATION � d�j . NO.�c�YJ S! 41SS NO. WEIt.UNITS I hereby offirm that I am licensed under provislons of Chopter 9 aD�RE55 Q� V (commenting wiih Section 700D)of Diviston 3 of�he B�iiness and J.} . LIC. �R�p Proiessions Code,ond my license is in full forca and effed. dTY ���'^�� � �� CLAS��� S�a BK pG . VALIDATION 50.FT. NO.OF NO.OF CHFCK License Number ��� .CIos�6��!� 9ZE - STORIES FAMILIES - ONE � . . � 1 VALUATION DESCRIPTIONOFWORK ,_+CA2/�.II I N� � � Controdor oie 1 a f f 060 .❑I om e:empt under Sec. � . �0.0 � M�/�6 3�e f r A hR- � , � � B.BP.C.for ihis reason .. . Wt )����"' !•�4�{� EGAIR ❑ .s � - �1 4 5 7 A USE OF D a - � - Date: EX�STiNG BLDG. I �n ❑ � �.. Signalore . -- PRiNi 1 FINAL n�(' �• • • •G'J OWNER-BUIIDfR DECLARATION APPIICANT h C J (C O. I' �yZ DATf � � � �V� . I hereby affirm�ha1 I am exempl irom the Contrac�oi s license � . 8�g Ob S/a�l`�1�� 95'X b a � ' �2�Q� Law for the foliowing reason(Section 7031.5,Business and P.DDRE55 � � FINAI � � � Pro(esslons Code): � �� �- �� vaE EN - �y • •2���� � BUILDING 1,as awner af fhe property, or my employeee with n00Rf55 I 0 9.0 8—8 8 woges os their sole compensation,will da tha work ond `���T� . �ha strocture is not inlended or oifercd for sole(Sedion TE` �� �l�S A 7044,Bvsiness and Professtons Code). � MOVING -� aCONTRACTOR N�� . • 1,os owner of 1he property,am e.cl�Sively canlmcfing �� • • • � with�icensed mntmcton fo construtf tbe projeU(Sec- -� ADORE55 � tion 70d4,B�siness and Professions Code). � • •J�,Jr� , RF�UIRED YAR� HWY IOTA1 SESBACK Xi CONSTRUCTION LENDING AGENCY - SET enCK PROP.LINE WIDTH w : .3 p,5 0� I here6y afiirm thal Ihere is a construUion landing agency(or � FROrvT ihe performanm ot tha work for which tfiis permi�is iasuad P.�. (Set.3097,e��.e.�. s�oe . 0 9.0 8—8 8 P.l. lendei s Nome (�h LOM4 Ref,N Landei s Address � ' � P.C.Fee S �d 7ermii Fee \l�) ' I certify tfiat I hava read this oppiimtion and state fhat the . . . Iseuance Fee lV IDMA P/G Y � �� above informativn is mnect.I ogree to comply with ail Counry � Invast�gauon Fee ordinonces and 51a�e laws relafing 10 boildi�g construUion, Totol Pee _ _ IDtM Perm.M. . . . and hereby outhorize rep se 'vas of Ihi�Counly lo enter � upon th o ve- nt n g�y f r�nspection pu poses. � J/�� SFF REVERSE FOR EX�LANATORY tANCUAGE / �gnat o}ApP�icani or Aqen� . Doie . .. . . . \ . �'�\ ` Z o o .. . • �,_ '" T � C .n� � o y ` , v '� c s ' O v' r� p, ° _ � o � o��� r+ � . . v - ff� m �o O O N n N .p .0 P 'O "' '.'"�^o • "•�. p 7 C �^ n '`�, Q� �� �c � . � . t O JO p n � - '� o,. � � .,� 3 �n . ' � � Q 9. O p • � �� � ~ . �.� N � � O � � �n f� ' .0 � . � . . ' O p G�.� � t0 O � < � ' • j, r, m C� y �. u o �o � o Z � ? '. � . Q, W�\ � . 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