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HomeMy WebLinkAbout1045A 1627A � 1 WORKERS'COMPENSATION�ECLARATION y��y' � � ' � ` �� � ._.... .�. _ . . . .. . . . . . .. . . . hhereby affirm �hc�I hava o ceriificate of consent lo nel( � `�— qpp��CATION FQR BUILDING P RMIT � � insure,or a certillcare ot Workers'Compensoflon Insuronce, , � or a ceriified copy thereo�(��.3900,tab,C.) / COUNTY OF LOS ANGELES BUILDING AND SAFETY � . PolicyNo. �u�—C��Company'-!�[h�%�T ��ni , 1 . �{ � Ceriified copy is hereby fum�ehed. FOR APPUCANT TO FILL IN ADDRESS ss�n /V. �i�G....�-.� d`��> � Certi�ied copy is filed wifh the counfy building in�pe[- BUILD�NG S � p �.rn��.D �� u � Ilon departmenf, ADORESS vJ om, � ' Z•� Appllcont�IV�[I/F S%lJD�'IA" ntr �D 9�r1 z�o �LDS iocAutr CER IFIUTE OF EXEMPTION FROM WORKERS' �-� - � NO.OF BLOGS. 1 NEAREST . COMPENSATION INSURANCE � SIZE OF t0T NOW ON LOT � CROSS$T. �This eecfion need not be completed if the permit is for one /L�g,� g n55E550R hundred dollotS(b1W)or less.) 1RA�T �1� BIOCK l0E`NOry. -7 MAV BOdC PAGE PARCFI - OWNER �"'C•v v�'VZ NO. O ��J/ USEZONE N�P �-Z�1�1 .G� I certi(y thot�in the performonce of�he wak for whichlhis /J pyy� f� /�/� ��T � permit is�ssuad,1 sholl nOt employ any persan In ony mpnnCr pDouE55 '�+'�'���/g���� v�� ��' "' CONOITIONS Q :o os l0 6ecome subjecf fo tha Workers'Compensotion laws. 11� /� / /c V� . . CITY fl 6� � ZIP (�(Q�J �� �: Dafa � Appli[anl � � ARCHITER OR c.� G TE�• (J/� D�SSRICT GROUP TYPE fIRE �ROCESSEO BY O - NOTICE TO APPLICANT: li, ofter makinglbis Cerlificoie o( ENGNEER c.�'�� �A '� N�� '�7 T� CONST�� � E"� ' Exemption,-you shovld become sub�ect ro the Workers' �7 �'Q Compensation provisiona ef the lobor Code,yau must(orth- ADDRESS � ��. ��"'L ��•�r I� ��" � d` wifh comply with su[h provisions or this.,permil shall be . . TEL. ���c„ STATISTICAI QASSIFICATION A�T• ��N�• Z deemed revoked. � CONTRnCrOR e j�If NO. •��� '' LICENSED CONTRACTORS DECIARATION � ��/ -�7� ❑ QASS NO.�DWEtL UNITS I hereby atfirm�hat 1 am licensed under p�ovisions of Chop�er 9 ADDRESS Z� r.�/��/ � �� SEWER MAP � (tommenting wiih Section 7000)of Diyision 3 of ihe Business and /�,�B�r��i2 uc. � BK . � � � VAUDATION � Proiessions Code,and my license is in f�ll force and effen. Citv/"�/ Cwu �p - /+� � SO.FT. NO.OF NO.Of CHECK ` Licensa Numberr7��I ZZ 1 b L1G Class �� SIZE �� STOR�ES� - � FAMIUES r - ONE A�1� VAlUAT10N ConiraUor� �W 1� � Do�e � . y.p DESCRIPtION OF WORK -� ��"'�"� . N� � s �� � — �I om exempt under Sec. n�"`�� ADDR a , f 1 p 4.5 A B.BP.C.tor this reaion G�����L �Y����i ST REPAIR � _ #' •�• •2 3 Date: ezisr�iNc aioc. C�i o�a ❑ � . .6 4.8 1 Signafure ' ' AP�oR iT - Z NO. Y 3 FlNAI OWNER-BUILDER DECLARATION �/ Q C!Y DATf/O'.,'�� • � '6�'8�� I hereby aifirm ihat I am exempl from the Contratfor's License ADDRcS �O ��l�l� v�U� J,G�� FINAt � � o&2 3—8 8 low for the followiag reason(Secfion 7031.5,Business and g . _. Profaslon:CadeJ: � "- - � . P E y ��'�� ❑ Bl11LDING 1, as owner of�he properry, or my employees wilh aO�ttESS wn�ne ns thrir soln co�^pensahnn,w?II�o!Fa..�p�L��a I�IITY � �he sMotWre is na�intended or offered for sole(Sectian . 70<4,Business and Professions Coda). rnOviNG TE�- a �ONTRAGTOR NO. I,as owner af�ha praperty,am extlusively cantrecting wilh IlcenSed cOnfracfars fo con5lruCl ih8 pfojecl(Se[• qDDRESS - � ��� iion 7044,8usiness and Pro�essians Code). '—�-��'- . �`.l„�`.1��. REOUiRED TOTALSFiaACK CONSTRUCTION LENDING AGENCY SEi anCK YARD HWv PUOr.lwE wiOTH � I he�eby offirm 1ha11here is a cons�rotlian lending agency for iaONi �1 6 2 7 A . �he per(ormonce of the work for which Ihis permil is issued P.L _ (Set.3097.Civ.C.J. SIDE , �(• • • • • � P.L. Lender's Name tOM1+Ref.p � � ��b 7 5 . P.C.Fee S • J . Pe.mit Fee , lendei s Add�ess /� � � �8�7`��' 1 certlfy thol I have reod thia opplicotion and stola Ihat the Issuonce Fee �V IDMA P/C M D 9,1 6=8 8 abova information is mrrett.I agrea lo comply with all Counry invesrigmion Fea . � o�dinances ond Slate laws rela�ing to build�ng construclion, io�ol iee IDAAh Perm.M and hareby outhorize representatives of t i"s County lo enler upan ab ve-m ntioned p��ee�ty for nspeclion purposes. , d t_��s _ � . �—ZZ� 3 fj SFE REVERSE FOR EXPUHATORY IANGIIAGE SignoN�e af Appl' or Agenr Da�e � � mT �z o ' 7 O ., C ] '� Cn T ' . ? C � C S ,. � O p O cn Q -� � ' � ; m 1 =J p- c m • o o n�^ ^ �r o � _ m � � �n � �- o� '� �� "�' �; , � T = � -� r P G~ r ,,� _ 4 �O D . 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