HomeMy WebLinkAbout1626A WORKERS'COMPENSATION DECLARATION - �y
I haraby offirm that I hvve a cerfificate of conseM to self . App�LaCAT10N FOR �UILDING PERMIT �
insure,or a cerfificote of Workers'Compensation Insuran<e,
or a certified copy ihereof(Sec.3600,Lob.C.) " ' ' � -
t ,p-,�,,.-c�3c,j� COUNTY OF LOS ANGELES BUILDING ANb SAFETY
P�o,I�icyMB..e-.� . .. � mpany�� ._...... _..
Certitied copy is hereby furnished. FOR APPLICl�NT TO FILL IN AD�RESS 1� � �J-�-
�'�Ij Certified copy is filed with the counry building inspec- BUILDING n- 'i
��\ tion depariment ADDRE55 � �'b (�� �y LOCALITV °��
NEAREST
Date�"�Applicar(i� CITY , P ZIP CROSS ST.
CERTIFICATE Of EXEMPTION FROM WORI RS' NO.Of Bl�GS. p.55E550R
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not 6e completed if the permit is for one use ZOnIE MAP ��r
hundred dollars($100)o�less.) TRACT BLOCK LOT O. �7. NO.
/: /� /� ' TEL. e /4 J SPECIAL .. . �
i certify that in the performonce of ihe work for which this OwNER W(a - � /'f2�¢ t-i,"� NO. S.3 CONDI710NS 6.
permit is issued,I shall not employ any person in any manner r D�STRIC7 GRDUP iYPE FIRE PRpCE55ED BY �
so as to 6ecome subject to ihe Workers'Compensotion Laws. AD�RESS J�b GLG� L �. CONST. ZONE �
,ry I ,�i C�
arv �E7�-'Sei]�; Cpt zia x.'^�,` �
Date Applitant STATIS7ICAL CLASSIfICATION APT. CONDO. �
NOTICE TO APPLICANT: If, after making this Certificate af azCHiTECT OR TEL. 'ry�
Exemption, yo� 5hould betoma 5ubjecl to ihe Workers' ENGINEER NO. CL455 NO.��WELL UNITS �
Compensotion provisions of fhe La6or Code,you mvst forth- qDDRE55 SEWER MAP � �
with mmply with such provisions or ihis permit shall be 7EL 7� �
deemed revoked. CONTRACTOR E �/ A.j NO. � -C�-� gK. 7G, I VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm ihat 1 am licensed under provisians of Chapter 9 ADDRE55�S'C� �S}GOryt � �%� NO. VpLUATION �
(commencing with Section 70W)of Division 3 of fhe Business and r(f/� ��C. f�'^
Professions Code,and my license is in full force and effect UTY � �c� �-1't' C�A55 $ '^�V �
S�.FT. NO.OF NO.OF CHECK ► '%I �=L.C�F�
Licanse NumbOr��i<.Class SIZE Z0� STORIES FAMIUES ONE
�'� ^ �'��•y�'� DESCRIPTION OF WORK��I A/P`.:4.�("1�E��NEW ❑ S F�, g m s e'��
Conrrocror �4 te� App � I � i 1 7.�'4
❑I d'm�exempt unde�Sec. "
ALTER 1� FINAL � R .I f �,C 4,_
B.&P.C.for this reason � DATE
REPAIR
Date: USE OF „,F'1�_ DEMOL � FINAL D C�G l+'—E 6
EXISTING BLDG. C/ g
$ignature APPLICANT �j TEL (j Y
OWNER-BUILDER DECLARATION PRINT) Z1 iJ. /L7G;.i NO.3 - �3�
I hereby affirm ihat I am exempt from the Coniractor's License ADDRE55�'$� �?�' �'r`IM � � � �
Law for the followinq reason (Section 7031.5, 8usiness and e- ! c- %hE � �� �� ^` _ /
Professions Code): aae eNr ---��� -•�-� -��-� --- �� ` T��`�
�BUILDING � (�, �L/
� I, os owner of ihe property, or my employees with ADDRE55 �`,J
ages os their sole campensation,will do�he work and
the shocture is not intended or offered for sale(Settion IOCAUTV
7044,Business and Professions Code). MoviNG ie�.
� I,os owner of the property,am ezclusively confracting NTRACTOR NO. �
with li<ensed controctors ta construcl 1he project(Seo- qODRE55
tion 7044,Business and Professions Code).
REQUIRED TOTq�SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK vARD HWY pROP.LINE WIDTH
I hereby affirm that�here is a construction lending ogency for FRONT ,
the performance of the work for which ihis permit is issued P.�.
(Sec.3097,Civ.C.). SIDE
- P.L.
Lender's Name �7
� Lender's Address P.C.Fee S �� `" � Permit Fee .
� I certify ihaf I have read this application and slate thm the Isso e fee
� above information is carrect.I ogree to comply with all County Investigmion Fea a��
ordinantes and Stote laws relating to building construction, 7ota1 Fee
u
and hereby authorize representatives of Ihis Caunty to enter
$ upon fhe above-mentioned property for inspeUion purposes. � -� "' ""''''-'-^=^'^-"��•�^�-�^-' - - -
_>....-:.>.:.._:,.._,. ... _. ..... . .. ..
� SEE REVERSE FOR E%PIANATORY LANGt1AGE
� ... ... ...... . ..
Signature af Applimnt or Agenl Date �_
��T�p��y��Y$9. 4lCA@�`t lPESP�GY�R'5 Pd¢iE5' .-,� T11�'N1�L. Uk Yf�iY�3t f .�� S�`�, .,
�---�^�==-� -...-.+a.,•,_-4.-a� ._ ,m.�.....�.,�.�.�.«,K.+.....�.,-..,,......�..-,.«n..__--,,.„�...-.w.�, I hereby c�f�rrnlh I n�e om�i hc C n'.p ;
,T� ��� �4����� t cc�s� �avv `.o sne.f li �o..o: (S c. 7031 S?
�a
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Fla. .7��'e &70. Qako � � �'�y,;irescl;�r.:;r�:.�;:-:;:z_�L::�-�.�u:i�::;r�.,;;�i,e�c,e,^�ea?is'n,
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, - - A:o:70�J0/�J�snisioro 3 of���f'res:ne-ra anu'Frofessinns
;
� Cod�•j or alo�at 1::!s esa.a�e�ht.'n_erefrassi dsrd 2be bus;s fn�tl+c
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� °+'° Dale isseivad ':- �
q�:�dc=asYe sr Agpreved — ... P.�,.n . s f e -...1 w�aFiar;/,z,50Qi.f:
Ves .�,`c� � . . . .
. . I os os�nar c�i5..arcNe-y,or my tmployees wiPh
i=� s ihair so!o c�-n sesicr,will do thawork,ond
Woter v;:fic:.�a � .._' I _ �,_ _ .----- -�� ;.ss a pen
�__._��.�_ � tiic`s'�uc}u'ra i;notdnten.ted�orcff�+redforsal�(Sec 704d;
f�kealth Daa�rfmont � '�"'--.- :;w:+.=r.:::ri�f'rofess:::;:s�.^r.�?c:Tbc�<'a;.;_-nclnr's Y,ices:se
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