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HomeMy WebLinkAbout1364A (7) - WORKERS'COM7ENSATION DECIARAitON � j - .� � f� I hereby alfirm iha�I ha�a a certifitatne oF�o�,e�,,o=e�f � APPLICATION FOR BUILDING PERMIT ��; insure,or a ter�ifimte of Workers'Com ensation Insuronce, or a ce�i'rfied copy ihereof(Sec.3800,leb.C.) � � COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company gUIIDING � Cerrtied copy is hereby furnished. FOR APPLICANi TO FILL IN AODREA �3 � � � Certiiied copy is filed with ihe couMy building inspec- � � BunDwG �^ . /� tian department. ADDRE55 .T�'3 GG ��/�a ��.` .�"J• Do1e ..APPlieont CITY Y/�INV` J �y�� ZiP �7�`� LOULITY - CERTIFICATE OF EXEMPTION FROM WORKERS' - . NO.OF BlDGS. . NEAREST COMPENSATION INSURANCE � SiZE OF lOT NOw ON LOT CRO55 ST. � � � � � (ihis section need not be completed if the permit is(or ona .. S3 � ASSESSOR h�ndred dollars(5100)or less.) . iRAtt � 3 BLOGK LOT NO. Mp,p BpOK PAGE PARCEL . . TEL. O/�O ��� MAP 1 ce�tify thal-in Iha performonca of tha work for which lhis OWNER � . ' L Np, � O � � �Z�-,3 C`S sermif Is fssued,I sholl nol em lo an erson in monner ADORESS � � Gy "�" D �G�� SPECIAL � o os 10 become sub' ct to ihe WorkenPCom atton ws. �2 `� `�', ��- ���UQ CONDI7ION5 Q � �/_ CITY �i�+'�-Ll.�t. .QIL 21P ����� V �Da1e�Applitam � � NOTICE TO APPIICANi; If, o�tar i thi Cerfifl of , ARCHITECTOR TE�. DI KT GROUP NPE FiRE PROCESSEDBY O Ezempfion, y0u ShOVId beCome Sub�ect l0 1 e orken' ENGINEER �� �p�T. 20NE V Compensalfon provisions of tha lobor Code,.you must forth- ADDaE55 � � with comply with :uch provisians or this perm(t shall 6e deemed revoked. TE�• StAtISTICAL QASSIfICATION ACT. CONDO. , ln CONiRACTOR � NO. � Z LICENSED CONTRACTORS DECLARATION � ,p ���,� _ QASS NO.�DWELL UNITS � I here6y affirm�hat I am licensed under provisions of Chopter 9 ADDRE55 C.i' r10. �commencing with Section 7000)of Division 3 of ihe B�sine5s and ��� ��R�P Proiessions Code,and my licenee is in full force and eHetL � CITv QA55 BK � VALIDATION � � � 54.fi. NO.OF L NO.OF CHECK Li[ense Numbe� Lia CIaSs � SIZE � STORIES FAMIUE$ - - � ONE � � ❑ VALUATION Contractor � Date � DESCRIPTION OF WORK .. N� �I om exemp�under Sec. � � �j+ � •�� ADD � s �/ /� , ALTER ❑ �1 3 b 4 A B.BP.C.for Ihis�eason REPAIR s � Date: USE OF OEMp� �_• • • • • � . E7(ISTING BLDG. � APPlIG4NT •..TEL. Slgnature � � -� - vk�M W(J/OAO . Q�. .j� NO.� ,�f�l FINAL � • •�l��Q OWNER-BUIIDER DECLARAiION �/ DATE I Z � � I hereby aifirm Ihof I om evempt from the Contractor's license � qDDRESS 23 Cl� ������,{� • '�4 a 0 0� law for the following reason(Section 7031.5,Business ond �"—� FINAL Professioni Code�: � � �- �- PRE ENT � " BY � (�9,Q(��8 8 BUiIDING I, os owner o(the property, or my employees wilh aDDRE55 . wages as lheir sole compensalion,will do 1he work and - �p�p,�ITY � rhe:rruciu�e is no�imended or oFfered for sale(Section 7044,8usiness and Professions Coda). - MOviNG TEI. . � I,as owner ot�he property,am exclusively contracHng COMRACTOR NO. � with licensed coNroctors lo ronslruc/1ha projatt($ec- ADDRESS � �ion 7044,Business ond Pro{essions Code). - CONSTRUCTION IENDING AGENCY SET�BACK �ARO NWY T�TApgOP.lWE WiDTH . I hereby aifirm thm ihera is a construttion lending agency for ieONT the performon[e oI Ihe work(or which ihis permit is issued . P.L. � (Sec.3697,Civ.C.). SIDE P.L. lender's Name � � � 3Z r7-� lDhV1 Ref.M Lender's Address P.G Fee S Permi�Fee +.]•-+ � ' 1 certify Ihat I hove read Ihis applicalion ond slate that the leevonce Fee /�� v LDMA P/C M above intormation is conact.I ogree to comply wi�h all Co�nty Inven�gauon Fae �+ ordinances and Sta�e lawa relating to 6uilding construction, Towl Fee J��v LpMA Perm.N cnd heraby aulhariza r resentotives of this Couny to enter �pon the obove•me ned roperty far fnspectlon purposes. �_� SEE REVfRSE FOR EX►IANATO�Y IANGUJIG[ S f A g nt pcle . . . _ix �' _ . �. .. �a g _ , , Z ! � , r. � r..v -C� � i� ° o . n� �`� o y. c7 �' � ' F . �c c �� o ^ � O �;, 9 p � o �C �w � � v 9 � vv � o � � p 4� ` O �. �p ��. � �6 . � u' O N`` . ! 10 O �' 3 �� -. tl L �p � o o' c �-° ' , c 9 '° " 3 m � a' � . • -o � p Q' 9 a O D' • 'J �� •, O O - � .' r ,�.'+ ('7 2 O 7 � a p f 7 �y . � � � O � '� m . . . �� , � Z � n .:i' 7 j U � 7 � � p �� p . �O 1� . . � � ` ' N . (^O ^� % �d N � p =.. � j , x �. u. . !� . . 1p � . 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