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HomeMy WebLinkAbout0526A _ _ . _ _. _.. .. . . ._ . _ _. _ � WORKERS'COMPENSATION DECIARATION '� �• ' -- . � - �- - -- - �� - /'� I hereby effirm iha�1 have a certiftcatPe ot�o�,B��,o.a�f � qpp��CATION FO�R �BUILDING PERMIT� ��; insure or o cerlificata of Workers'Com ensotion Insuronce, ar a certified copy�hereof(Set.3800,Lab.C.J � � -� � - • - - - � . COUNTY OF LOS ANGELES BUILDING AND SAFETY r Policy No. Company . Q Cer,itied copy is hereby fomiehed.. FOR APPLICANT TO FILL IN BW�DING � � � 1 ADDRE55 � Certitied toOY��filed wirh fhe covnty building Inspec• ��- BUitOiNG �1 � fiondeparfinent. � ADDRESS �05 / .�STO.P/G �,P. / Data ' � APPllcant � GITY.. . . /g� 21P... / �i S IOCALITV �. CERTIFICATE OF EXEMPTION FROM WORKERS'� �- � � NO.OF BlDGS. - NEAREST . _ . . . . - � COMPENSATION INSURANCE `� 512E OF LOT NOW ON lOT I CRO55 ST. (Thif seHion need nof be tompleted if 1he permll is for one - �1 - 7�./DLWr ASSESSOR hundred dollon{5100)or less.) . . . i TRACT dS� BIOCK l0T No�- ra +► µ,�p gpq� PAGE PARCEI iEL. / USE ZONE A1A I certify Ihat in the performonca of the work for which thie �"/NER �b✓I�T NO. 60^ � permit is Issued,I shatl not employ any person in any monner ADORE55 02 / G STO��G-�iC. �� GONDITIONS O so os�o become subject to the Workers'Compensatian ows. ,I ,(� U GTY / �i� ZIP � ;x•Date V � � APPlicanf - . . . C� ARGHITECT OR TE�. DISTRICi GROUP TYPE FiRE PROCESSED BY NOTICE O APPUCANT: If, citer mokin Ihis C tifimre o( NGiNEER NO. - CON57. � ZONE F�-- Exemp�lon, yov should 6ecome s�bjetl to'the Workers' �-� Compensotion provis�ons of Ihe Lobor Code,yo�mu�f forth• ADDRESS .1� . �\ ��J � Q�.. W wiih eomply wiih sucb provcs�ons or this,perml�shall ba �- � deamedrevoked. � - - � . - COMRACTOR �SF�-F TFL . STATISTICALClA551FICATION APT. CONDp. (q �• Z LICENSED CONTRACTORS DECLARATION . � -� - �-- - - - ���,_ .. CLt55 NO. ��- � �WE��UNtTS � � I hare6y affirm that I om licensed undar provislons of Chap�er 9 ADDaESS NO. . (commendng wiih Section 7000)of Oivision 3 of�he B�stnesa and . . ��G SEwFR MnP � Pro(eseions Code,and my lieense Is�n full force ond eHatt CITV etnSS BK ��� VALICATION 50.Ff. NO.OF a� NO.OF �HECK � license Num6er � " Lic.Class ' SIZE SiORIES d`-� Fa.l�niuEs � � - ONE � � VALUATION Contrac�or Da10 - � � �ESCRiPTIONOFWORK / � � ADD Q s \ �v�Q I.JU , ❑I am exampr under See. �� - �d Y�� �� . .� - � � \Q �\,�2 ALTER ❑ : 1 B.BP.C.forthis reason _. REPAIR � - - - � � � - � Dafe: USE OF � E%ISTING BL�G. DfMa ❑ $Ignature . . . . - � - APPIIUNT �7 '� TEL. FINAI PRINT ry /�f wA�rNo. ba 3 ' OWNER•BUILDER DECLARATION q � DATE . .. I heraby affirm that I om exempl from the Conlractor'e Utanse pDORE55 oCCC � �$iD.f'/L. .� �� � - law for�he following reoson(Setlion 7031.5, Business and FINAL �Dfess(Ons COde�: --' - ' � - PRE NT sr �0 S 2 6 A ��- BUILDING #. . ;� , ai owner of ihe praperty, or my employaes with ADDRE55 . � . wages as their sole compensotion,will do the work and �ha shucNra Is not in�ended or offered for sale(Section ����TY , � � • •3 Q 5� ' 7044,Bustnees and%ofesslons Code).� � � MoviNG �-�� - - TEL � , I,os owner of ihe prope�ty,am axclueively contracting CONTRAROR NO. �� � • •3 O,J�Q F� � ` � wl}h licensed toniraclars fo consiruct ihe pro�ecf(Sec- ADDRE55 O�O 4-H S �ion 7004,Business and Professions Code). CONSTRLICTION IENDING AGENCY SE�BACK - YARD HWY T�TAp�TpiWE WiDTH I hareby affirm that thera is a construclion lending agency for FRONT the performance of Ihe work(or which�his permit is iswed • P,L � -. . .� (Set.3Q97,Civ.C.). S�oE P.L. lender's Nama � � � � � ° IOMA Ref.8 . � Lender's Address : � �� P.C.Fee S Perm�t Fee�� � I certify that I have read this opplitorion and state that tha . , . . . hsuo�ce Fee � �DAM P/C M ' � . . obove informollon B corcect.I ogree to comply wilh oll Counly invesigonon Fee . ordinances ond Slo�e laws��elating to building tonskuction, _ To�ol Fee� LDMA Pe.m.N . � and hereby authorizc represeMa�ives of this CouMy to enrer � - upon the abova-mention property for Inspeclian purposes. � .[� SEE REVERSE FOR EX�IANATORY IANGUAGE Si Nre of A limn�or Agenl - te� . / � z o --- o . _� � , -- T' � � � G .� � ` f� � U` (9 U�' ��. 7 �9 � •�� 9` ' . � '� . .p P ; V t � 7 �'� �,^ n . � � U n ..�t � , ' �0 fl i0 q O 4 r F. � n� � S '� ��, . . 9 U,� �'o � 7�'. o -c _.. - � ,�r n p p,p._ o p .� m � \ Z O � � C �. 6 O i•'� 'O .� . . . 1 t^ O Qti, G, O O 9 .. p � � ✓ S a � �.^. j O Q° L ��. J � . ,• � . 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