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HomeMy WebLinkAbout1687A 1688A (10) � . ,_ ---- __.__ .. .. .. _. _____--.--, __._ ..._ _ .._. ._-- ._ _�._._._--, .- � , - - WORKERS COMPENSATION DECIARATION - -�.'�, , - ; : � � •� ,• ,:.;�.. .. . i � - . ..,.. _ _ � : .. -' " 1 herebyoffirm fhat I have,a cerlifimte of��o�=e�„o 5e�f . � qpp��CATION� FO�R�BUILDING PERMIT�- ��� insure,or a certiLcate of Workers'Compensation Iniuronca, oracertiiiedcopythereof(Spec:3B00,lab.. )' .. -. ,, ...-.._ -._.. . ..--- -----�--��- - , - .� : - . . _ .. . ----- - ... ..� �. .,... �• PolicyNo.�� P�7-/��fr1��Yy � - � � _,. COUNTY OF LOS ANGELES � BUILDING.AND�SAFETY- .,::-, � , ��.� O Certified copy is hereby furnished. • .. , � FOR APPLICANT TO FILL IN � ADDRE55 � � \1Q�1��(J �a, I � Cenified copy is filed with 1he county building inspec- - 6uuDiNG �" � .p { - � �ion de arlm L���� •.,.,- .' - .''� � .. A�DRE55 \ y�i�1�71 f i . ,,.,a�Z��� � f " - ,,.. . f -- --_ --�- . : : y/ ^'� --_ __ - _ , , Date�� �pplicant� < �\ � � Ciiv S/t•�� Zia LOCNLITY `� ��CERTIFICATE OF EXEMPTION FROM WORKERS'•� ��'�� '- �-----�-�- �-- --�-�-- �� ----NO.OFB�DGS. �- �� -�----+ r.rFqREST.._. . _.. .'_ ` . __._.._.. ..: ' �� ��� ��'�COMPENSATION INSURANCE" .. SiZE OF LOT NOW ON l01 � �p$$ST. �1�. i (ihis section need not be completed if the permif is for one ---- �- -� - � ��-- --� -- � - -��---L-- : ASSESSOR :'-" , - -- �--�� �=�. -.� h.undred dollars(§I00�or�ess.) ., 7RACT � BLOLN LO7 NO. /qqP BOq( •'' PAGE' PARCEI I cerlify that n Ihe�perfarmance of Ihe. ,� �� ��� OWNER � - �� TE�� � U Of�{E M.4P , ., � .___ . . .. NO...."__ ""' . work(or which this � � -/ NO. � � permit a issued,I sholl noi employ any person�n any monner qDDRE55 � .v�� �, -�-�y-�-� �ECint� - � -�--- - � -- ��- �� � �� �a . __.__ . . .. ... . CANDITIONS ! .�.... �U so as�o become�sub'ett to Ihe Workers"Compenwtion Laws. ...,. �.-, , , �.,., ,. .'.. �..,.: .... � ...'--'- _.._.._._ . - �-- . . _ . . _ Date' . ....� .� � APPlicont� . .� . ...�. . � --'- CITY _. 21P_ _ . . , . . NOTICE TO APPUCANT.If,�aFler�making fhis CerLf�cate of ENGinI�EER R �` � NEO. . `4 DISTRICT_. .GROVP TYP -_.. _,FIP.E _PROG:..D Y . -� Exemp�wn,�you�should become�subject to �he�Workers' -� - -� - CA T. ,ZONE :� � Compenwtion provisions�of the La6or Code,yo�mus�forth• ApoRess � t ' _1_� . _ .___ .�_i�,:,.,�2. � �d with comply with suth-provisions or�ihis perm�t shall 60 �.�-- . � � -� ����- TE - � � ,� deemed revoked... .. :.'....�. ,� : ...• . ,.,.. ' ' S7ATISTICAL QASSIFICATION , I . APT. CON00.'. - .;Z Y LICENSED CONTRACTORS DE PIARATION�. P CONTRnCiO ..,_ �.--._.....: . ..`I��. _ _ . . . . . � . ._'...... ....... ... .... _ _, _.. . ^ QA55 NO. �� DWELLi UNITS I hereb affirm thai I am licensed under wvisions of Cha ter 9 ADDkE55 NO Q'� (tommencmq with Secfio Y7000)of Divisi ull of Ihe Business and .__. ..__. .__ _._.._... ..._..... .._.._...'_ UC.. .- -.-.J ��R MAP '--�' . . " . . Profess ons Code,and m license is m f� force and effect. CRr �iq�,5 � -- � . --�-----'. _ .. , '--VALIDATION' . LicenseNum 'r'` . Li�.� ., . ., . .-__BK. cG. � . . � 5(�.FT. NO.OF NO.OF CHECK '� � ' 5 � ', � _ . ____'___ " . C.Class�'-'- $12E - -O'- STORIES FAMILIE$-"""" ONE � L ON . . � � . . . ......... ..... .. ... . . � ./c] �,�� t�� ...VA UATI ."- . . ,. Coniiactor � ' ..;,Date���� ��RIVTIONOF WORK-- \� ' " NEW'"'� c'�/ O �). . . .. .. . . � �, . .,. . . . � "' ' ..._ ADD � s / O i ^• ❑I am exempt under Sac. �. ._. . ._ ... .-------.... .... .�..... _ . . : :�.:. : �- �.� _ . ., �, ALTER ❑ ; , - <� 6 E�rI A . ' B.BP C.for this reason � REaniR..❑ . .s.. -�-----... • ..... . ......._. __._. .. -. -. ._..... . . ___.'_....__ .____.' '� USEOF � . . ..: "---Dale:��` ExiSTING 6LDG. DEMOL i � �• • • +2 3 .-...', -� ._ ._ _ __.'Signoture ... '".-_'.�_ ..-.- _ ..- _ •-`" APhICANT TEt. FINAL �j -_�� • •2�,Q Q -,i � OWNER-BUILDER DECLARATION PRINT L No. 2 _DATE-3��'L�I��,� -I hereby affirm�hai I am exempt fwm the Contmctor's license - � �� � �� "� --� '�1 ' a "� "-" - "--�- --'� �-i, �� � • ��Q����� , law for Ihe follawing reasan(Sectian 7031.5,Business ond ADDRE55 � -7 . !� FINAL�� �,� - ' `-� � ' ------. ._._ _._.. ____�.___.. P • Br_. ..._ �/f ;_ -; 09., s�8� `Professions Code):"' � R N � - � BUIIDING - I, as owner o(the property, or my employees with ADORESS - "... ___ ._.... . .__ ... . . . . � �• � ' � __ __ ' ��wages as Iheir sola compansation,will do tha work 6nd � - � _'-' . , ----- - -- ---.. .I�as owuner of ihe po peety,am xdus verly co iSaUing , ON`IACTOR "'... . ...... NO.. ._. _. ._..'. '-'' - � � I � , ..� , .'�' _"_r_" ..... .. . •�� with Lcensed coNrptlors io[onstrucf ihe ro ect Seo- �-�-�- �-----� � � - -• tion 7044,Business and Professions Code�P � ( ADORess � ---� � ; - ��� � -� � � � �� �-�� ;' - ���-�"��6&8 R , ��-- -��- .. .REqUIRED__ TOiALSETBACK � ' ` �+ �� ' ...�-CONSTRUCTION LENDING AGENCY�.�.._.. ._-..... -SET BACK -YARD' HWY. .. PR07.UNE WIDTH� .......-�-�--'-"... ............_._'__._.__ ._c n o.� �-�.� � �._... 1 hereby affirm thai there is a consiruction lending agency for FRONi .; � � � � -�he performance of�he work for which�his-permit�is issued -...'--� �-a.L ... .- .- ..-. .. _-. ...--�-- ... .-----.. .-..____---._--__�-- -_-_'-• �-�_�-z 2�5�.. .. � (Sec.3097,Civ.C.). SIDE - - � _.""._"__'_. .._.____._ __ . ._ .. ..... ..._ .'__ .. P.L � - ���, . �.'.. _. _.. _.._.._�'!''a °.G2SOc.� lender's Nama -.. _ . .. ...... ..---�� � . m q ��` ' � --.._._. . . .._ .. . ....._._. __. oC �7/ 'l I LDMA Ref.N , O�J.� S-�i-I . . _ _._._.'___ _ .. _... - P.C.Fe E ".' S' --. PermiiFee. ..._�P-(/� - lender's Address - -�- - �--- ' } � L ! , � _I rerlify ihal I have.�eod�his opplitalion andstate fhat.lhe ___ . _.___ ' .__._._' __... Issuonce Fee .-��-'.5�.- - �L�MA P/C A'�'- - .. . ,__... _ '_''' .. .. . ...� � abova iniormation is wrrecL I agree to tomply with all County Inrestigonon Fee z q �v i •"�i g _ordinances and State_lows relating lo,building tonstrvction, __.___ ___ _ __ -� . ..__..___.._.__ -.Tae�Fee____._. .._'__._� IOMA Perm.k-..... . ... .... .'.....;. ....r ...-..i "' and hereby authorize represoniativas of�his Coun�y to enter u m upon ��e-men'o ed property for inspecY n purposes. - � � a --- ---�--- --._-- -�- ----.. ..^ . .. ' .... ._......'--"'-- -- -----'.. ... ..._-.. --'--`------ - a �"�� � SEE REVERSE FOR EXHANAiDRY LANGIIAGE . ' n _- � na�ureofApplimntorAgen� ....- .. ._.--..pata_. 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