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HomeMy WebLinkAbout0898A 2425A (4) W�RKERS'COMPENSATION DECLARATION : . � � /'� � I her�y of,,m ihotl have a cerlificate of�o�,e�,�o,e�f � - APPLICATION� FOR BUILDING PERMIT � 'LI insur or a�e.�ifico+a of Workers'Compensation Insuronce, or o certified wpy tereof��Sec.3800,La6.C.J � ' - � - Pol�cyNoSS��Zf—�@"ompony � :c COUNTY OF LOS ANGELES BUILDING AND SAFETY � Cenilied mpy ia hare6y furnished. FOR APPLICANT i0 FILL IN BUILDING Certified copy is f�led wiih�he co�uQ��y y)�J in pec- eUi�oiNG / AD�RE55 0 (Op (� t�/Q � ti0n deportmem. ��� � ADDRESS� W �/�«�S '�'ew - Date l5—J� ApplicaN .. . Ci7V Lv LOfAI�TY CERiIFICATE OF EXEMPiION FROM WORK S' � � n� NO.OF BLOGS. . NEAREST � � . COMPENSATION INSURANCE � . SiZE OF LOi� !� NOw ON lOT D CROSS ST. (This settion need not ba completed if the permit is for one g�p�K LOi NO. �ESSOR hundred dollars(E100)or less.) �, TRAR Q �7 MAP BppK_� PAGE PARCEL . � . , TEL. ;7 USE ZONE � IO � I certity ihat�n ihe periormonce of�ha work�for which this �' ' OwNER /� No. yG� V No. ! permil is Issued,�sholl not employ any person in an'y manner qDDRE55 �i(/ (l'�'�LV �E��A� ��" so as l0 6etome subjett lo the Workers'Compensalion Laws. � CONDITIONS 0 arr v h [4 zia /� � V Date Applimnl '� ' ' � . . . L1.' NOiICE TO APPLICP.Ni: If, ofier moking�thia Certificate of ARCHITECT O TE�• DISTRIC7 GROUP 7YPE FI2E PROCESSEO BY O Exemption, you ahould become subject to Iha�Workars' ENG�NEFR O. -�- �pry�� -ZON. V Compansation provisions of the Lobor Code,yo�m�st forth- qpDRESS 1�y'�R� v"' � W ' � Q � ith comply ith soch p�ovisions or�IhiS permit'�,shall be ._ .. , � 7EL. • - STATISTICAI CLASSIFICATION APL CO DO. N deemed revoked. � � �pNTRACTOR NO. ' � ( Z LICENSED CONiRACTORS DECLARATION , / � � ���,,,; , � QASS NO. �� �WEIL UNITS I hereby offirm thot I om litensed under provisions of Chopter 9 nDDRE55 N N✓�' • NO.��� ��R�P (commancing with Secfion 7000)of Division 3 of the Business and /� C" � '�IIC. � ,_/ Rofeuions Code,and my license is in full forte ond eHeU. CnrL(Jl/� � - �" CLA55 BK.- � VAUDATION � ��/���/ K^ SO.FT NO.OF NO.OF , � CHECK License Number o 7 � liC,Closs_.Y / SIZE STORIES FAMIlIES 'ONE UATION CoNroclor�IL. (� pa�e� �-3/"&� - DESCRiGTION OF WORK N� � O OW^ noo � S ❑I am ezempf under Sac. . AITER O :o a 9,a A 6.8P.C.for this reason � REPAIR � s Date: � USE OF � #• • • •2 S EXISTINf.BLDG. ��`r'a ❑ Signoture � �� � �'� � �� APPLICANT' iEL FINAI� /yM . .. � •9 1 t 6 3 OWNER-BUILDER DECL4RATION �. PRiNT NO. . DATE «`� x 1 hereby affirm that I am exempt fwm the Commctor s license � / ��� ' ' •9� �•�J� Law for tha following reason(Section 7031.5,Businass and AookE55 p � -Bi1' � FINAL � . 6Y � 0�� f�—�i 8 Professions Code): �- � � � . . � . ❑ ' � BUIIDING I, os owner of the property, or my employees witb nDokE55 wages as�hair sole compensmion,will do�he work and - � � - - ' ' c 2 4 2 S A the slructura is not iroended or offared for sole(Section ��CAlI7Y � ., j��� 7044,Business and Professions Code). , � - MOVING - TEI. -� � - {�• L • • . � . � I,as owner of�he proparty,am ezclusively contracting coNTanCTOR MO. with licensed contractors to[onstruct Ihe project(Sec- qDDRE55 � I,��O$�O O tion 7044,Business ond Professions Coda). �, ' � 'I.O B�O O z REOUIRED� 10iAL SETBA K � �- • �. � � CONSTRUCTION LENDING AGENCY �� � - � � SE7 BACK' YARD HWY PR07.tMF wioiH � ' I hereby affirm ihot there is a construcrion lending agency far fRONT � � � ' I Q� (1—�8 - the performance of the work for whith fhis permit is issued . P.L � � � • " (Sa[.3097.Civ.C.). '�, SI�E P.l. Lender's Nama � � - � � � � LDNA Ref.M Lender's Address P.C.Fea S �. ` Permn Fee C�7-Z'�� . � 1 cerlify that I have reod this opplica�ion and state that the � ieeuonce Fes ���� lDhL4 v/C ' obove infwmallon It conact.I ogree to comply with CII CAVnry Invesrlqolion Fee O $ ordina ond S�a�e laws r lating to 6uilding eonstruetfon, Toeal Fs� � �� J��� LpMq v�.m.N and er y th � ro sentotives of this County ta enter � � � � - � o e o �nw .d-pwperfy for(nspectlon pvrposes. 1 �„. 1n �O'^� � � � ��� r�.»\'it�t w . . , . S[E REVERSF FOR E)I►LANATORY UNGUAGE Signa� of Applicanl or AyeM - Oota � . . _ . . . � �'..� . �. . i '�� ._ _'_ '._ "_ ....'_.'. ""� .. �. . . 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