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HomeMy WebLinkAbout1885A 1918A (11) WORKERS'COMPENSAiION DECLARATION � ' : ' � ��1.. 1 hereby.affirm�ho�I ho�e o�e,�;f��a,a of�o�5e�„o self APPLICATION FOR BUILDING PERMIT insure,'or a cerfifimte of Workeri Compensa�ion Inzuronce, ' or a ce�tifiqd copy ihereof(Set.3900,Lab.!C:)� � . ,q ,'.�� COUNTY OF LOS ANGELES 6UILDING AND SAFETY - . PolicyNo ' �.. �:"� Company .'._ "' � '-��. / BUIIDING -., " ' � Cer rfied copy�s hereby furnished. FOR APPLICANT TO FILL IN qopgEu._., ' r' :; . /i -. � ' � Certified copy is filed with ihe covMy building iqspec- BUILDING �� � _ , A�ORESS � . tion deportment..J ,� � .�L. . �" . ;:.,��r,:;;;T ' /; '. / .•:,r.. • Date � Applicant O7Y � 21v 'i � tOCAUTV � -� r �GERTIFICATE OF EXEMPTION FROM WORKERS' -� NO.OF B�DGS. NE4tie5T � "�,%/�I��( COMP£NSATION INSURANCE� � '�� SIZE OF 107� ' NOW ON lOT � � CRO55 ST. I � ' � �� ' ' C �. � �This sdction need not be camplated if.�he parmit is for ona , n55E550R �.. � hundrod dollars(E100)or less.) : :� ; tRnCt BLOCK LOT NO. -: Mqp gpq( PAGE PARGEL 4 , , . � �., TEI. USE ZONE �P � . , I certify ihat In the performance of�rhe work for which this � owNeR -. � � No. Np, U . permit is bsued,I shall not amploy ony penon in ony manner :_,,,,5._� �E��A� � � so as to bacome subject lo.the Warkars'Compensafion Lows. ADORE55 � . CANDITIONS CITY .-'.'`��° �:'��: ZIP } ,�t� ' } Date �Appl�ca+nt ; ,. ' ., � • ARCHITECT OR TE�•' DISTRICi GROUP TYPE FIRE PROCESSED BY NOTICE TO APPUCANT: If, after making�ihis Certificole of ENG�N!R ' ���� ` NO. ¢ ' • Eaemptlon, you should become sub�ed to the I Workers' , CONSL....-;� ZONE \ � � Compensotion provlalons of�he Labor Code,you musf forth• qDDRE55 � I C�. ���-4+n �_�.— �� \ �d with comply wilh s�ch provisions or'this permil'��sholl be � • ., 1E�. STATISTICAL QASSIFICATION`S, APT. CONDO. �L deemed revaked. �ONrknCtoR -�' �• /���7 NO.� ' ' � .�� W UCENSED CONTRACTORS DECLARATION ! � . �i�, . , aa55 NO. � Owei4:UNITS h_ 1 hereby affirm 16a1 I am Ilcenead under provisions of Chopfer 9 ADDRE55 '• /���'�' �' �"! NO.� SEWER MAP (commencing with Section 7000)of Division 3 of the Businessond . ���, � ' Professions Code,and my licanse io In fuil farce and aNect. CItY� � - Gu55 % BK � VALIDATION . . „. �� ` _ � SGI.FT. N0.OF NO.OF CHECK License Nombar ''� LIC.Closs � ' S2E STORIES FAMIliES ONE �/ � VALUATION � !'i' ; ! ..,�. . 7 ,l�' i—'�( � �ESCRIPTIONOFWORK ��� .. <• . NEW Q �. �. � . Contracror Date �p � ,''ti /• f S ,C..�C�1 a 1 �'��-/�1 � �I am ezempt undar Sae. �� � � �! ��'�', , .� e��s,.����? . . AITER � 1.�. .�.,v: B.BP.C.for thia reoson � REPAIR ❑ s '��n�,�'{y��,(]� � .� Dale: "�!" - USEOF - DEMOL ❑ j . . E%ISTING BIDG. � �'�'",., n ( I.'' � � APRICANT! . TEL ��!,�i C;L C)y�i.i Signature ���' . . ' � . FINAL ' �OWNER-BUIL RDECLARATION - vR�NT r NO. � DATE � � ; I hereby affirm that I am e mpt from iha Contracror's Licansa ' �"�'�'t"'�`"n ' Law for the following re son(Settion 7031.5,Bvsiness and AooREu��+ - - FINAL 1�., +Q��� ,i Professions Code): By ��1 ���4-I � BUIIDING ; � t � I, as owner of the propeny, or my employeee with. nDDRE55 � � , � wogas as thair sole compensoiion,will do the work and �p�AIITV ' ' � I rhe s�rociura is not inlended or oifared for sola(Section ' . 7044,Business ond Professions Code). MOVING ' TEL. ❑ � CONTRAROR ' NO. � � I,as owner of the property,am exclusively confrociing wiih licensed contraaors to construct the prOjeU(Sec• qDDRE55 � � • tion 7044,Business and Profeszions Code). ; � . - � � � � «� {, h ' REQUIREO� TOiAI$ETBA K "�:�� .•�+y/1 � � CONSTRUCTION IENDING AGENCY �; � 5eT a4CK; YARD HWY PROP.lwE WiDiH ` , � I hereby affirm�hal thera is a construction lending agency for pe0ui ' ��i::,;,��':?;•.,�; �ha performance of fhe work for which this permit is issued P.L � `,.,.i . � . ' (Sec.3097.Civ.C.).��� , SIDE - � ����:'�!i7(��(a P.L � .. . Lender's Name ,i .: r j��s!�j(��-� LDMA Ref.!1 m - P.CFee2 � ��.� � i�';�i PermitFee }.�;'�..fl .. . . .7.� •y ` lender's Address � �� ' " � ' C,y,F, , �� , � 1 certify that 1 have read this applicotion and state that the issuonce Fee ��t:"•ra LDM4 P/C M � o6ova informotion is mrrect.1 og�ee�o mmply wiih oll County Invemigo�ion Fee . $ ordinances and Stote laws relating to building construUion, �� r•, t'�'� - To�al Fee �� _ L�MA Parm.M ° and here6y authoriza represen�otives of ihis CouNy to enler ' � . � � opon tha_abdve-m/entioned operty for inspection purpases. � � �./ /If " � ;SEE REYERSE FOR EXPIANATONY LANGUAGE . � / Siqnoturo af�p�icom or Aqent ,pate � � - . 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