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HomeMy WebLinkAbout1151A 2439A _ WORKERS'COMPENSATION DECLARATION � ' � insureborucertifkat�eofWorkes''Compensolonlnsuranca' . .� APPLICATION FOR BUILDING� PERMIT � or a cerfified copy thereof Sec.3800,Lab.C.J . - , � �zSs 1 / COUNiY OF LOS ANGELES BUILDING AND SAFETY P❑olicyN��'��/�Company S/����^�C - Certified copy�s hereby furnished. FOR APPLICANT TO FILL IN ADDRESS .?.��S-� �- e++-� � Certified copy is filed with the county building inspec- BUIIDING �{ � tiOndeporirllen�. . � . ADORE55��� J� .�.✓ �E=�v �aA��TV .(/r�. NEARE57 oare `��ApplimRt J • arr .'�,.-.-.�..�rl 8.., ziv ! Cos ceosssr. _ � CERiIFICATE OF EXEMPTION FROM W KERS' NO.OF BlDGS, ASSESSOR COMPENSATION WSURANC• . SiZE OF lOT�.3/O k�,3G NOw ON LOT MAP BOOK PAGE aARCEL USE ON �P q �� (This sauion need nof be completed if ihe parmil is for one � Os� hundred dollars(E100)or less.) . , - TR/+�T ' s 7 BLOCK lOi NO. �� �� NO. d"Y . - . � TEL. L{OOO(� SPECIAI Y I cerfify that in tha performanca of tha work for which this owNER � r� � e6CC: :�i NO. - CONDITIONS 4. permit is issued,1 shall not emplay any person in any manner � � . DISTRICT GROUP TYPE FIRE PROCESSED BY Q ADDRESS i S GZ-M G / A3 CONS� ZOplf� so os to become svbject to ihe Workera'Compensotion Laws. !v �` ��� �� UOfe Appliconf ' � CITY Z�P STA715TICAL CLASSIFICATION APf. ONDO. O NOTICE TO APPIICANT: If, aFier moking this Certificate of ARCHiTECToe Z+ � /. iEt. � U ENGINEER �Ya. NO. CLA55 NO. �WEIL UNITS � �Exemption, you should become subject to tha Workers' u, Compensalion provisions af 1he Labor Code,yov must for�h- � qooaE55 � SEwER MAP �� � with comply witb such provisions or��his permH shall be .�/ �� � '� deemed revoked. � �� , coNreaCroR 2,.� N�o.�(�o. 77 - 3 - BK• ' �• VALIDA710N LICENSE�CONTRACTORS DECLARATION ' � �" � LIC. I hereby affirm thol I am licensed onder provisions of Chapter9 ADDRE55��V J ,to..J l/,�w NO �.P•23 VALUATION (tommenting with Seclion 7000)of Divisio�3 of the Busineu and � / / �� tIC. _/ _ _7 O� � Professiona Code,and my license is in foll force and effecL CITV e.t H a. L- ti- GU55 �Q U�� -5 SO.F7. i NO.OF NO.OF CHECK LICenSB Num bef P���3"5— LiC.C�ass� S I Z E �7 s S T O R I E S F A M I I I E S � O N E •��,N O O, , 2� � �� A G {J' /����� S J COnffOCtO�'/Qi`�'��e�i�0 I��,_����'eic�-+ OESCRIPTIONOF WORK NEW � �• • • •`Z TJ , ❑I am exempt onder Sec. � � � o �/� �C ���} ,9,2� ADD � • 1 5&5 3 . . . i/ 'S /•�Q- AL7ER � paTE� �3�.`.�. 1 5 3.5 3��. B.BP.C.for ihls reason - � �`M' o�'n`Y REPAIR ❑ • � � � - Dote: USE OF � . p��� � FINAI 0 Z 0 3—8 5 � EXISTING BLDG. By � $ignafure - , APPUCANT � iEl. OWNER-BUILDER DECL4R,4TION PRINT�+�+s •`� /� ��dn�No.BG/-sc�>3 I heraby affirm thol I am exempt fram the Contractor's Licensa� � � ► . Law for the following reason($ection 7031.5, Businass and � AODRE55 - - . > Profauions Code: - � � � � I, as owner of tha ro er � y. p y � ' Bu"o'"� � . -�2 4 3 9 A p p ty, or m em lo ees wifh ADDRESS ' wages as their sole compensation,will do�he work and � ' r�• • • •2 3 . fha s�rucmre is not imended or offered for wle(Section , LOGnuTY i - � 7044,Business and Professions Code).. � MOVING 7EL. ' � � I • •4 6 7 5 CONiRACTOR NO. � I,as owner of Ihe property,am exclusively camrac�ing . • � � - ' '� • • d 4 6 7 5�. witM licensed comractors to constroct the projed(Sec- ! `;;� � tion 7044,Business and Professions Code). ADDRE55 . O a Z G�8 Jr � REQUIRED I YARD HWY T�TAL SET&4IX FROM E%IST. 2 4�I.O ft CONSTRUCTION LENDING AGENCY � � � � sei snCK VROP.LINE wio7H , � I hereby affirm that there is o wnsiruction lending agancy for - FRONT ' " � ' � Ihe performonce of tha work for which ihis permil is ias�ed a.t. i . ,�. • • •'�� tSec.3097.Civ.C.). � . . . SIDE " ' . .. ' . r.i. f •252Q0 : Lende/s Name (-� q !� � � � . � $ � � P.C.Fee S � �v O���.I Permit Fee C1� I . . � �2`�2 Q� . lendar's Address 'I ^ ' . ' � U � 1 cenify th6t I have reod this applimtion and swte that tha � �"'} �ssua<e Fee �" . �$'2�6�$5 � abova information is mrrecf.1 agree to comply wifh oll County Invesiigation Fea � �� . . . . ordinances and 5tate laws relating to building mnsiroaion, Toial Fee and hereby oWhorize representa�ives of this County to enter �upon t obove-man�ion property or inspectlon purposes. . . i - � " V �J ;����S- SEF 11EVERSE FOR EX�IANATORY LANGUAGE ,� Signaturo pplicontorAgenl . Do�e � i I / .. .. � _ ...._.. .`"__ : . . _.__ " ' ___..— . .. ._ ..._.J � . , . _. . . . �..� _ . :. . . �. � .�, � � `�. .-.,�T' '�i - E � . ..._ ,,. . . .� . . . �' . � . , -.: .,.�_ ...... . ....�. .� ,�-... i :' u:^.V: �. i . � � : :,1., c.� a yc c�; . ... . -... . . . ,. .� , Juoy uo�ayu3 .. .�.� . ... .:.. .._ . - :.::. �... : � -�:.._.�.�, .._ _....- ,.. : ,. �.. ,_,. � r. 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