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HomeMy WebLinkAbout1217A 1218A (6) WORKERS'COMPENSATION DEQARATION � � � - - � I hreby afF�rm ihar I have o cer�ificote af consent to eelf App���CATION FQR BUILDING PERMIT � iniore,o�a ce�tificale of Workeri Compensotion Insurance, � � o❑raYertifiedcoleoc�P7�f��+�a.3Y00,��C.)- �� COUNTY OP LO$ANGELES BUILDING AND SAFETY Polic No � an � BUIIDING �l � �1 `yL�� Certiiied capy is hereby furnished. FOR APPLICANT TO FILL IN ADDRES$ �j• JV � Cerlified copy is filed with�he co�nty building Inspec- BUitDiNG / / �� IiondeporimeN. n A�DRE55 b 4"b /V- ��7�L4 M Date �•• •��Applic t � L< �.� CITY �Ot�'f n Lt✓� ZIP LOCAIITY t ��� CERTIFICA OF EXEM TION FROM WORKERS' NO.OF BlDGS. NEAREST � COMPENSAiION INSURANCE SIZE OF tOT NOW ON LOT CRO55 ST. ' (This section need not be tompleted if the permil is for ona /+SSESSOR 'hundred dollars(5100)or�ess.) TRACT BLO�K tOT NO. MAP BOOK PAGE PARCEL ,1� / TEI. USE ZONE µ1P 1 I certify Ihat in the per(ormance oi the work For which Ihis OWNER /v (A� A NO. � permif is iSsued,I shall nof emplay ony person in any manner qD�RE55 ' `] /�l SPECIAL Q so as to become subject lo the Workers'Compensotion Laws. CONDITIONS Q Date Applicanl CitY ZiP � NOTICE TO APPLICANT: If, after making�fhis Certiiicafe of ARCHITECTOR TE�. DISTRICT GROUP TYPE FIRE PROCESSEOBY O Eaemption, you should become svbjett fo Ihe Wo�ke�s' ENGiNEER No. CpySL.--,� ZONE U /�.` ♦\ Compansarion provisions of the Lobor Code,yo�must forth- qDDRE55 �v U W wiih comply wiih such provisions or this permit sholl be I �- deemed revoked. . Gl/ej-r �,e TE�� STA715TICAL CLF SIFI ATION APt. CONDO. z COMRACTOR 4� C��O��/l —7S�F LICENSED CONTRACTORS DECIARATION ���, � M55 NO.�DWELL.UNITS I hereby affirm that I am licensed under provisions oF Chop�er 9 ADDRE55�� r � � n70. 7� (commencin9 wirh Section 7000J of Division 3 of the Bosiness ond UC. ����P - Professions Code,ond my�itense is in full force ond eNett. CiTY Gt/��+ /''t v� QH55 � VALIDATION - � /-} SQ.FT.� �NO.OF NO.OF CHECK gK' �' License Num6er��Lic.Closs •U SIZE STORIES FAMILIES DNE VALUATION Conrraclor 4/�t'-� G-�C'� pme - O $ DESCRIPTION OF WORK � SP� n,C,_ N� � f I AOD � •� , ❑1 cm ezempl�nder Sec. � � � � e� ALTER B,BP.C.for this reason . 1 Z.� REpp�R � S . Defe:T?� USEOF DEMOI ❑ / EXISTING BLDG. Signatur � /� APaIiCANT \ � _ /, TNO. 3- `7_j FINAL lU l�}�� . . ' OWNER•BUIIDER DECLARATION PR�NT J /C.�. DATE i f O I hereby offirm that I am exempl from the Contractor's Licensa -- � r _ ' tow for Ihe following reasan(Section 7031.5,B�siness ond ADDRESS � — FINAL Professlons CodeJ: �� � pkESENT BY �� 2��']A ❑ BU�LDING ' 1, as owner of fhe property, or my employaes with nDDRE55 wages as their sole comoensation,will do thw wnrk nnd � tt° ' ° '2� ' Iha snucture is not in�ended or oifered for sale(Section ����TM 7044,Business ond Prolession5 CodeJ. � MOViNG TEL.. , � • �L�J,�� � t,as owner oI tha praperry,om extlusively contraUing CONTRnROR NO. • • •2�O O U wi�h licansad conrracrors ro consrruct the projeU(Sec- - qpoREu - ' � '" " . rion 7D44,Bustness and Professions Code). p CONSTRUCTION LENDING AGENGY SEQBACK �ARD Hwv iOiAPROv.IINE WIDTVI O�Z 9'V S I hereby offirm�hat Ihera is a tons�ruttion lending ogency for FROrvT 7� 2�.g a the performance of the work for whicb this permit is issued - v.l. _ . (Sec.3097.Civ.C.J. SIOE � • • • . •� P.l. lender's hloma � ' P.G Fee 5 �-5.�0 Permif Fee �'"'"R°��" I • •3 6 7 5 lender's Address � � �� r x • n •3G'�J;, I cartify Ihat I have read this opplication ond state Ihat fhe beuonce Fee �Q..� LDMA P/C M obove informmlon is correct.I ogree to comply wi�h all County ,���,,,9,,;0�F�, . 0&2 9—8 8 � ordinances ond Stote laws ralaling to bullding conshuction, To�ol Pee � � LDMn verm.M and ha�eby au�horlxa reprefentatives of this Counly to anter upan�3p abova-mantfoned property for Inspectian purposes. �� // -- L-� (�- z 1./ �J SEE RFVFRSE FOR EX►IANAfORY UNGUAGE C --Signature of Applican�,or Agent ppte �� _ - o ° ,} ' S. �, `. �' � . ; � • _ ,n � ;� a n . � ��v-- � . N �Q p � i:- � 7 (� r (�� n � p -,j n p c� Y � � p p � 3� �� '� .v(I 9 r,, b � o � Q O r '= ..° 3 'V �' i t� O t�'�c,' `� C z a V '� ? � �, N.`� ' _ . '� r, r� � C�, j g O � � O� �O ?, �- � . ' . Y p p � 3 v f� ''o j�. "c ^ N T? 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