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HomeMy WebLinkAbout1285A (9) WORKERS'COMPENSATION DECLARATION � . , . � . ' . � insore orafclertifimlelofWorkeserCompenstiooln�;a��eso'; � APPLICA�TIQN F�R� BUILDING PERMIT o terfified copy thereof(Sec.3800,lob.C.) _ . COUNTY OF LOS ANGELES BUILDING AND SAFETY . P❑olicyNo. Company � ' BUIIDiNG ///� Q _� � �A. . Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 `r c(sv it..G�� � �Certified copy is filed wilh the county building inspeo- eUiLoiNG. i /� . tion department. AD�RESS � 9 � 2 LOCALItt �-�'� . 4'�-�-C� NEAREST Dote Applimnt � CITY / � ZIP � i CROSS SL , CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. n55E5SOR � � � COMPENSATION INSURANCE SiZE OF lOT NOW ON LOT � MAP BOOK PAGE PARCEL (This seciion need nol be comple�ed if the permit is for one � �(��.p`3 USE ZONe MAP /�7 �3�/ , hundred dollars�5100)or less.) � . _ TRACT eiocK ioT No. / �� No. a TEL SPECIAL I certify ihat in Ihe perfo�mance of the work for which Ihis OWNER NO, - OT� CONDI710N5 0 permit is issued,I shali nol employ any person in any manner ADDRES �/� � � � � DISIRICT GROUP TYPE FIRE PROCESSED BY (J CONST.� ZONE � 0., so as to become subject 10 the Workers'Compensation laws. �/� �� � ��� O ' /� r t Dote Applitanl • 'L�- CITY • Z�P � STATISTIGILCWSSIFICAiION ACT. CONDO. (~J ' NOTICE TO APPLICANT: If, ofter making this C6 ifimte of � ARCHiiECi OR � � - - . - TEL. , W Exemptian, you should become subjeU to the Workeri FNGINEER NO. CV SS NO. �/ DWEIt.UNi75 � :Compensaiion provisions of�he Labor Code,you must forfh- ADDRESS �� � ' SEwER�na.v � a with tomply with s�th p�ovisions or this permit sha�l be � — deemed revoked. � TF�' ' gK, � p�, VALIUAT�ON . CONTRACTOR NO: ��LICENSED CONTRACTORS DECLARATION � � �i�, . I hereby affirm ihat I am licensed under provisions of Chapter 9 . A�DRESS NO. VALUATION � (tommencing with Se[lion 7000)of Division 3 of the Business and ���. ' . . � Professions Code,and my license is in full force and effect. , CiTY � C�ASS � S ��"r' � � � , � � SQ.FT. NO.OF NO.OF CHECK. � " �License Number � Lit.Closs Size STOeiES FAMIllES OrvE • . ' - � NEW � S � . Contractar ' Date DESCRIPTION,OF WORK . ❑ . � � � �� ADD 1 am exempt fram the licensing requiremenfs as I am a litensed orthitett or a regizlered professional eng(neer _. _ � ALTER F�NAL _ at�ing In my prafessional wpaciry (Section 7051. - '� �� REPAiR .� DATE �-/���5� '� B�siness ond Professions Cade). U, OF � � � � ExISTING BLDG. 7 �EMOL ❑ FINAL � 8y lic.or Reg.No. � Dore ADp�I�ANT TEI. �� , ' . -- -- - � OWNER-BUILDER DECIARATION � . ' IPaiNr� � No. I hereby a(firm thot I am exempl irom the Contractor's Licenze � �q���,�,�, � � ' � _ Law for the following reasan(Sectivn 7031.5,Business and ADDRES ' !? "� � f`''"� " Professions Coda�: Paesetii ! , p $� 2 8.5 A _n .. . . BUIl01NG . . ./n...�.(r /�/S 0 � `� I,as�owner of�he�croperty, o�my emcloyees wi�h qoDeE55 7"Y""�-� woges as their sole compensaiion,will do the work and . v �' •" "�'j �� �he structure is not inrended or offered for sale(Seaion �OCnliiY - - � - 7D44,Buslness ond Professions Code). . MOviNG �� TEI. � ��,• •2�Jr� � � I,as owner of the property,am extlusively contracting CONTRACTOR NO. � . • •2�5 Q� � wi�h licensed contraUoro�o consvuct��he project(Sec- qDDRE55 � -�� tion 7044,Business and Crofessions Code). - - p RE�UIRED TOTAL SETBACK FROM E%IST. 0,�.� U��2 ' CONSTRUCTION LENDING AGENCY SET BACK VARD HWY PROP.IINE WIDTH � I herehy affirm that�here is a conslruclion lending agenty for , FRON7 � the performonce of ihe wo�k for which this permit is issoed P l. (Sec.3097,Civ.C.). , - -� SiDE - � P.L._ Lender's Name . . . , � s Lender's Address P.G Fee E Permi�Fea �� � � I certify�ha�I have read this opplicaiion and slare that the issoa�ce Fee ��� ' . above informalion is correct.I ogree to comply wi�h oll Counly , Imesi�ga�ion Fee � � � � - � ordinances and Sbte lows�elating to building conStioUion, � and hereby ao�hori:e iepreseniaiives of this Coumy to enter Tmal Fee ,�,,;�,.J D opon the above-mentioned proper�y for inspection purposes. ����� � SEE REVERSE FOR EXPlANA70RY LANGUAGE � L 6.C1 ' S�g�o�u.e oF li�ont or Agenl Dote �� w >; o 0 0 0 � o iQ. o �o c o nv m m o � -'•' '� `' - o` o �o - c �- T � � , om a o 0 o i• ^ m � 37 •c � Q,g. : x' o � ., ,�, m� � a ° � ' C I I � 0 � �.., !'J l0 n � �9 � Q � O b � � � T ' . � a,z x °� ,- - n-� _� �n � ._, �,o m• � � o n �+ � m O f I .a. � � 0 3� n 3 0 ° m m D p 'D� � o c ;, :�'. �o' ro ❑.n o - v _ „ � �m � I � C • O -�O 0 O � O O (i � n ro � . . a i o _ a w � v � ; 3 0 'o 0 � � ' • � V o `� ; m o Q o c: . - .. � � v a 3 � o � � � � + a . ; �o I � O � Z o Z u' o '� o ' � « o I� _ • � A � c 4 •c • o � '_ Z a p 3 ^ o r � . . , Q Q y O � I ti �' �'4 N . � D O � 'O O - � O � c O O b - ° a,o < a. o a \ - i r � �� i _, c .� / ' _ �� ' '9 �. � ' rn .. • � �- � ' � � - A � � , � ' _ ' , .i , � 0 ` , � . i. .�' � • m - • . 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