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HomeMy WebLinkAbout1537A 2528A WORKERS'COMPENSATION DECIARAiION � � �� � �� �� � � � ��� �� � � � �- � - -��' - - ' � I hereby affirm ihat I have a cenifimte�ol�o�se�,�o,e�F � � � � � �APPLICATION FOR BUILDING. �PERMIT� � �j insc�e,or;a�erY(ito�e of Worke�s'Compensafion Insoronce, I I � o.C L'errfied copy�hereo�(5ec.3800,l . COUNTY OF LOS ANGELES BUILDING AND SAFETY � Policy I�����Company � Cenified copy is hereby lurnished. FOR APPIICANT TO FILL IN BUILDING�ab ADDRESS � Cenified copy is liied wiih Ihe county building inspeo- BURDiNG. C / tion depa��ment.. . , , ADDRE55 e,(/ J 1 �. �ale Applimnt CIiV (W10 . �•�.. . ZIP IOCALITY CERTIFICATE OF EXEMPTION fROM WORKERS' � _ NO.Of BIDGS. _ . NFqREST COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T CROSS ST."� �� � (This section need not be mmpieled if Ihe permit is for one ., . . ASSESSOR - hundred dollars(S100)or less.) TRACT- BLOCK LOT NO. Mqp e00K PAGE PAR�L �� / � �/� TE�' USE ZONE N✓aF i cerrify ihat in ihe performonce of the work for whith this OWn7ER �119�^� �`O�t�� n10. — /�� i � a permit is issued,I shall not employ any person in any monner /� �2 C/� SrECIAI . p so as fo bemme subject to the Workers'Compensation Laws. - ADDRESS i V��rpLP�(/ $1 � CONDI110N5 O ` arr -P�/A— V+ zir � Dafe Applicont ' �� � ARCHITECTOR � 7 ' 7E1. ' 13 � NOTICE 70 APPLICANT:.H, after-moking Ihis��Cerlificote O( ENGINEER ('�4L�;1/.i ,S( .ti NO. � �Q DISiRICT GROUP �NST. 20NE � �D�Y V Exemp�ion,.you should 6ecome.su6jec�.to.the Workeri . .. . / . / / /� -_������� W Compensation provisions of iha Labor Code,you must forlh• qDDRE55� , L� l�V� L/f v ^' N wi�h comply wi�h such provistons ar rhis perm�� shall 6e . 7¢t. ")i � siniisncn�cws iFlSqrioN nvT. eor:oo. Z deemed revoked.� � �oNTenCTOR � NO. —�/ � 4 UCENSED CONTRACTORS DECIARATION� . /.// MSS NO. �d�OWELL.UNRS � � �-r�.No: 3�o?G I hereby offirm that I am licensed under provisions of Chapier9 �� ADDRESS 3 lO4"+�2 (commencing with Section 7000�oi Divisian 3 of ihe Business ond LIC. ��R�P � P�afessions Code,and my license is in full force ond effecL � � CtTY G N.H ��� � nqu �5 BK:.._ � � . VALIDATION � \ 3 p' � SQ.F. b�L NO.Of NO.OF �, CHECK �tCensa Number � ��i G � Lia Clasz � � �� SIZE�/ �- StORlES �-� FAMtlIES �� ONE � . T7� /�� . �I� �l! .. ❑ VAWATION . �1 5 3,7 A \Conlro[tor�/ T �Pf Date b% � �ESCRIPTION OF WORK AD� � O p . �=I�n, � N� : �5 O ° � , • • I am exempt under Sec. �U�� �• •2 J � AITER � B.BP.C.for this roason REPAIR � S � • •9 1.3�o . Dofa: ..... USEOF � l N� DEMOL ❑ •e •CJ��J�� EXISTING BIDG. �-' APPLICANT ��--_��.�.� -..TEL. 7 `� Signoiore /N (� vawt /---�J ' o. ��—U'�SG= FINAL p��, 0 9.1 3-8 8 OWNER-BURDER DECIARATION r� /� DATE .�j7, '✓ I here6y aHinrt that I am ezempt from the Co�trocto:s License � qooRE55� .� .- F'G�D",@�aGS �� �l�S � � Law for tfie following reason(SeUion 7031.5,Busidess�ond FINAL�.� � � � Professions Cade): . , . . ., . PRE ENi. . . . . � SY — � BUILDING � o G�o n . � I, ee ewner c!!h^proper!y, er my employees•si!h ACCR:;S �' � 2 v c,v n wages os their sole compensation,will do the work and � - -� - � � � �-- � - � ' - �� � , � � � � �he structure is nat intended or offered for sab(Section ����TY � - #a . . e�� � 70dd,Business ond Professions Code). . MOVING , . ._ . _ . TEL , . . , . . . ❑ I,OS Ownel o(Iha ro ert am ec[�USive� tonira[tin CONTRACTOR NO. P P Y. Y 9 I • � � B.00 with licensed controctan lo conslrutt fhe project(Sec- qooNE55 ��� - ��- � - � �� ��" ' �-- � �� tion 704a,Business and Pro(essions Code). .. . ... � . : ��� �j��?; CONSTRUCTION LENDING AGENCY. . .� SE�OACK VaRD HWY ��TApgOP.L�NE � �W�DTH � 1 hereby aiiirm thal there is a construction lending agency for FRONT � �Q� 9—S S tha performanca of Ihe work for which this permit is issued , P.l. . (Sec.3097,Civ.C.). SioE - , � P.l. Lendei s Nome� � - " � � � � 7 v LDMA Ref.8 Lender's Add�ess . . P.C.Fee S Permit Fee � . . ' . I cartify that I have read this applicaiion ond stme�hat the h:vonce Fee �O l�hu a/C N , � ' �abave infa�maiion is mrrect.1 agrea to comply with all Caunty � invastigaiion fee �J � ordinances and State laws rela�ing to building conslruction, Taiol Fee d tDMA Pnm.M � and herehy authorize reprosentotives of ihis Covnty to enter �� - � � upo(�.e abava-mentioned property for inspeclion purposes. -- ^ . �o n r ^. . ._ .. . . �� ^��/`—+-e2� �� SEE REVERSE FOR EXPlANA70RY LANGUAGE / gnature AppGcan�or Aqem . .. Doro . . . _ . _ .... ._. .... . . . ... .._. . .. . .. .. . . . ... . . . � _ ... _.. , . .. - x -' , o 0 - _� i ro_ � 1 -1 � v-"� � l, o- `� ' ' r �� a � .sa �� �. r, � ' 1 .. �, � ;� �� ��� �� • �� � E, >� o '" n � p x �o i �� �o b' �� � �� �.,, �� g ;r L: n a \ m �� � � � � � C�� � � ,.� p O i � ,i. � . ` T ,� � O' ry�G � �� .,q O 9 � ? � ` ,+ � e9 � .� �� ; �^ r � O 3 � �y O .p,. . �D n p O � "^" . � , , �.1. 9 TT nU p 7 m � a F� � c� ?„ �o ^ `� ' �� . Z ry a io m m n� � ? -c a. 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