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HomeMy WebLinkAbout1736A (19) WORKERS'COMPENSATIONDECLARATION � APPLICATION�� � . . . . . � .� . . . �. . �. � I he�e6y off�rm�ho� 1 hove a certifimte of mnsent to self � � - ' �OR� BUILDING �PERMIT . inwre,or a certiiimre of Workers'Compensarion Insurance, _ or a cerri�ed copy tbaeof(Scc.seoo,lob.G.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PalityNo. Company BUiLDING � Cerriiied copy�s hereby furnished. FOR APPLICANT TO FILL IN nooee55 ,S � Ceriified copy is filed with the tounty b�ilding inspec- BVii�ING ��� G���� C IIOn t�epo/1min1. ADDRE55 Dale Applicant CIiY L/1�/�' I LP ` LOGAUTV CERTIFICATE OF EXEMPTION FROM WORKERS' � . . . . NO.OF BIDG. NEAREST COMPENSATION INSURANCE � 5�2E OP lOt P70W ON lOT � CRO55 5t. �This setlion need not be completed if the permit is for one �7 � n55E550R � . hundred doliars(5100)or less.) . iaqCr.3 6lOCK : lOT NO. µqp BOOK PAGE PARCEI .1 rcf�A�L /v �co NO � �(J� U�JONE MAP I certify thot in the performance of rhe work for which this OwNFR Np, permit ie issuad,I ihall not employ any parson in any manner qDDRE55 30C:J� "�h'i� \.'! ' K O�� CONDITIONS � ao os to become s�b�ect to�he Workeri Compensotion taws. -7 q � � . . . . . CITY �L�J� � ZIP j /� / . - _ I . . U a DOfe APP���a�t ' qRCHiTECt OR TEI. DISTAICT GROUP iYPE flRf �ROCFSSEU BY O NOTICE TO AVFLICANT: If, of�er moking��his Cenifimre of ENGiNEFa NO. ' _ �� �3 �pNST. �� 20NE � �� V Exemption, you ahould become subjeU.fo the Workeri � � Compensotion provisions of Ihe labor Code,yoo muet forlh- qDDRE53 W� wNh [omply with such p�ovisio�s or�Ihis permit shall be . . . . TEL STAt1571CAt C10.S51FICATION A7T. CON00. � dcemed ravoked � cONiRnCide NO. .'9 1 Z IICENSED CONTRACiORS DECLARATION . . . . . . . LIC. CLA55 NO. •�_l_DWELL UNITS I hereby effirm tha�I am licensed under provisions of Chapler 9 ADORESS NO. � SEWER AAA.P (mmmendng wi�h Seclion 7000)oi Division 3 of ihe Businesi ond UC. � . Professions Code,and my license is in full force and effect. CiTV CtAss gK � VALIDATION �� � Sq.FT. NO.OF NO.OF CHECK �� '��(�A licenseNumber � � LIa�Class SiZE � STORiES fAMilIES- ONE - . ❑ VALUATION �• • • • •� � � OESCRIPTION OF WORK � NEW S SOD� Contractor Data A /"�} aoo ❑ � , 1 • •3 b 7 5 ❑I om exempt under Sec. � ��� ''µ G y�-" AITER ❑ • • •3�7 5 c=i i B.BP.C.for ihis reoson � �-h+�� _ � ZG {�PAIR � S . . use oF 0&1 8,—8 7 Dale: EXISTING BLDG. . DEMOL ' APPL�CANT TEL'- Signature ���( . ,,IPEL ' �CG No. . — •��� FINAL OWNER-BUIIDER DECtARATION � PRtNi DATE _1 hereby affi�m rhm I om exempt from fhe Conrractor's Licen:e � qpottE55 ��CG�rJ� � � FINAL � . - taw fo�the fol�owing rea�on(Secfion 7031.5,Business and 6 ' -Profeseions Code): . . . .. . . .... . . .. . . Y ❑ BWIDING � � I, as owner oi the proper�y, or my employees wilh aooRess wages as iheir sole compensation,wltl do the work and ip��iiv � the atrocture is not Intended or offered for sala{Saction � ,,( 7044,Business pnd Professions CodeJ. - MO��NG - NFD ! J�O /N 5���°c/ / ✓�S � � I,as owner of the piaperty,am excl�sively centracting cONiRnCiOrt � witb(icen:ed coMroUors to construct 1he projetl(Sec• qDDRESS � Kf • fion)044,8osiness and Professions Cade). �' � � CONSTRUCTION IENDING AGENCY � � �- - - 5��eqcK YARD Nw'� T�TAppOp uNE ' wiorH -� - � - 1 hereby affirm�har there is o mnstruction lending ogency for feONT �� . the pe�formante of ehe work for which Ihis permit is issued P-�. � - (Sea.3097.Civ.C.). SIDE � O.l. lender's Noma � -;^� (DMA Ref.M � ° P.C.Fee S � Permit Fee � � � � p lender's Address ]� � 5 I eertify thot I have raad Ihls applicarion and state ihat ihe Ivuanee Fee O '�`� IDMA 7/C M _ � � obove Informatioo is torrect.I agree to comply wNh afl Covnty in.eeaqanon Fee I ordinonces and Smte laws relating to building construction, Tmal Fee� E� ' '�� � IDnW 7e.m.M � - ' and he�e6y au�horize repromntatives ot ihie County to enlar � � � upon tha obove-men�ioned property for Inspec�fon urposes. � /I���������1 f � 7 SEE REVFRSE FOR f%►LANA70UY IANGlIAGE��, .. . ... . "Signalure of Appl�<on�of Agent Do�e �� - ' . �. � PIANi TO APPLICANT � INSPECTOR'S NOTES -,�, 0�1'11!K-f,S�ryI.UP:H_UGCLARA'1'IOV - I hrtreby nffirm thoi I nm exempt from the Contractor"s � To: , . . . .. keturnod�.. . i , . � _ . .. .. �.l cence.tam•"for,the:riollow�iny.renyyn..�(Sec. 7091.5'� „APPmvod� I3 . r.asnndJ �rscinns( dr:.hrtq<LVnr:,�utth•�rGi.! No. Date No. . • .Da1e, • _ .. .. ` � .. " .`, .' .• .. '' rvyuires�frrn�i!fu eonslruct..+ltrr,i�nprnrr.Jninr,liclr, -- -nrrrpnirunr trure {'fn� i i se�u u al,nrryurrr� � �.' . ' �- ' . . ��' - . . !br apphwn�l�rsurl�-Ti�rnrrt tn/�7r'a r'{qneJ stutv�n�•v�i �__ _ _:'-' . ' •,- . ._. . ,._, :..:_. - - - - - - � r� � J 1, ... � � :. . ..._ . _ _._._ ....._ ..-. -_' :_ �_. _. r • .'"". ,.��:�� pur,uanr r,����pr,,,,.�����s�� r [,>n• ' :� ��', j .r. � : 4.� .- �� .:.� -.�.tru.11nr'c I.tmncr L�ur(Cl+ap�rr'))(�mm�irucin4���d 1co ' �. .. __._ . ... .. ... � ' _ . ... _ ... ._. ...._ '._. _ .. _. � . :. . , � .. ri�n 0 of U r sinn r/the Itusin�u anJ Pr��J nns ; . 70O J i i 3 � rui J••- !`� -- + ' ' � _.-.• �r_`"�•'__. "_ .. ....��^`:�. i?� .�.'� __CuJclnrtlatL�c�rsrlcmptlLcrcJrnnrunJlhrFnsulnr�b� j5 r. ' " '._._.._' . _ . __ _ . . . u77r,crJ cxempn.irs::Anv-rn�lalmn.u�Ji•clinn'U37.i b�. r , . S; i`:...p��: :...._ . r-. ,. �... . .. � .._ _ ._. . .._.___._.__."_ __ . .._ . . .. -Reqtiired��- ' - , �rt�app7i:en�(nraprrnntl�hjrdclL�applicnn�tiuuril , � ' ��-� .`D'ot R 2eived ' .... �. �� FpProvols �:. or Approved�, ��� .� C r... . r nr�(rnn . n . .. . � -'._ . �'Yes.. _No -- - � . . . ..,. . . •' frnuf[i'�!� � >r.[la.i/�rLunJnJJllnn/tSU01.J.. . _.. . ,.._� ._ _.._ .. . ,�_._ , ., . _ . . . .. _ .. ._. _. _.�._.. � ,. - - .�,-. � �:.... _,, ' ,._ .� . �,.: ' . �_� I,as o.vner of fhe property.o�my employ�ces wrth L":o'er.Cec:.h:o�e _r` �.,.C. "� ..._ : ��_ . � _�":.• _- .,_,,.. _.. ..�._ _ . .. . . ._ . .. _, ._. ._.. ., woges asJhe�r so�e campnnsar�on.w�li.de rhe a�o.L.nnd � ' � ^ � �� � •�� . •� � � _ he si c� e.s noi tended o of(e�ed fo sa e(Scc 70�J; ' � � � i -. r � . .. , , .., . ��,� . . �' : ,.,t HrahhDe;,�onmeni ''-.., /�• - ",�' . .. .. . - . . . . � .. ...�f3�vnresunJPr�/�.cs�nneG�d�. fbe�.(. +tre�tnr.l.�u,n�r _.. _ . . -.:,.. _ .� __ .__.. _. . . . . _._. . .. . - `�C, '.. r- . -' � + /.-+u Jnrs nut ufplv tn an merter oJ froper(e�rh��builds , ' _ � � � FtreDcacrimcnt -."-___ . .._'.._ _. ____ . _ .... _ .� � . �-- � ____ �< � , o i j •rad•rr n anJy( J ssv�!u��,rLbinese!/��r - ' ,. " � . . �dr�,�1-!bis mon',amplo}r�s:���J.roridcJ fGr+t su:L�inr- ��.• . . . �� . ' ':j�rnrements'arr n�rt rrsrenJed ior oJ/errd/or sal�. fl. G od 9'�� [' �'_ � �� i ..._ ...._ _._.. . ._._.._ _.__ ._.______.__ . -..� �' tro�errr>.�Ge b�iilJrnK or i�irprm e»ren!i��ulJ u�ithrn nnr : �, �.. �. 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