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HomeMy WebLinkAbout1607A �� WORKERS'COMPENSAiION DECLARATION � - ' �" � - -� � � �' � - � �� - 1 hereby affirm ihot f have a cenifimte oF�o�5e�,�0 5a�� � � �- ��APPLICATiON�-FOR BUILDING PERMIT � insure,or a ceriifico�e of Workers'Compensation Insurance, �r a cernHed copy thereof(Sec.3800,lob.C.) , ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Poli yNo.�L�a2L�i�S�Company_StrLl`�'.� r-�J�S1� � � Ce�rfed cop'y rs he�eby furnished. FOR APPUCANT TO FILL IN BUILDING��sO` _ ADDRESS �� Certi(ied copy rs filed wiih the counry bu�ld�ng insper BUUDwG tion deponmenL /1 AO�RE55 2,350 C7Qt3a.lY) ��'Wl CSl'• / l Oa1e —�. — �Applicant •" t ,Cv� .. CITVDI bwJ 21F LOCALITY � `��(1(�� ' Q!� �, � CERTIF�CATE OF EXEMPTION M WORKERS � - NO.Of BLpGS. ) NEARES7 �I COMPENSATION INSURANCE ' 9zE OF LOT- � NOW ON lOT �7 - - CRO55 57.' d"42 - (This section need nol he com leted if tha permit i3 for on0 ASSESSOR . hundred dollors(f100)ar less � - ' -�' � TRn�T �� - BLOCK � - lOT ti0. � Mqp gppK PAGE VARCEL �/� TEL. I certify ihat in the pe njEfoPihe work for which thiz � OWtiER �rL`� L(.� '�� NO. USEZOtiE �P . ��� �� a permi�is issued,1 shall not �lo+�any person in any manner qooaE55�.�J^D� ��7�7'�1D KYYY�•CGI�• SPECIAL O� so as ro 6ecome subject to e Workers'Compen5oti0n Lows. CONDITIONS - U � . .. . '. .. CITY yy�pk'7 . /S ZIP . . . � Dare Applicont . O NOTICE TO APPLICANT: �f, after making this Certifitota of ARCHi1ECT OR /� NO.���� DISTRiCT GROUP 1YPE FlRE PROQSSED BY U FNGINEER L,� � Exemplion,.you should become subjecl to the�.Workers . , CONS ZONE - � Compenw�ion provisions of the Labor Code,you must forth- � r lG �� � N itb comply wilh such pravisions or this permit�,sholl be ADDRE55 ��, . G'�- ? - TEL. � STATISTIULL CLASSIFICATION ' APT. CONDO. Z deemedrevaked � � � COntiRa[7oR � �� �t/ T nlo �D�GY � LICENSED CONTRACTORS DECLARATION '. � - �i� �1 CLa55 NO. DWEtI.UNITS � I hereby affirm that I am licensed under provisions of Chop�er 9 � nDDRE55 �2 - NO.'-tZ5�70 (tommencing wi�h Section 7000)of Division 3 of tha Business ond ('7 ��C SEWER MP.P . Professions Code,and my license is in full.force ond effecL � CiTv f� �. � � � � �IqSS .nj-1 BK , � � � VAIIDATION . /�� ��//. /�' $O.FT. — NO..OF NO.OF CHECK Li[ense NVmbOf YZ� •�� LiC.�lais� �� � SIZE STORIES. FAMILIES I ONE � n - VALUA�N Comracro���I�{C�tSY- pa�a � . DESCRI7TION OF WORK �MC�Jb w P'aTc� N�'" ❑ — ' /� noo � f r , �I am exempt under Set. ' -��Lo-�IEuJ FArn�� K-r/1• O 11 AL7ER 8.8P.C.for this reoson �H� 5 �i � REPAIR � s . . Dafe: � USE OF ` DEMOL , EXISTING BLDG. �SIOC�LLC�i ❑ SignOture - APPIICANT . TEL. � OWNER-BUII ER RATION � PRiNT i I(J ST A,/�Y� NO. 4�O'I � FINAL - � DAT ! I hereby oHirrrt�hat 1 am ex , f rn the Con�rouor's License � 2 - ' �� 6 O.�]JS law for the following reas n(5 tlion 7091.5;8usinass and ADD2E55 �f�.rJU o��Z al'Ylp�Ut`�• FINA L � • • ProfessionsCodeJ: �._ .: . . ; _, By �• •• a v � ❑ BUILDING . � . -. .. . . . I, as owner af Ihe properfy, or my emptoyees wilh ADDRESS � —}�� -�� r woges as�heir sole compenw�ion,will do the work ond -- . . ...... . . ._.. . �� /7�.g�cG .�LZ-+R Q- � � 7�l.2 J the svucture is not inrended or offered for sola(Section LOGnuTV � s • 1 7 G.2,5� 7044,Business pnd Professions Code). � pnOvin7G iEL. 0"���—��a�� � I,as owner of thg property,am axclusivaly tontracting CON7RACTOR � � NO. ,J , p q,� 5-F3 II with licensed controctors lo tonslruct tha project,(Sat- qpoRE55 ' � -' ' ' � -- - - 7 � tion 7044,Bosiness and Professions Code). �� _ ._.�____ ��� , , �. REQUIRED TOTAL SETBA K " � CONSTRUCTION LENDING AGENCY S�i gqcK. YARD HWY PROP.LWE wiDrti � - ' �� . I hereby affirm ihaf ihere is o constroc�ion lending agency for FRONT � � - -�-� ' � � ihe pertormance of the work for which ihis permit�is�ssued v.i. " � � �. � (Sec.3097.Civ.C.),�. . . . . .�. . - - SIDE � � � P.l. . ' - Lender's Nome � - _.. ' � � � � � I b 3.7 •��,RaF.» Lender's Addresa - � : - ,. 7.C.Fee i - aermn Fee . ' � � I cartify thal I have reod this applicoiian and state that the issoonce Fee ,V,_ O LDMA P/C N ' _ obova informatfon is toryect.I ogree Io comply wilh all Couny � ��- In�estigation Fee � � q ordinancas and Srate laws relating to bvilding consrroaion, Toiol Fee t�M4 ve�m.N ' � � on ereby oWhorize�epresenlotives of ihis CouNy�o enter - -�� � u o r e abo mentioned property far inspeclion purposea. . � � A LL�4'�fta� %IJ�Of! • SEE REYERSE FOR EX►LANATORY UNGUAGE � S�gnoturo oF Applicont or Agent po�e . . � � ✓ _ _. ---- _ __ - . � ' ' luo�j uo iaw3 ... ,_ . ... - . . ... � . . _ i' f�� . . . ,. � � -fouy . . � . .. ., ,i � . . . � , . . . , . . . pa�sod g Pauo� . _.., .. . . ... ._. , . , . . . . �r .'.r'_. .'. . .._ . .�.,�. . _. � _____ , . f',..� , '.. � . .� -iaqwnry asnoH ... - . , _ . L --.-. --�--'-�� ioua�e3-y�o1 ._. _._. _...._'_...._'_.__.__.___' . ,o ua�u� , . ' . 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