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HomeMy WebLinkAbout1402A 1609A WORKERS'COMPENSATION DECLARATION � .. � �; .. ._... . . _ . I here6y e�f;.m that I hava a�e.��f��o�e of�o�se�„o 3��� . ..APPLICAT��ON-FOR���BUILDING �PERMIT� � insore,or a certifimte of Workers'Compensation Insuronce, � � � � or a terti(ied copy thereof(Sec.3800;�lab.�C�.,)/' COUNTY OF LOS ANGELES . BUILDING AND SAFETY P❑olityNo.C���Company /-�'�C� �C�L� . . ' ._ BUILDING l' p� . Certified copy is hereby fumtshed. FOR APPLICANT TO FILL IN aooe¢ss �� 3 'V a�T-f ►T/t1/tPt� � Cerrified copy Is filed with the caunry bui m n5p0C- BUILDING , }.� �T�� y• '�y�,, tion d pa ment. . ADDRESS 3 �. ����N��l�••+� -. LOCAIITY. "`�-��_,(�f.f�'�� y. NEAREST Dete l�� llpplicanl CITY �!�C� ZIP CaOSS Si. � G � � - CERTIFICATE OF EXEMPTION FR RK NO.OF BLDGS. �+SSESSOR � ' COMPENSATION�NS E SIZE OF LOT NOW ON lOT MAP BOOK ' PAGE PARCEL � (Thi�eection need not ba compl d if pe ar one USE 20NE MAP hundred dollars(E100)or less.) TRACT BIOCK L01 NO. • NO. . . �7 7EL: ' � - : . .'. SPECIAL ^ OWNER r � NO. CON�ITION$ d t tertify that in tha performance of the work for whkh this . ... DiSiRicr .GROua NPE FIRE :PROCESSED BY ' 0 permil is issued,I shull not employ ony person in any manner - - � �� � '�� � ��� � ��--��- ��-' '' ' ADDRESS n r_CONST. , I �E � U _ so as to becoma subjetl to the Workers'Compensafion Laws. `r .[� V C _ , � �� . . ._.. -. . . �� Dale � Appli[ant . Cltt ZIP � STATISTICAL CLASyf 1 TION , APT CONDO. O NOTICE TO A7PLICANT: If, afler making this Certificate of ARCN�iEROR TEL , �1 �Exemption, you should become sub�ect to-the Workers' � ENGINEER - �NO. - nq5$p�p, e� DWELL UNITS .4 Compensotion provisions of tha Lobor Code,yoo must forth- ADoaESS � ��� � � s�R uwr Z with comply with such provisions or fhis permit shall ba deamed revoked. � � - . CpNTRAROR .� �tl'�4�J'e4��2 NO.�SSa�SZ � BK.--� PG, - VALIDATION LICENSEDCONTRACTORSDECLARATION- � -� ¢.��� �p��•'QG{L, LiC.��.1LL I hereby offirm ihat I am litensed under provisions of Chapter 9 no�RESS/5 /P� oAV �•• NO. 7J Fj�i � VALVATION f � � (commenting wi�h Setfion 7IXpJ of Division 3 of the Business and � ��G /��.� . � Professians Code,ond my license is in(ull force ond effecl. Cltt Li�--- ���/� M55 �� f Y�!/ � �� � SQ.FT. NO.OF NO.OF CHECK , License Nvmber � lic.Class�- SRE STORIES FAMILIES ONE . � : - - : ��� ua2n • Conira[tor O1e ��� �- �ESCRIPiION OP WORK N� ❑ �I am a ec. _. ._'f'^/.]Li�. . S�'�x�I/�. �y,�� ADD_..� - #�•�• •,•i� /LO/�lLa. ALTER � FINAL .... _. _._ ..._.. .... _. .. .--__.. .__- ❑ ��DATE � I • •J29LI- 8.8P. .fo this reason � �� - ��--- - REPAIR � � Dafe: USE OP . DEMOI.❑ .- FINAL.. .. . : .. . • • e�2.0;':� . EXISTING BLDG. � - Br � st9�or�rs ^P���^NT rE�. 0 4 1 1 r�i 6 OWNER•BUILDER DECLARATION . PRMT NO. _ - � -� � � � � � . i hereby offirm thot I am exempt from Ihe Conlractor's License � � �,Y���-�L t1� /^,�i^�j'? Law for the followin9 reason(Setlion 7031.5,Business and no�ae55 _.----�---- -. � �- - � � Professions Code): vae5enr ' �� � BUILDING . .... � I, as owner of ihe property,or my�amployeerw8h - - AODRE55-... -------------------- --'-----� .-.. '..`. . . . .. .. . .. . . . - . . wages as their eole tompensation,will do the work ond � . Ihe sMucNra is no1 iMended or offered for sale(Section tOCAUTY . �. . ._. .__._. . . 7044,Business and Professions Code). MOVING TEL. � � I,as owner of the propery,om eadosively conhacting �'�TRARort No. �� ���� .- with licensad coMmcfors fo constroct the projecl($ec- ADDRESS {� ' ' � � • . fion 7Qdd,Buslness ond Professions Code). _.,__ .._ _ _ , ' . _; �� REQUIRED 70TAL SETBAIX FROM EXIST. CONSTRUCTION LENDING AGENCY SET BAGK YARD Hwv PROP.uN WIDTH I s .Ll Q.�.S � , I hereby affi�m that Ihere ia a cansfruction lending agenq fot _ fRONT � the performance of the work for whicb this permit is issued 7.L , . .L;?.?5� �Sec.3097,Civ.C.). ' SioE � � lender'sName - P.L _ ... _.._ . . ._. .. . ._... . .. _. ��.�.i'_'�g . . . . .. ` .. .._ . �� . .. .. .._... . . . ... .� lender's Address P.0 Fee S � Permi�Fee .. . � I certif that I have read thls a Ilmtion and stafe that the � � ��d� - Y PP Issuonce Fea abova information is covect.I agree ro mmply with nll Counry Invesugation iee �[ � ordinances and 51ate laws relating to boilding constrvction, � � - � 7oral Fee 7 �� �� �� � - � � and hereby o a e representatives of this unty to enter - vpon the ob a- ntioned properry for" pection purpose/s1. � . � - --� - � � � � - - - - -- - - � � � � � 7'/�� �i ., . _SEE REVERSE POR EXPMNATORY LANGUACE, _ _ . ._ __ _. ___ _ _ , . o r of Applicant or Agent � Do e � -��� ; � - z � 0 . - � _n S_ -�. --• -- -- ��j� 1�'• a o nv m Q o a 19 ¢ m � i � '1�E T r -1� O R � N 0 S. . 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