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HomeMy WebLinkAbout1894A 3736A 3737A / WORKER5 COMPENSATION DECLARATION `� - � �� I heraby affirm ihai I have a certificate��of ronsent to self . � .. . - App�ICATION FO� BUILDI�NG PERMIT ���� insore,or o certificate of Workers'Companshon Insurnnce,ar , a certified copy-thereoj(Sec.3800,Lab.C) � � � � COUNTY OP LOS,4NGELES BUILDING AND SAFETY ���j-�, -Po�ityNo. Company - � Ceriified mpy is here6y fumished FOR-APPLI A T T FILL W d eu��o��vc- �-�� W ��:1 ��� 1 ' AD�RE55 �1 `� �� Ceriified-copy is filed wifh ihe couNy building inspeo- eUILDING h � � 1lon dBpaftmeni,� - - . ADDRE55� 47C .�-Z,E.� �� f: �LOG°.LITV `__�j,���V�, � Date '.Applimnt - . . . . . CI7Y -� ��� ZIP�� ��� CRO55557. V...S�;V - "�p..,`L� =h,.�� � � CERTIFICATE OF EXEMPTION�FROM WORKER$'� � � � - NO�.OF BLDGS. � a55E550R � COMPENSATION INSURANCE - - . SIZE oF LOT ' � NOW ON'LOT MAP BOOK PA�UE�- PARCEL (This secfion need not be�completed if ihe�permrt is for one � � USE ZONE -MAF . �^�op � ' ' hundred dollars($100)or less.)- . . - TRACT v � ' B K 1 LOT_NO. NO. -��� � ,�.� q 9 � � I certify that in ihe performance of the� ork fo wh�h th OWNE - ,Q .�.; '� TO.�) l�eC[1 .. __.---_GONDLION�-� . � DISTRICT G UP TVPE FIRP PROCESSEDBY� permit s iss�ed,_I.shall nof employ_ny pe son q -,y ann r r� f - . � �,.9 so as fo be 'e subje<f}o ihe Wor-ers' ompen fi Lo . A�DRE �3� � (/3 (t5.2?d� . � � CONST. ZONE � _f6��� � \t�, �- � .fi(���-� � � Date pplica t �-. CITV �� - Z�P STATIS7ICALCLASSIFICATION - APT. CONDO. � �g NOTICE TO�APPLICANT: If, ofter mokin this rtif�i ot ��of ARCHITECT OR TEL. ,q � ENGINEER NO. C4AS5 NO. w`'� �WELL.UNITS_ . Exempnon, you should -became subject to the Warkers' � � Compensafion provisions of the Labor Code,�you must forth- --� AooREsS � sewea MAP � � � � � with compiy with such provisions or ihis permlt shall 6e - � . � � � �deemed revoked. - - - . -t � ,,, TEL - - - � . � . CONTRACTOR C!"�.� ✓ NO. bK. PG�„ VALIDATIQN , . . - . LICENSED CONTRACTORS DECLARAT4QN � -� � . .�ic. . � � I hereby affirm that I m licensed der provisionsof Chapter 9 ADDRE55 - NO. VAWAT�ON �.. - . (<omm� cing with S tion 7000)of D ision 3 of the 8usiness and � � � . � �i� - 4 ` �r� � � Profess ons'Code,a d my license�s in full fo ce ond effecc CITv CLASS $ - .m�"L..� � ' - � � � ' SQ.Ff. NO.OF NO.QF CHECK ' License Num6er ' Lic.Class SIZE STORIES FAMILIES ONE� -. x ' , ����9'��p` ' Caniracfor-�� ' Date-.._ PESCRIPTIONOFWORK � NEW � g �'�'���� . �� , ,�.�'j . . ❑- .. � . � . ._ r.^ � ADD - �I am exempt from ihe licensinq requirements as I am a �j /� �ic'�',y]?C .t� � � �� _/j„�.O' , licensed architecf or a regisfered professional engineer , � � ALTER � FINAL G �/,J . .- acting n my professional capacity (Section 7057, .�'" -�j�� /�a�q �' �,�„+°"��R d DATE f� \ /R l . . ^,�.��1� . �Business and Professions Codej. � USe OF - . � � � - ExISTINGBLDG. - DEMOL � F�N'0`��q,./-y , av ,���� �3.1 Fi.-�F�2 � Lic,or Reg,No. �ate . APPLICANi TEL � � - - �OWNER-BUILDER DECLARATION -- (PRINT NO. " � � . I here6y affirm that I-om exemptfrom ihe Coniractor's License .p�y ��+ �� �f�7 � . . . -� Law f the followang reason.(Sedlon 7031.5, Business and Ao�RE55�iT-G. �� IC.OI. I � . : . . � M-�"Prof ssions Code): � -� . � � � pRESeNT . �� � . . � .� °.�j,7�J,b{� -.� . / . . 6UIL�ING , � a, � I, �s owner af fhe property, or my employee6 wilh � AODRE55. �� m 2� - { ' -wages as iheir sole compensa?ion,will do the work and � . �. �� . � . . f - the siructure isnot intended or offered for sole(Section � �OCALITY - , - �. � . � 7044,Business and ProFeasions Code). � MOVING , � � � . TEL. � �.°"�1..7� �. � I,as owner of ihe property,am exclusivcly confrocfing- CONTRACTOR NO. e a+:�4`j�fj-�.. w ih licensed conirpctors to consirucf fhe project(Sec- qDDRESS � � � tion Z044,8usiness and Professfons Code). , �- � � � " - � - REouieeo rorai sereAcr.FROM Exisr �a,1 b.w b'2 - 'CONSTRUCTION LENDIN6 AGFNCY SFT 6ACK� �YARD HW'Y pRnP.I.INE WIDTH � _ - ' I hereby affirm ihnf there is es consiruction lending agency for � pk�Nf- � � � . � . �\a 7�7 � the performance of the work fnr whid�this pe�mii is issued ��P.G. � . � � � � t{ (Sec.3097,Civ.C.). - . - si�E � - - � � � - � � � #�� a �a1 P.L Lender's Name � � (�s�- 1 � �49,25 " . Lender's Address . . . P.C.Pee$, .�,� �P mir Fee ,'D_ � - � � � w I cerfify that I have read this appllcation ond staie that the . �� I <_e Fee � &�����g c�~ � �above infonnation is�mrre<t.I a r to comply with all County � In�asiig<�r�o��FPe - . ��,'� (�,�*�j�� � , � �ordinan-e nnd State Inws in- o building constructidn, ioiol Fee s : � - . � add h nuihorize rep .entaifve of -�s Cooniy�to enier - m upb bova�mentio pro�ierty��.in ection purposes. �� . . � � -��� - �` ���� � � . �,�-� __ LANATORV LANGUAGE- -- _ ___ _._- , . , . . ____ ._ --- ___ ___ _ _... — S9noNreof�ito�-- � --- Da�e i � -- � � --- . . - � ... : . . .c ..... EE EV SE FOR EXP ` V � � � ;� y �t . . � � �� :: .. � .. �.� ��.�, 4 . . . � a am�o3w � � r,r.�.�`S''o'" ��d.�C `� . . . s- � . p� v� p � 8°' ^ .-p V � z.'�*. ,D- i � � "CS 4 q''�°y . y � G .� . u y �. �+,`3� . , � G ffi �:�1 r n�y �'��,.��;sl? a �'o c�a � y m 3 ds „� i r�.� � � . � � ?o. ''a;� � O � '� wo`eo�ugi �� u+�,_ �°+ y, ��,�..n .� �s.d.o� . � . . . 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