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HomeMy WebLinkAbout1024A (5) WORKERS'COMPENSATION DECLARAiION � �f I hereby afflrm that I hove a certificate of conseni lo self �p-pLICATf-O-N-� FOR---B�UILDI�-N�G_ Pf�RMIT �S� insure,or o certifimte of Workers'Compensation Insu�ance, � - . or a certified copy rhereof(Sec.3800,�a6:C.)_,_.s� GOUPITY OF LOS ANGECES BUILDING AND SAFETY �"'"- - PolicyNo. ComP�„Y��'��� . � - .. . ... � BUILDING ' - � Cert�fied copy is h�Lsy furnished. FOR APPLICANT TO FILL W nooeess Y����` G�" -��'�`�`� (� Certifiad c.,o�py'�s filad with the munty 6ullding inspeo- BUILDING y�ry / - �T-�- tion d�pd7tment. A�DRESS��y-�s{ �4'- �+r"�' � "' �.}EAREST :,;,�.�.�,,,,�' -tbf Ja�6 Z'3",iPL`' ..�si'4...� . t Date ��. �. .Applicant . -. . . CIT .' . . . CROSS SL� . CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. A55ESSOR SIZE OF L01 NOW ON LOT .N1AP BOOK PAGE PARCEL � COMRENSATION INSURANCE - �- � � � � � - US NE � -�MAP -'3 � (This section need noi 6e completed if the permit is�for one TRACT � I�" 6LOCK LOT NO. � ��- NO ���j�.3�. hundred dallars($100)or less.) � . �- � . -��_ ��0d�� SPECiAL �- OWNER �'' NO. CONDITIONS �' I certify ihaf in ihe performonce of fhe wo�k fof which this M1 - DISTRIGT GROUP-TYPE iIRE PROCESSED BY � permi(is issued,I shall not employ any person in any manner � �,���� ,�;����tiq;,�!,. CONST ZONE - °� so as io beCome subjeci io 7he-Workers.CompenSaiion Laws. ADORE55 . ._ . �u � �d �- 6`: , i �,�,a ��` . . ��, . 'D.P � / � ��� CITY ' "' �."�,�, ci- ZIP ' _ qQra����,�� � STA71571CALCIASSIFI TION APT. CONDO. .� Appliton��P,�. ���- ARCHITECi OR TEL. ¢y� .. �,p NOTICE TO APPLICANT: If, after maklrVg this Ceriificate of ENGWEER NO. -� CLA55 NO.�i.-.DWELL UNITS_ � �Exemplion, you should become subject to-�the Workers' - . . . � Compensqtion provisions of ihe I.abor Code,you must forfh- ADDRESS � SEWER MAP � with comply with such provisions or this permit shall be _ ,. TE�,/� ( VALIDATION . deemed revoked. . �� . � � � � CONTRACTO .a� �fi. �� NOL%�✓ •e�7L�,c� BK. PG, UCENSED CONTRACTORS DECLARATION - ��, �-�,� �e tlC. I hereby affirm ihaf I am licensed under provisions of Chapier 9 ADDRE55/�.�i l . � �4'��� NO. VALUATION �mmmencing with Section 7000)of Divisio�h 3 of fhe Business and � LIC. � �/�y ��'�' Prafessions Code,ond my license is in fulf force and effect. CI7Y _P �..at .�f -- ��Au Y�:I�� ► -- - � - .SQ.FT NO.OF/ NO.OF. CHECK . � . License Nomber��� � r� -Lic Cfass � SIZE,� .'� STORIES FAMILIES ONE - . ,� NEW � S :t O 2 c:I� �t`�"'-L� Da)e "����"� DESCRI,TIONOF WOR � Coniracic � � '- R ... ADD � ,�/ ,�S e �' � �� �I,am exempt under Sec . . . ` �/`�� �, g �`✓�'"�• AITER ❑ . .DA E` "� (�� ��..� ' ':��>�" B.&P�.C.for fhis reason � .L��"-�Z�C_..� REPAIR ❑ �, c s�� � � USE OF . FINAI J L.7`)�' Date: EXISTWG BLOG. DEMOL ❑ By M,I �6.C E'"�E3�� � APPf ICANT TEL. . . Slgntiture - � 'PRINTI ... NO. - � OWNER-BIJILDER DECLARATION . . � ► - . I heraby affirm that I am exempt from the Coniractor's License AD�Re55 �Law for the following reason(Section 7031.5,Business and Piofessions Code): � � � . PRESENT � � . ❑ -BUI.DING �I, as owner qf ihe properiy, o:�my employees with ADDRESS woges as fheir sole-coinpensation,will do the work and LOCALIT� � - �he siruclure is noi In�ended or offered for sale(Seclion � - 70d4,Business and Professions Code). . MOVING TEL. � I,as owner of�ihe property;am ezclusively contmding CONTRACTOR NO. wifh licensed conimUors io consiruct ihe project(SeG ADDRE55 � - - tion 7044,Business and Professions Code). - � .REQUIRED YARD HWY TOTAL SETBAIX FROM E7(IST. CONSTRUCTION�LENDINGAGENCY � � SEfeACK PROP.LW� WIDTH. � , I hereby affirm that ihere is a conslruction le�ding agency for FRON7 ; �he performance di the wnrk for which this permif is-issued P.L.-� . �Sac.3097,Civ.C.). � SIbE � - / P.L. m Lender's Name��`�✓r��'�� . $ � � . P.C.Fee$ �f� Permit Fee "G-,,� - Lender's Address � I cenify thpt I have read ihis applitation ond state that the � - Issu ce-Pee �� �'� � p6ove in�ormotibn is correct.I ag�ee to comply wi�h.all.County �Imes�igation Pee an y� ,o' ordinances�ond Siaie laws relating to building construction, . To�al Fee ') v and hereby authorize representatives of�this County to�enter m upo they�KS�e-mentioned praperty for inspection-purposes. �� � - � � r�)-'����o� .�� ' l .�A��Q,,,,/ �- ,,,�,��- 'SEE REVERSE FOR EXPLANATORV LANGUAGE es ��I Signalure f Applicant or Agent Date-� . _.__ �€ � : m-r � P— '� �� c� 4 � 5 � ° c°'o. � a� $ vs b =n� Gg � � T?�� s R � ma � � ��O O E � � Q i a & g� G � 4p �.. t F -G. i nro fD � CC 5 ,� ��:. �'t6 � � � � �"3 �tJ fl (� � � I —� � S � k 4 �' �.-�.� � � � � ^ � �. �Q [a.: �, � ¢D � f , � �� I ��� ii ��� _ j � g ° �-o q �' k � ' '� i 3. �� � �` q ,�a � � s � �, �� , � � �� � �' o � � � � � � s'� I � k � r � �� �y � �� i � -e�" � � �• � i 1 � � � € �O d ,� � y h �s � . { i fi,� Q Ti � .:`d,� @7 ;I 3 ` Q ' ' � m � � ^ � ` [� � 3 � � �� ?�r�� . � � a 1 i � � � � � � � � 1 � r � '� � � 3 � � r � ' �s�� � .� i i, � i', � I ,( Q; i K � � � � � -� � �� � r r � �.:' � � � � J � � � � d � f � "� � �� � y � — �! ' ' ` j �� � � � ; � � � a � �� �.��� �� _ � , � � F! 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