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HomeMy WebLinkAbout1550A 1551A (9) � WORKERS`COMPENSATIONbECLARATION p - . � � � - i nereby�`firn 'hai i iave a cerfiticaie oi consent to seif p���'■ ��i�pN����f?l��-��U-I�C-:DI�NG �PERMIT � � insure,or o cenif cate of Workers'Compensdtion Insurance, /'\ r or a cerrified copy thereof(Seo 3800,lab.C.) COUNTY OF lOS ANGELES BUILDINCrAND SAFETY Po�;�yNo" 7634"=817�mPa�Y PSC. Indemnity Ce�tified copy.is he�eby fumished. POR APPLICANT TO FILL IN BUILDING .y. �i ��a �� ❑ ADDRESS K..�-�'+1� /�^� � � Certified copy-is filed with the coonty b�i�ding inspec- BUILDING ), � r�o�depa.rme�f. nooaess l�$$ 22885 Hilton Head Bld . 26 �, �ote� Applicam G _Mr(;ti�nni c CITY n' ZIP LOCALITV ' CERTIFICATE OF EXEMPTION FROM WORKERS' �� � NO.OP BLDGS. _. NEAREST_ . _ . . . . . . . . � � - ��� COMPENSATION INSURANCE � - SiZE OF LOT NOW ON LOT O RO55 5T. (ihis section need not be completed if-.ihe permit is for one ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TE� USE ZONE - �P )J / I certify ihat in the pe�formance of the work for which.ihis OWNER E�t1tIIdIlSOI1 DeV. N(�l$81,tF]�.52 Np_ /f��'����'7 �� permit is issued,i shali not employ any person in any manner SPECIAI - � so as to bemme subjeci to ihe Workers'-Compensation�Laws. ADDRESS ]_�QI�(]OliltReYCB DP. � CONDITIONS :V : aTv Irwinda].e Z1N 91706 ;� Date Applimnt � ;0 NOTICE�TO APPLiCANT:ilf;after`making ffhir-Certifimte of ARCHITEC7 OR - - TE�� DISTRICi GROUP NPE FIRE PROCg55fD BY Exemption, you should becomB�subjeCt�to'fhe�WOrkerS' ENGINEER ��tE EIl . N02132rj1{. � CONST.- ZONE �W � Compensafion provision9 of 3he labor Code,you must forlh- qD�Re55 $25 C07.pI'SCjO Blvd. LA 9D041 '�� ��y�'j with comply with such-provisions or�this-permif sholl be TEL ' SiATISTICAt CLASSIF�CATION APT. CON00. :� � deemed(evoked. . . � - � CONTRACTOR L:t1tIl3RSOIL ll@V. NO. . _. -LILENSED CONTRACFORS�ECLARATION--. ���_ �CLASS NO. � '�"� DWELL UNI75 I hereby aHirm ihat I om licensed under prov.isions of Chapter 9 ADDRESS 23861 EZ `lOYO NO. 4 �Ei G gyyER MAP (commencin with Section7000 of Drvision 3 oflhe�Business and Professions Code,.ond my license:is.in.foll furce dnd effect. CITY �E1 TOTO CtaSS B-i gK � VALIDATION � ' � SO.YT. NO.OF NO.Of CHECK . License Number 465688GBC �9a Ciass B-�- S�Ze $Op S1oR�E5 PAM�uES 4 oNe � . .. .. . �� . . . . . VAWATION � . Confractar ��RS011 DEV. pa�e � DESCRIPTION OF WORK ��'���X�'������ NEw ; ;f�'� �p-� � J`�� � CARPORTS �� ► I am exempt under Sec. ' e � AtTER � aTl` .."'d�� I B.&P.C.for ihis reason RE�AIR .❑ S . � USE OF ' � `�'�� � � Date: ��:�� CEMOL � I EXISTING BLDG. � -� APPLI�ANT • TEL s a {J;{1� T ' -�Signature S.McGinnzs �714861231 FINAL �-�pf : 'I OWNER-BUILDERDECIARATION Pe�NT _ _ _ , _ NO. .DATE �eD-SC� �-- --j�']g t�:�,�Z J ; � ,�I here6y affirm that I am exempY from.the Conhoctor's Li[ense , - � Law for ihe following reason�(Secnon.7031.5, Business and ADDRE55 ll1&IIIOriCl Bd� FINAI� �. � - Professions Codej: .". .. ' . .PRESE BY ���i/.;,`�-�'' -. . . '�.�- .".� � eUIIDING � _ � I, as owner of the property, or my amployees with ADDRESS ' � wages as iheir sole compensation,wilbdo ihe work and ;� G r the structure is not intended or offered for sa�e(Section � IOCALiN ' . � '� � J}t�f} 7044,Business and Professions Code). MOVING tEL. � I,as owner of ihe property,am exdusively contracting CONTRACTOR NO. �:��' ° �' "-� �...�;;l � with licensed contractors ta construct-ihe projea(Sec- - "�- "---�"-` tion 7044,Business and Professions Code). ADORE55 . ( s ��J'�,-7 C?. � CONSTRUCTION LENDING AGENCY � REQUIRED YARp. HWy. TOTAL SETBACK FROM _ SET BA�K PROP.LINE WIDTH � , �()��,�`'V I hereby affirm that there is a consiruction lending agency for PRONT � '� � '- ��the performance of ihe work for which this permit is issued RL � , U �,1 �.o�1:�-rJ= "+ � (Sec.3097,Civ.C.). SIDE ! . . P.L . . . � � .,. . Lender's Name 7ky t-) toMA Ret.R : - - �� P.C.fee$ ���� PermirFee t-1�/�� � ,� ��-�� m lender's Address - � � ; �u, -� ; � .I certify that I have read this applimtion and state_that the Iss�ance Fee � LDMA P/C A - - � -� � - m a6ove informatian is correct.I agree lo comply with all Caunty Invesrigation Pee / -- ordinances and State laws�elating!o building consfruction, 7o+al Fee �/ <�-SJ LDMA Perm.# -�� - u and hereby authorize�epresentatives of ihis County to enter � � upon 1 �ove-ment� ned prope i fo�inspetfion urpo 3. . � a . '� �--�._. . . . ._.. .- .._t.;�.._ _.: , SEEREVERSEfOREXPLANATORYLANGUAGE n -----Sig ture�aYAp i onror Agant - - � a�e ,. � � � . �� m�n n= m T N v Cn T v � �'j -n = Z 1. ��3 0 0 ° ° ' �Q- o o m° ° ° �l-o �p m � �p a � o 0 - m i � N s -s � � � � �° " a � � �,co ° a �' ° m o - �n�° � � ' a `�° � o flo D � fl vQ rn � � � � T � z X m� _ _. F 3 � ]. �.Q _ c� -a p n � �� m' o f 3 ° s� � � fl �� C�� 0 9 � � y . o �3 ' � o c �', o t° fl-o ° � -° '. 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