HomeMy WebLinkAbout1514A WORKERS COMPENSATION DECLARATION � �
I.hereby affirm thai I have a certifimte of consent to self A�'�LI�f��lf31�1 F�� ��11.1�:L�i��11G ���Rlilil� u
insure,or a certificate of Workers'Compenstion Insurance,ar
a certified<opy thereof(Sec 380Q Lob.C.) �+'1C�@Zlty & C'aSUdl'ty
�OT�T80 538���9�y CO. Ot N. Y COUNTV OF LOS ANGELES BUILDING AND SAFETY
Policy N .
� Cerrified�opy is he�e6y furnished. FOR APPLICANT TO FILL IN nooRess-%+.d.�V�l � �'�-�.���"�-. ,�'..�-<f� �`
(� Certified copy is filed with thecounty building�inspec- BUILDING . �
KJ tiondepariment � qoDaess 228�90 E. Hilton H LOCALITY ���-•��..-A"+<�,rQ.� �-c1
� NEAREST �.� '
. Dote 2-1-82 ApplicaniD. A. Mosiman arv D' nd ziP cecsssr. :<"'��--".��° .ft:��-�---���_:2-'
CERTIFICATE OF EXEMPTION FROM WORKERS'� NO.OF BLDGS. . A55E550R ��-
COMPENSATION INSURANCE � SIZE OF LOT NOW ON LOT — — -MAP BOOK PAGE PARCEL -
(This sedion need not be completed if the permit�is for one US[ZONE MAP
hundred dollars($100)ar less.) TRACT BIOCK LOT NO. �� NO. `,..i'j�'� �
TEL. SVECIAL �,
I certify that in ihe performance of ihe work forwhich thls OWN Of AIYL2Y�1C�. — .-�U� . CONDITIONS (a
permil is issued,I sholl nol employ any person in any manner • . . UISTRICT GROtIP TYPE FIRE PROCESSE�RY §�
so as to become subject to ihe Wa ef'��,o pensation Laws. AD�RF55 CONST.�,. LONE � �
��, � a,v Los Angeles z,P90010 �� �1 '� f!-(_ .��d.�.`.t-`` �
Date `�—�.,r.a_--Q� Applicnnt s' � �`�����'� STATiSTICAL CLASSIFICATION APT. CONDO. j�
NOTICE TO APPLICANT: If, ofter makin th�s.Certificate af �� ARCHITF(70R 7EL — �/ 'r�V _,.,�' �p
Exemption, you should become subje[t to the Workers' � ENGINEER PRC TQUPS NO — CLA55 NO.�DWE�i.UMTS� `` �
Compensation provisions of ihe Lnbor Code,you musi forth- qDDRES SEWERMAP �
with comply with such pravisions or this permit shall be "
deemed revoked. CONTRACTOR NO 714 8K PG, VALIDATION
LICENSE�CONTRACTORS DECLARATION LIC .
I hereby affirm thot I am licensed under provisions of Chapte�v ADDRES52 29�� (�'O1�ClE,'Yl .S' L' svn. 344 01-9 VAlUAT10N 2 I �j�.(�.{�
(comrnencing with Section 7000)of�lvision 3 of the Ciusiness and LIC Z lEj 5 3 Q.Q�
Professions Code,ond my license is in full force and effec!. ❑TY D1dIT10Y1� Bar GLA55 B—�. $ �a s-�, m�1
S4.FT. . NO.OF ND.Of CHECK � .
License Number 344019 �,�.clqss B-1 s�ze �"' sToeies �' Fnnnu.ies . oNe 9 3 . . i s 5 0 4,0 4
DESCRIPTION OF WORK COTICIO�S NEW � $ aK '�C� J ��J
Coniractor Cork Harbour pote 2—�.-82 ADD � � �.a�Q Y�O�c;.'
� I am exempt from fhe licensiny requiremenh qs I pm a .
licensed architect or a registered professional engineer � ALTER. _Q FINAL p�,p g—g?
acting in my professionol cappciiy (Section 7051, REPAIR � OATE �
Business and Professions Code). use oF - -
� EXISTING BLpG. DEMOL � FINAL .
B�
Lic.or Reg.No. Date k°PUCANT TEL.
owNER-suaoEROEaaRarioN �PRaNT�D.A. Mosiman n,o594-1841
IherebyaffirmthatlamexempifromtheContracior'sLicense �2900 GO]-C�CTl Springs Dr.
Law for ihe following reason(Section 7031.5,Business and AD�RES �
Professions CodeJ: PRESENT � � "
6UiL�ING
� I, as owner of ihe property, or my employees wifh .ADDRESS � �
wages as iheir sole compensation,will do the work and ,/ ����`'
ihe structure is not intended or offered for sate(Section - �oca,�iiv �)e.
7044,Business and Professicns Code). - MOVING TEL i�jr'2
� I,os owner of the property,om exdusively conlracting CONTRACTOR NO- 6,,
with licensed contrqc�ors to consiruct ihe projett(Seo ADORE55� �
iion 7044,Business and Protessions Code). �
CONSTRUCTION IENDING AGENCY SE7�BACK� YARD HWY T�TA�pROPA NEFROM WIDiH �
I hereby affirm thaf there is a construCion lending agency for pRUNT � �
� ihe performance of ihe work for which thls permit is Issued P.L � � �
(Sec.3097,Civ.C.). SIDF
H.L.
Lender's Name NONE �
Lender's Address P.C_Fee$ ^ Veimit Fee � .
� I certify that I have read ihls appllmtion and staie that ihe Isswnce Fee 8..r70 �
iabove information is correct.I ogree to mmply with all Counfy I��esilg�fian Fee
ordinances and State laws relating to huilding construction, Tmal Fee 917.�J� � - �
° and 4 ��y aut�iorlre�epreseniatives of ihis County to enier �
s upon e�ic�K 6e�enfloned pinperry for Inspection purposes. . .
����t� j�/� � �_�� SEE REVERSE FOR EXPLANATORY tANGUAGE �
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