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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 � � Signa �re of Appll:on.c;r A9em Dote � . . �s / �j- � �` ?? S � ^ �` " - � � �:� "�? � � . ,�_.- ��-- . _....---- � O... �..� ��N� .� q� (� Q � qW ❑ o,��p �� �' p r' fn "^ �' 6 ����d K' l7 �n i:� n;.-� � 7.� �9 T h . e.f.i__a_�--�, n s _' a � � � � �°.��i 3_ A , s c°. � a � � y, rt� �7 -� o c 3. � a . � 5 � Is o: � � a V..� (l�. � o A � � � � Q � ' ' a� s fl ��� � , � i,n o � � n � q� � I� -.�Z� X �;�C 5 O �Qo� .� (D - �a(^0 O o � .W . � g (� � T �O C O O � C � �� � ,7s • � n µ p� . C? 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