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HomeMy WebLinkAbout0845A 2994A (4) ,WORKERS'COMPENSATION DECLARATION ,y affirm thot i have a certificole of consent lo self qpp��C�4TION FQR BUILDING PERMIT � =,or a certificote of Workers'Compensation Insumnce, ��,certified�opy thereo4�5ec 3800,�ob.C.) COUNTY OF LOS ANGEIES BUILDING AND SAFETY �olicy No. �Compony � Cartified copy�s he�e6y fumrshed. FOR APPLICANT TO FILL IN euuniNG ❑ ADORE55 �� h (� Certitied copy is filed wifh the county building inspec- eUILDING /� tion departmenl. ADDRE55 /� � G(r' �11'� i�> . Date Applicont CITv 1 � ZIP �OJ LOCAtITV CERTIFICATE OF EXEMPTION FROM WORKERS � NO.OF BLDGS. NEARES7 COMPENSATION INSURANCE SIZE OF LOT � �' � NOw ON tOT � CRO55 ST. (This section need not be complefed i4 the permif is for one 7gqGT 23 � BLOCK l0T NO. Ca� ASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL / TEL USE ZONE hWP OWNER CSG{�1.1 t3 , No. �a-•Y � �" I certify that in the performance of the work for which this y` ` � �/ NO. j��1 '�� � permit is issued,I sholl nol employ any person in any manner qDDRE55 4��� ! ����q'o(� SPECIAL so as to 6emme subject to the Workers' ompe sption laws. CONDITIONS � ��t. zip V "�ate 16��AppliwM • . ' � CITY . ��.'�,7.vtc?•I �� � NOTICE O A LICANT: If, after m❑ ing ihis Certifimte of ARCHITECT OR �,, / TEL. c�ey DISTRIQ GROUP NPE FIRE PROCESSE�BY O ENGINEER � 71G�/1 NO. ltiC1'i( � CUNST ZONE I— Ezemption, you should become subjetl to Ihe Workers' t V Compensation provisions of the Labor Code,you must forth- AooaeSS "'—' ith comply ith such provisions or this permit shall be TE� b { t� � 4 � pW.,� deemed ravoked. CONTRACTOR P/�. NO. d'�r�(0 STATISTICAL ClA$SIfICATION APT. CbNDO. (n Z UCENSED CONTRACTORS DECLARATION ��� CLASS NO. DWEIL UNITS_ � I hereby affirm thot I am licensed under provisions of Chopler 9 ADDRE55 S - N0. `�� �yyER MAP (commencing wilh SeUion 7000)of Division 3 of ihe Business ond ��� Professions Code,and my license is in full force and eHect CITV "�a�t?1.C- . CLASS '^'�` VALIDA71pN SQ.FT. NO.OF NO.OF CHECK BK' �'' LicenSeNumber Lic.Class SIZE d STORIES Z FAMILIES ONE /._/ � ❑ VALUATION ��` DESCRIPTION OF WORK Et f/�Y (Jd NEW �� Coniracior Dafe d ADD � S � �-"'� �� �I am exempr under Sec. o � 0 4 Tq4+�.� (' �(���rj a �� Q4 ALTER , 1/ B.BP.C.for�his reason vl t` � . d ��a7-srq � REPAiR ; �' •�° •z 3 USE OF '~ •/ �EMOL I /� I..3 � Dote: E%ISTING BLDG. ° re7yi.f� � d ❑ �� }(7�� _ $ignature APPLICANT, TE�� � FINAI ry, � � � OWNER-BUILDER DECLARATION PRINT p 6YN�2 NO, l 0 DATE � ��6 '�&� �`�� I hereby affirm thot I am exemptfrom ihe Cantractar's License qDDRESS 7"3� J I�,j'�d �I� � � pf�� Law for fhe 4ollowinq reason(Section 7037.5,Business and f- �� FINAL Professions Code)� PRE EN �y � By ❑ BUILDING 2�,� � (��� �� I, as owner of ihe property, or my employees with ADDRE55•-� '�'� `-' ,{. wages as iheir sole mmpensation,wili do ihe work and �OCALITV ✓�� Jj I � '�'S� � , ihe structure is not intended or offered for sale(Seciion '✓"N•�" 7044,B�siness and Professions Cade). MOvwG TE�. �.�.� (,as owner of the property,om ex[lusively conirpcting CONTRACTOR NO. n with licensed contractars b consiruci the project(Sec- ADDRE55 �2 9 y'4~ lion 7044,Business ond Grofessions Codej. �a � ���� REQUIRED TOiAL SET6ACK FR CONSTRUCTION LENDING AGENC� SET BACK YARD HWY pROP.LINE WIDTH ° .. I hereby offirm that there is a mnsiruction lending agency for FRONT ?, = fhe performance.oi the work for which ihis permit is issued P.L ��J,�yr�(?�'�`U ($ec.3097,Civ.C.). S�DE p�. jc� zy �� Lender's Nome f"�� ���+ LDMA Ref.k w Lender's Address P.C.Fee 5 Permii Fee at�1 , � 1 certify that I have read this applicotion and sfate fhat ihe Issuance Fee ����� LDMA P/C M � a6o�e information is correct I agree to mmply with oll County Invevlgorion Fee �7 q ordi ce and State laws reloting to building consiruction, Total Fee ���1 :S IDMA perm.N a hereb authorize represematives of ihis County to enter pon the bove-mentioned prop ty for inspeUion purposes. 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