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HomeMy WebLinkAbout1484A 1485A WORKERS'COMPENSATION DECIARATION � � ' �� � ---' ' - -- "" ''� � � � � � � -� � � � I hereby offirm �ha�I hove a�e,f��,�o,e o,tonseM fo=e�� � � � �� �� APPLICATION� FOR BUILDING- PERMIT � insure,or o cer�ificore of Workeri Compenso�ion Insurance, . osa cerr(ied copy ihereof(Sec.3800,tob. .) . COUNTY OF LOS ANGELES BUILDING AND SAFETY Polity No��mpany � Certified copy h hereby furnrshed. FOR APPLICANT 70 FILL IN eW�owG O Q Q ADDRE$$ J rJf Certif�ed copy is filed with�he county build�ng inspec- � BURDiNG � � �l lion de arfinent. AODRE55 Dare_���Applicam�LUfMC�C—���. CITv ZIP IOCAIITY � �1 E TI CATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. NFAREST �,�``^_ ��` COMPENSATION INSURANCE SIZE OP LOT - - -- NOW ON LOT � � CROSS ST. N��.r� (This settion need not be tompleied if the permit iz for one �RACT � BLOCK LOT NO. auESSOR hundred dollors(EI00)or less.) � � � 1V1Av 600K PAGE PAR�L - � � 1E1. USE ZONE NAF I certify Ihot in the performance of the work ior which ihis � OWNER NO. � �. C a __ permit is issued,I shotl nol employ ony person in ony manner SaECinl O so as lo become subjett lo Ihe Workers'Compensolion Laws. ADDRE55 CONDITIONS U Date Applicant . . . ,�: CITY ZIP .S O NOTICE TO APPLICANT: If, after making this Cerlificate of ARCHiiECTOR iEl. DiSTRiC7 GROUP ttPE FIRE PROCESSEoeY �j ENG�NEER NO. E.emptian, you should become subjecl to Ihe Wo.keri CON ZONE W . _ Compenso�ion p�ovisions of thc Labar Code,yoo must forth- qDOaE55 � �� �� � Ci� � with mmply with soth provisions or this permit shall 6e ( - deemed revoked. ' � CONTRACTO \ � N�' STATtSTICAI C1A551FICATION APT. CONDO. Z \ IICENSED CONiRACTORS DEGLARATION � tiC. Ctq55 NO.0•1 Dwetl.UNRS I hereby afiirm 1Frot 1 om licensed under provislons of Chopter 9 ADORE p, - (commenting wilh Section 7000)af Division 9 of Ihe Business and ��� SEVhR 1�V . , Rofessions Code,and my licrose is in lull force and effec�. -- CITY � 55 �� � � gK ,, �. VAU�ATION ����.(� 50.f NO.OF NO.OF CHEGK license Number�-r?����� Lic,Class� � 512E STORiES FAMIUES - ONE � � � �} V 1 VALUATION Coniroc�orl�.��ZmL1,�l�Oflt�are _ __ oeseei io OF WORK � N� ❑ S ���� . ADD �1 am e�empt under Sec. � —1- '1{�yp ❑ . a Autlt' B.BP.C.fo�this reoson r`^� Q ,CQ�i � � REPAIR � _ Da�e: USF OF . _ . _ . ._ . DEMa ❑ . . .. _ . �� Q��1 P E%ISTING BtDG.� r .Signoture APGLICANT . . . � T FIN L,� ' ��e • • •2 J OWNER-BUIIDER DECLARATION CRINT� �� D YE � I here6y afiirrtl Ihot I am axempt from the Conlractoi s license - �- -��� SL,L.'S '�S e\,1Q �• � I ' ���O O Law fo�the following reason(Section 7031.5, Business and ADDRE55 FINA Rolessions Code: ' 6 = ) . . . . . _ . . PRE ENT _ . . . _ . Y � —� � � �2�GO c.:� � BUILOING I, os owner of�r,P prope�ry, or my employees with ACL`R:SS V 9�Q`7—O O wages os�he�r sole compensation,will do�he work and ' the srructure is not imended or offered for sale(Section ��`��TY ' �,� 4��� . 7044,Bustness ond Professions Code)._ . MOVING TEL � ` � I,as owner of�he property,am exclusively comratting CONiRnC70R � - -� - � NO. � � � #� � � � � � with Ikensed conrroctors ro construct the project(Seo- pDorre55 tion 7044,B�siness and Professions Code). � � • •3 6 7 5 � CONSTRUCTION LENDING AGENCY . SE�BnCK YAR� HWY T��Ap�P�NEFR- WIDTH - - � �� I hereby afFirm thot there is a tonshuction lending agency fo� � FRONT � � �3�7� fha performance oi ihe work ta whith this pe�mit is issued . a.�. - � � - O 9.O 9-H H (Sec.3097,Civ.C.). �- � Si�E P.l. lender's Name � �� � C LDMA Ref.M lender's Addrcss � - _. . P.C.Fee f Perm�i Fee � . , � , 1 certify that I have read this opplicatlon and stole that the �ss�ance Fee { LDMA P/C N obove in�ormation is corrcct.I agree ta tomply with all County ��� Investigo+ion Fee � � ordinancez ond Stale laws relaring ro b�ilding construc�ion, io+al Fee i�hte,ve.m.M and he�eby authorize represenlaiives of ihis Counfy ro enier � - - u n�he ove-mantioned proper for inspeclion pvr os� �r ,��^ A O 0���� $ SEE REYERSE FOR EX�LANATONY IANGUAGE Signat�re af Applicanl ar Aqenl �o e . . - , , . -' —. ;._ _-j1?� o - --I '`y' �' '1 `` � --(c'' +T U f.. � ,�� '� ,'t t '�,',� v_ .��• p � �• � -..�p :j. \ : � � r- a �'� '� (a'I J. ,c �= '�'� r4 �O . C j�+ ^ � v •D p '9 j +�.� q ;� . �O ` � r n c 1 --o � ,3 ° � �`,'..,� 1•,s ' �� O O�' ' .:. � -.�'� .• p = �` ` � q p_� 1 ,� '� . -o � O � O � ` G O .Dp ? ,O,n � � O O 7 �' '�. r �,t �� '� ! � 'ja Q fG 3 n � p r�' -'O c�. '�� 1 _ • Z w�'�' n Q i 7 � :9 �� f 1 � . '',i.�. 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