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HomeMy WebLinkAbout1483A : .. . _... . . . WORKERS'COMPENSATION DECLARATION .- - - . � ' I here6y oHirm that I have a cer��f�coie of�a�,e�,�o,a�F - - �APPLICATION FOR BUILDING PERMIT ins�ra,or a certi{ico�e of Workers'Compensation Insurance, � or a ce�nRed copy thereof(See.3800,Lob:C.� - � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � .. � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUIL�ING �.��.7� • OADDRE55 Certified copy le filed wlth the counry bullding inspec- eUUDING �'1� /� l (�' .Q I tlondepartment. - � � AooRE55 L-;7 r, � �I. � I � } ,Q !/.� Da7e Applicant Cltt \� � �. I1 ��) ZIP �"j ��(i� IOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' � - � 52E OF tOT C X '�7 SSNOW ON�LOTS� � C OSSSST.� � � COMPENSATION INSURANCE � � � (This aeclion need nol be campleled if Ihe permit is for one TRACT �7�I k.v BIOCK LOi NO. q - ASSESSOR hundred dollars(E700�cr less.) A MAF BOOK� 7AGE PARCEt OWNER �Ht� Y' .� C CLr' i�r'�1T`' 3to �7��� USEZONE MAV J 'r I certify thal�in the performance of Ihe work for whith lhis I1'n R_� �. / O���'�"� permit is issued,I shall not employ ony person in any manner ADORESS � . � �� «�( r fil'�[S(- � �ECIAL � — so as�0 6ecome subject to the Workers'Compensatlon laws. � d CONDITIONS � j 7 U . Dme ' Applimnt - CiTv � •�• ZiP I �^S - � NOTICE TO APPLICANT: If, after moking�this Certificafe of AR[HITEROR TE�� DISTRICT GROUP ttPE � FIRE PROCESSEDBV O Exemption, you should became�sub�ect to tha Workeri � . ENGINEER NO. / NST. 20NE U Compensation provisions of the Labar Code,you must for�h- qoDaE55 ` � W wilh comply with such provisions o� this permit shall be . . n-' TEI. STATISTICAL CIASSffICATION APT, CONDO. .U7 deemed revoked. � � - CONTRACTOR NO. Z UCFNSED CONTRACTORS DECIARATION . . . . ._ ... . .. .._ ���. . . _ M55 NO. � °'�'� �DWELL UN�75 � � i hereby affirm that I am licensed under provisions of Chopler 9 AD�aE55 NO. ��R�P (commencing wirh Section 7040)of�ivision 3 of ihe Business and ���. Professions Code,and my license is In full force and effect. CITY M55 BK � - � VALIDATION � ' SQ.FT. NO.OF NO.OF CHECK Licensa Num6er � " Lic.Closs � � SIZE - STORIES � � FAMItIES - ONE � � - ❑ VAtUATION . CoMraefor � Data DESCRIPTION OF WORK N� I�h7'� AOD ❑ : o , ❑I am exempt�nder Sec. � � AITER 8.8P.C.for lhis reoson ,. REPAIR ❑ - -_ �� 4 fl 3 A � Dote:�'� USE OF EXISTING BLDG. DfNa ❑ - Signotoro � � �� APaiG".NT TELtN+ FINAL �• �• • •2 3 OWNER•BUILDERDECLARATION PR��'�T �� � �- I1,I S NO. . 1-2325 DATE I hereby atfirm thot I am exempl from the Contractor's litanse � � ' •5 4 1 9 law for the following reason(Sectian 7031.5,Businets and ADDRESS FINAL ' Profeseions Code�� � - � By • • •5 4.1 9= U BU4DING � I, os owner ot the proper�y, or my amployees with ADORES$ 0 9 0 9—8� wagas as their so�e compensalion,will do the work and ���TM , _ the slr�ctvre i�no1 intended or offered for sale(Sectlon 7044,Businees ond Professions Code). � MOVING TEI. � I,as owner af Iha property,om exclusively contraeting CONiRAttOR NO. with litensed cantractors to construtl tha pro�etl(Sec• � ADDRESS tian 7044,B�siness and Piofessions Code). REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY � �T gq�K vaaD Nwv pgOP.LINE wioTH � � �� � I hereby affirm Ihm thera is a mnslroc�ion lending agency(or FRONi � the performance o!tha work for which�his permit is isfued . 7.L . (Sec.3097,Civ.C.). SIDE � P.l. lender's Name L� / IDMA Ref.M � m Lender's Address � ' - P.C.Fee S � V � / Permi�Fee , . � 1 terlify Ihot I hava read ihis opplicalion and stale that the . issua�ce Fee LDMA P/G M . , _ obove informotion is cortect.1 agree�o comply with oll Counry imesrgm�on fee 'q ordinances and Stata laws relating fo bvilding constrocfion, Toml Fee LOMq ve.m.# � ond here6y authorizc representolivef o(this County 10 enler � upan Iha o6ave-meri`tione�d�pr/p/perfy for inspection pv�poses.(% o �,�(�}{�,.CC /l=j��(,(�,Cd� y—�"'iQ�] SEE REVERSE FOR E%PIANATORY LANGUAGE - SignaNre ol App�icant vqgent Do�e � . . . � - g � r .- i�O � no m1° ry � � ° ° o 'o o ° o � �� ° 1 p s . m -.. v_+ o in o F p � ^� � � o � m 'n � � - !9 n n Q 4 ., iG � ip .� o � - -n Cl= p 0 ....0 � " 7 O .� � L C' ^ p 7 O G 9D1 m� o o _ � a � � a, n o ,o- i° a ��.' n� � � a �^ c '' , o . o � � I ao < ° �"� v u� a'v' J _° � ^ a ` o . o ° = K �,� � q p' 1 0 `° o m, oo � �- o , o . 3 P°C 1D O Q � u� O M - ? 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