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HomeMy WebLinkAbout1398A (7) WORKERS'COMPENSATIbN DECLARATION � � � � insua66rafcertifca'teofWokes'�Compesalionlnsu;e��" . APPLIC�TI-�N���FQR�: BUILDING PERMIT - - ar a cer�ified copy rhereof�See.3800,Lab.C.) COUNTY OF LOS ANGELES_ BUILDING AND SAFETY � Policy No. Company � BuitDiNG � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN n�oeess �L��� � Certi(ied copy is filed with fhe counry building inspec- BUUDiNG �. � fion depoilment. ADDRE55 � 1 W� LOCALITY /'��� � 2..n NEAREST ' Data - Applimnt CiN QJ C3Q� 21P CROSS S7. CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF BLDGS. ASSESSOR COMPENSATION INSl1RANCE SIZE OF LOT NOW ON lOT - MAP BOOK PAGE PARCEL (This sectlon need nof ba completed if the permit is for one � . � USE ZONE MAP /� hondred dollars(5100)or less.) . ianci 1��5.� gLpCK � . � LOT Np. �' NO. TJX� 3 ' qI y /�� ' A-� TEL' SPECIAL I certify that in 1he performance of tha work for whith this OWNER '4'\��C W�u� NO. -�^�a'� r CONDITIONS a perm�t is issued,I shall nol employ any erso in an � . . .. DISTRICT GROUP TYPE FlRE PROCESSfD 6Y � ADDRE55 UI C���S CONST. ZONE U _ so as ro be ome ubject to the Wor pe n Laws. n, ` �,�y� , ��1�� lX V�--� .d U—i -� C Dafe �� Applico t � ' ��— CITY �P STATISTICAL CL45SIFICATION' APT. CO DO. p NOTICE O A PUCANT: If, a e mo ing ' Ce icote of ARCHITER OR . tEt. � - V Exemptlon, yo� shou�d becoma subje[f f e Warke�s' ENG�NEER NO. CLN55 NO. �WELL.UNITS w Compensation provisions of tha Lo6or Coda,you must Torth- qooREss SEwER nMP � with comply with such provisions or this permit shall be /�� 7EL. � deemed revoked. �pNTRAC70RL(J ��NO. BK. - PG, - - VALIDATION � LICENSED CONTRACTORS DECLARATION t ., - ul�i�, 1 heraby offirm that I am licensed under provisions of Chopfer 9 AD�RES �W ,� 2L71 NO. 3 VALVATION - � (tommencing with Section 7000)of Divislon 3 of the 8usineu and �-`__f �+ ���. O� . Professions Code,and my license is in full force and effect. �iN /�"!�\eS `j��,qs�—{�� E , � ��� $Q,FT�'.9... NO.OF N .OF CHECK , License Nomber �lic.Clase size 4"+v ST02IE5 FAMILIES ONE �1A�,�jp�zae u1 � _ N� � s CAMrOCfOr S'^Ed� pa�e� DESCRIPfIONOFWORK ❑I om eaempt unde�Sec. 1C �^h'16F� 4� � a�o._. ❑ c"1 3 9.8 R - -R�'�T'YI MN�O ALTER � FINAL . . . B.BP.C.fol tlti5 reason . � � � REPAIR � DATE �• . • • e ,� ' USE OF � BINA - �1e' E%ISTING BLDG. �EMa y � � e�J 6.7 Jr Signa re � APRICAM TEL. .. E -BOIL DEC ATION � FRINT NO. _ � Z,'r�o � •3�,7 5� I hereby irm that I am exemp 4 tha Contrac�or's Licensa �(� law for ihe following reason(Sec�ion 7031.5,8usiness and - ADDRE55 -� �- -� �� os�s—ab ProfessionsCode): � pRE ENi '-� . . ❑ BUILDING , , I, oe owner o(1ha property, or my emplayees with ADDRESS � wages as iheir sole tompensation,will do�he work and . _ _ 1he strocture is nat intended or affered for sale(Sec�ion , ����TM .. . . . 7044,Business and Professfons Code). MOV�NG TEL. � I,os Ownef o�tha properfy,om extluslvely controcling , CONTRAROR NO. .._.. ....... . . . . wilh litensed contractor:to constrvct the pro�ed(Sec• I qDORE55 �fion 7044,Business and Pro(essions Code). . .. REQUIRED TOTAlSETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY � SET 9ACK YARD HV✓1' pROP.LINE �✓IDTH , - I here6y n(firm that there is a construc�ion lending agency(or pRONi . � .- ���. ... . ... . . . . the performonca of the work for which this permi�ia issuad � p.t. � . �Sec.3097,Civ.C.J. . � SiDE - r . .. _ _... _ . . .. . .... .. _ . . P.L. lender's Nome � . . . . .._. .... _ . _.... .._ . . . ._... Lender's Address , �.C.Fee S Permit Fee �-� - I ce�tify ihat I have read lhfs applicolion and sta�e thot the � �� he�ooce Fe� ��d� s� above information is correct.I ree to tomply with a�l County Invea�igoiion Fee � ordinonces and 51ote la relaY g fo boilding consMutlion, � � � ---�6�7� � �' - �� � " � nnd ha iz e r atives of fhis County f enter To+al Fea up m ' ned properry for inspedion p pose. � � � � � - �� � �� - � - � � _!_�' � " SEE REVERSE FOR ERPLANATORY LANGUAGE � ' �gnofure o ppli nt or Agenl po�e . ... . . . .�..V. ...... . . . . . . . ..�� :± 2 _�. -- - o c r fn :n"a �i1 �il Q- '...... 0 � m " in o p � O o j fl- o �p., m � �n �i �' m-n fl� � O 7 p 0 C � n 7r d 7 n � m � � S � I ' � °� �- T � 3 Q' � �°- � n _.^�° `-°-� '° �'a � v ,� �� , , i �o � �n � a. o o D <c o ,:: a m . A � � o � �o I m o < o Fa z1 0 3� no a -n =, n _ I � Z x �� � o� �,� ; 'o ❑v � v -1 3 n•' �. t� � C .� �c e oo c u .� i K m o � oo I 3 C ° h • � ,In 0 0 3 p o p � �_. � "' -�o m c m n . 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