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HomeMy WebLinkAbout1066A ,�� � WORKERS'COMPENSATION pECLARATION ' � � I hereby affirm rhot I have a�e«;��ro,e of�o�5e�„o,e�f �-.,APPLICATION FQR BUILDING PERMIT � � insure,or a tertificate of Worken'Compensolion Insurante, � or o certified copy thereof(Sec.3800,teb.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY Poll[yNO. Compony BVIIDING n � � Certified mpy is hereby furNshed. FOR APPLICANT TO FILL IN ADDRESS �57� �C W l E�T � Certified copy is filed with the coumy building inspee- eVaowG / n � tiondepoftmenf. � ADDRESS � niOCJ � �(f LOCALITY /�l�, Date Applicanf CI � ��_ /, ZIP � ` 5 NEAREST � CROSS ST. ' CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGs. n55e55oR � GOMPENSATION INSURANCE SIZE OF LOT NOW ON l0T I MAP BOpK PAGE PARCEL (This settlon need nol be tompleted if tha permit is for ane USE Z e �P Q ~'33� hvnd�ed dollors(E100)or less.) TRAR BIOCK �Oi n10. �� NO. � � 1 TEL / ,�/ SPECIAL I cartify that in tha perFormnnce of Ihe work for whith this OWNER 0 11'�I'�N NO.7�y' 6 ' � I,v CONDITIONS f1 permit is issued,I shall nol employ ony person in ony manner • � �{ DISIRICT GROUP TYPE FIRE PROCESSED BY Q _ so as�o become subject lo the Workers'Compe�501ion LawS. /+DDRESS 7� i�G W A �, E % J2• CONSi.�/ ZONE V f /� -1 r /O .�3 �i 1 �.t� `�e Dafe� � � Applicant �� �`. ( C S � QTY �� ,A ZIP.-/I /��D STATISTICALClA551FICATION APT. CONDO. O ARCHI7EC7 OR � � ':.TEL, � NOTIC TO A PLICANT:.If,�afler making thts Cer iftcale'of � � . � ���' � � q J � � U ENGNEER�:�. �.� NO. . �CIA55 NO. --�DVJELL.UNITS w Exemption, you�should become�subject��to-the Workers' � � , . . _ ,, y Compensation provisions of tha Labor Code;you must forth- � � qppRE55�� � � SEWER MAP N with tomply wJh soch provisions or�this permil sholl be n 7` � �� n � � p��I/� �p � l deemedrevoked. - CONTRACTOR r7//�� � �� �K NO.��ys 17'��3 - . BK.- - PG, VALIDATION IICENSED CONTRACTORS DECLARATION '/ � I hereby affirm thef I am litensed under provisions of Chopter 9 � ADDRE55 {}" ��'��f� NO. �-(U 7�� VALUAT�ON- (commencinq wiih Setlio�700D)oi�ivision 3 of tha Bosiness ond th� - LIC. ��G/ E � '7 r p` � Professions Code,and m license is in(ull torca and effecL CITY� I �f �S CtltSS �ti J � , � g (� f j 5�.FT. ,/ NO.OF NO.OF CHECK llcense Nomber � J 7 li[.Closs ` �" � SIZE �6 7� S70RIE5 FAMILIES ONE � � DESCRIPTION OF WORK N� ❑ � E �o�,�a�;a�P�,�,� cR��,�,Fs oa« � e � , q ADD V� �1 am exempl under Set. Q ^� L-I¢ 1« ��1� nUt� ALTER � FINAI B.BP.C.ior this reason � ' � DATE REPAIR Dote: u5E OF � DFMOL ❑ FINAL �1 0 6 6 A EXISTINGBLDG. CS. fAICC B Signature . ADpIICA � TEL.7 Y �• • • • �.�. OWNER-BUILDER DECLARATION PRINT � �/C'S No. � � I hereby affirm thot I om azampt from the CoMracror's License '• /� u � ��• •4 9 2 5 Low for tha following reason(Seclion 7031.5,Business ond 'ADORESS ��K � G�f ll�s �al�' /� •J�1 • ► ��� � Proiesstons Goda): va Nr � (/� � • • •4 9.2 5 cSr ❑ BUILDING . s'�/ L� �!/ � I, ee owner of tha property,or my employeez with ADORE55 � ` O�,,$`$4 woges as their sole compensation,wil�do tha work and ���TM - thc strottore is not intended or oitered Ior sale(Section . \ . � 70dd,Business ond Professions Code). MowrlG iEL. \ � � � I,as owner of the property,am exclusively mntrading , � NTRACTOR NO. ' wi�h licensed contracfors to construct the projecl(Sec- qpDRESS tion 7044,Buslness and Professions Cada). _ � . - REQUIRED 70TAl5ETBACK FROM E%IST. CONSTRl1CTION LENDING AGENCY � SET BnCK YARD- HWY p�p �INE WiDTH � • I hereby affirm that fhere is a mnsrrucflon lending agency for .FeoNT - the performance of the work for which Ihis permit is issued v.t. . �Set.3097,Civ.C.). sioe .. . P.L . . . .. . Lender's Name +�' ` 9 . P.C.Fee E Permit Fea ,j C'r/� Lender's Address 1 certify Ihat I have reod Ihis opplfcotion and state that tha � �� I�euonce Fee �C• } � � � � above information Is cortecf.I ogree�o comply with all Counry Imesr�gotion Fee .7 ' ordinances and SIa1e lawz ralaling lo b�ilding mnsfrucfion, Torol Fee �/• '� and hereby authorize representatives of this Counly fo enter C upon�ha above•menti ned properry for Inspection urposes. � � � � � � �I� , � , SFE REVERSE FOR EXPIANATORY LANGIIAGE , . Sigrwture of Applicant a Agenr � ` Dfite . . ml a o �g • � �. _ �' -..�" ', , '\ . 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