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HomeMy WebLinkAbout1241A (6) __.m�_--- WORKERS'COMPENSATION�ECLARATION � I hereby affirm �haf I have a cer+ifimre oF�o�5e�<<0 Se�F APPLICATION FOR BUILDING PERMIT insure,or o certificate of Workers'Compensation Insurance, or a cerrified copy ihereof(Se�.3800,Lab.C.� COUNTY OF LOS ANGELcS BUILDING AND SAFETY Policy No. Company � CertiFled copy is hereby fornished. FOR APPLICANT TO FILL IN ' Bu�towG � aooREss "'1 �. L �Ct.�.� � Certified copy is filed with the county building inspec- gUILDING. ���� ����^ � - � tion departmeM. P.DDRE55 .Z `%. Dale Applicont CRY O/v ZIP ��' LOCALITY L✓ ��'� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF 6tDG5- NEAREST COMPENSATION INSURANCE - SIZE OF LOT NOW ON LOT CRO55 57. (This setlion need not be completed if the permit is for one /� -7 ASSESSOR hundred dollors($100J or less.) TRACT ��p BLOCK LOT NO. �L ry�qP BOOK PAGE PARCEL TEI. � USE ZONE O )I./' � I cenify tho�-in the performance of�he work for which this OWNER OC�[. NO. - � 3 a 'F permit is issued,I shall not employ any person in ony mannei C SPECfAL � so as to b co s�bjec7 to the Workers'Compensation Lo�vs. ADORE55 �(�� �� �. � � g("Q'�J�; NOITIONS U ����� CIiY .�i-�L.�.�/�%��L� ZIP ��O�O � Dafe�� Appficont.� ARCHITEC7 OR TE � NOTIC TO APPUCANT: If, ofter m king fhis Certi4icate of FNGINEER �U Sf.� NO ..(J� ' DISTRICT GRO P TVPE FIRE PROCESSED BV O Ezempfion, you should betome subjed to the Warkers' . ` � � CON57. ZONE f � pens pr pDDRE55 ��� � � Y ', Com ation ovisions o4 the Lobor Code,you musf forih- (� with comply with such provisians ar this permir shall be -'i TEL. 7� S7aTISTiCAI CLASSIFlCA710N APT. CONDO. t�'f) deemed revoked. CONTRACTOR ND. �Q Z LICENSED CONTRACTORS DECLARATION � t�C. .j� CLA55 NO. OWELL UNITS �' I hereby affirm Ihat I am licensed under provisions af Chapter 9 AD�RE55 'Z r , NO. T '" - ... (commencing with$ection 7000)af�ivision 3 of the 8usiness and n�� �L� ��� SEWER MAP " � Professions Code,and my license is in full force and effect Ciiv �pyiv� 1�+7•-�- C1A55 �'� gK � VALIDATION y � SQ.FT. NO.OF NO.OF CHEGK Litense Number---�����Lic.Class SIZE STORIES FAMILIES ONE . :. '�"Po ��i` �� �� � , .. � VALtdAT10N.. CoMracfor�YTC�J /GCGJ f a�e DESCRIPTION OF WORK NEW noo � S � C�� z 1 2 41 A �I om ezemp4 under Set. � � �� � , ALTER {f a a s e 2�'j B.&P.C.for this reason REPAIR ❑ s Date: 115E OF . . . .. � DEMOL � g�m?�'1 3 . EXISTING BLDG. � Signature APPtICANi � ... .... .. �,j(A� TEL. �� FINAI .. .. ... � `� �:"7 O�? `�� OWNER-BUiL�ER DECIARATION PRiNn �-y" No. � DATE I hereby affirm that I am exempt from the Contractar's License . �� •�-� �-� '!�.�- ������ ��•`�� `8 7 low for the fallowing reason (Section 7031.5,Business and AODRE55 �-/ FINAL ProFe55ian5 Code): PRE N ,..:.....-� .....-. . . ......-�... ...-:...� BY � CI, os owner of the property, or my employees with AODRE55 � wages as their sole mmpensation,will do the wark and �pCAUTY � the structure is nat intended or offered for sale(Section � 704A,Business and Professians Code). MOVING T��. � I,os owner of the property,am ezclusively contracting CONTRACTOR NO. � with licensed mMractors to cans7rucl the project(Sec- qDDRE55 �� y,�� tion 7044,Business and Professions Code). REQUIRED TOTAL ETBA K CONSTRUCTION LENDING AGENCY SEf eACK YARD HWY pqOP.LME -� `NiD7H � 1 O I hereby affirm that Ihere is a construction lending ogenty for �FRONT � the performance of the wo�k for which this permit is issued P.L. (Sec.3097,Civ.C.). SiDE P.L. Lender's Name . .. ..�7. ., �:•:- . ....-.....--.. .- LDMA kef.# = P.C.Fee S I� � Parmi�Fee , ' Lender's Addiess � � � $ I certify that I have read ihis applicorio�and state that ihe Issuance Fee IDMA P/C M abo�e informo�io�is correct.I agree�a comply wifh oll County Invasrigarion Fee - � � - �� ordinonces and Stote laws relating to building canstruction, To�a�Fae tDMA Perm.# and hereby authorize representotives of ihis County to enter $ upon fhe pbo�e-mantioned property for inspectian purposes:� � � ��-"����" ` " "'"`� ` .� �' ' . � � � � .�.;:a; � . �.,.,. , a:�.... 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