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HomeMy WebLinkAbout1475A (8) WORKERS'COMPENSATION DECLARATION f7 I here6y�affirm �hot I hove a certificatPe of consent to self APPLICATIO�I FO�t- ��JiLDI�NG�-PERMIT �;J i,�sure,or a certifimte of Workers'Com ensa�ion Insurance, or a cerrftied copy rhereof�Sec.380D,iab.C.) COUNTY AF LOS ANGELE$ BUILDING AND SAFETY PolicyNo1���'��?'� Compony ���Y� �1,te.1� : � Cer��fied copy+s hereby fu��ished. FOR APPLICANT TO FILL�l`J� " BuuowG � ? �✓ �`.1 i AWRE55 ' ut�✓ � <'-d-.d-t's '� ❑ Cerli4ied capy is filed with the county building inspeo- gU�LDiNG tipn deportment. ADDRE55 �j , -.�• r � ome �—�� Appliwnt t - � arv '�,1 zic tj �ocnuTv �EV�C3' ����, '�a� � CS CERTIFICATE OF EXEMPTIO F M WORKERS' NO.OF eLOGS. EAREST ' COMPENSATION I RANCE SIZE OF LOT NOW ON LO7 � CRQ55 ST. (ThiS sec�ion need not be<ompleted i4 the permif is for one TRACT �J Q 5 BLOCK - �' LOT NO, �7 7 MA7 BODK PAGE PARCEL hundred ddilars($100)or less.) : � TEL � USE�g NE MAP )���+�� 1 I certify thot in the performance of the work for which this �'/'�NER NO. � . '��r` �.:+ f NO. 9 ..1 � �� SPECIAL permit is issued,I sholl not employ any person in ony manner ADDRESS _ � �� CONDITIONS so as to become subject to the Workers'Compensation Laws. � C.1 Date Appli<ant CITY ZiP � NOTICE TO APPLICANT: If, afier making Ihis Certifi[ate of �+RCHITECT OR TEL. D!STRICT GROl1P NPE FIRE %20CESSED BV Q Exemption, you should become subject to ihe Worke�s' ENGINEER NO. { CONST. ZONE � � CompenFation provisions of ihe Labor Code,yau must forth- qDDRE55 " � �-. �� � � � with comply wi�h suth p�ovisions or this permit shall be d- /'^ 7EL STATISTICAl0.A551FICATION"'�� APT. CONDO. (T� deemed revoked. CONTRAClOf4._. "��� NO.�' !)/ ;a° iICENSED CONTRACTORS DECLARATION ' ii�_ C�ASS NO. �'e' DWELL UNITS I hereby affirm ihat I am licensed under provisions of Chapter 9 ADORESS } ',1�; �1j i p NO. � G?� (commencing with Section 7000)of Division 3 of the B�siness and ��� ^� SEWER MAP Professions Code,and my license is in full force ond efrect. C�i� ( ' :�, CLa55 T] eK � VALIDATION SQ. NO.OF 6 NO.OF CHECK — LicenSeNumber�t?�� �•y`^� Lic.Cla55� SIZE y �' STORIES 7 FAMIUE$ � ONE / / YALUATION Coniractol�-�/wL'-�V�-/:\Y� -}2 5^r Data DESCRIPTION OF WORK �"j ADD ❑ i �,!' /��� �I am exempl under Sec. �'�=' A�TER � , B.&P.C.for ihis reason REPAIR � s � ? 4'i.�A. � - USE OF �' Dafe: EXISTING BLDG. � " DEMOI ❑ jt c e e. . c j Si nature APPLICANT � �.^ TEL FINAL '� 1 -- '� " � � � 9 vRiNr) a..E _ ; r No.; `� r�� j �a�;�„�: I � I u 6 i;ti OVJNER-BUILDER DECIARAT�ON DATE �. f;',`,�.�� g, � I hereby affirm ihat I am exempt trom the Coniractor's License _ ; � a s "j 4 tj,(j(i s�., Law for fhe following reason{Seclion 703L5, Business and f+DDRE55 1�' FINAL � ���`'� -' Profe55ion5 COde): PRE EM ' � BY ';'/F�V�F ��/:`C�'-�,_�; -� - � BUILDING . , I, os owner of ihe p�operly, or my employees with ADDRESS wages as their sole compensation,will do the work and ' 1,; ' . � . ; ihe struclure is not intended or offered for so;e(Se<tion ��A��TY � 7044,Business ond Professions CodeJ. MOVING iEL. � I,os owner of the property,am eztlusively contrattinq CONTRACTOR NO. with licensed coniractors to construct the project(Sec- qD�RE55 - � tion 7044,Bosiness and Professions Code). CONSTRUCTION LEN�ING AGENCY ' SET�eACK YARD HWV TOTAP pTP��NE WIDTH I hereby affirm that lhere is a construction lending agency for FROM - �he performance of�he work for which�his permi�is issued a.t. (Sec.3097,Civ.C.). SIDE P.l. Lender's Name - s �"7 L, f"� LDMA Ref.# . r �� �� V.C.Fae$ Permi�fee �J J , Lender's Address E � I cerfify tha�I hava read lhis appiita�ion and stafe ihat the �sauonca Foe ��'``-�� LDrAA P/C� above information is correct.I ogree to comply with all Caunry Invesrigarion Fee / /� � ordinances and State laws relating to b�ild�ng construction, iowi kae f�`+�' � Cj IDAM ae.m.# ' d hereby autho presentatives of this County�o�enter � _ _ a :upon e obove-m tiorZr�d property for inspecti n porp�oses. � � � � � �-��� '������ n �. .-, , �`i::} SEE REVERSE FOR EXPLANATORV IANGUAGE SignoNre of Applican�ar Agani- 0 e � >.,..._„�,.—..............,,-:�-,,,-,�..._.,,«-.,.-�.�....,._�.�.,-..�,.�..a.s.-,<�,-_....-,._........--.'...^"�""�"-•---��,..s.,,..,......�..-.�<- _ ..___.. .�__._,_. � .. __._._ .. _.,,�.__._ ...._.._ , .___.._._ .� .._�_.._._,�__.n__._._.�.v..___. ,. ..���::� �,.�, � �:;..�`[�,- � �. �,.�=et.�..C...V�va:�'T»:; -.3-.� :�.:. . 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