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HomeMy WebLinkAbout1007A . . .. . . . . ... . . . . .. _ . . . ' �WORKERS'COMPENSATIDN DECLARATIO� . ' . •� .� � � --'�' � ' _ � I here6y affirm�hat I have a certificafe ef�a�,e�„e,e�f �- � � -- �� APPLIC�ATION� FOR BUILDIN�G PERMIT � ��� insure,or a certifico�e oi Workeri Compenso�ion Insaronce, � . oIa cer�i(ied copy rhereof/(Sec.`.�'�B00,La6.'C.�) ��� � � " - � �� � � ' � � -- � -�, PolicyNo.�G b� �lCompon� ST'�Y_ i r�pJ�. COUNTY OF LOS ANGElES BUILDING AND SAFETY ��, �' �� Certified copy is hereby furnished. . —T FOR APPLICANT TO F�LL IN BUIIDING ADDRESS � . CerriFied copy Is filed wirh the covnry bvtlding inspec• BUaDiHG � � �tion deparfinenl. • . ADDRESS �Z. (i L L,..t�,v r/� Date7 • 3 U .�7Applimnt CtTY - �� -f- ZIP IOCAUTV CERTIFICATE OF EXEMPTION FROM W RKERS' � . NO.OF BlDGS. NEAREST + COMPENSATION INSURANCE � , SIZE OF LOT NOW ON lOi CROSS ST. � "� � " " - (This seclion need nol be completed if Iha permil Is for one TRAR BIOCK �pT�.�p. ASSESSOR hundred dollars($100)or less.) . NL°�P BOOK PAGE PARCEI TEI. � US Z NE 1�1P � OWNER ��� I certify thot in the performance of rhe work�for which this C NO. NO permil is iss�ed,I shall not employ any person in ony manner SPEC�ni � so as fo becoma subje[t to Ihe Workers'Compensailon Law7. ' ADDRE55� �C CONDITIONS u� . 0 Daie Appllcanl' � - CItY 2IP � . U NOTICE TO APPLICANT: If, after��moking�lhis Cerfificale of ARCHITECTOR TEI. OISTRICT GROUP TYPE FIRE PROCESSEDBY 0 Exemp�ion, you should become sub�ect.�o the Workers' . ENGINEER NO. � n � �pNST. ZONE F... Compensarion provisions oF tha Labor Coda,yo�m�st fonh- I� 3 � W ADDRES$ wlfh comply with such provi:tons or this permit shall be a deemed revoked. , - w CS � TEL. 1� STATISTICAL QASSIf TION APT. CONpp, � .. . CONTRACiOR S NO.r q�'{_ S`1 Z LICENSED CONTRACiORS DECLARATION . , ���. MSS NO. DWEIL.UNITS I hereby ai(irm ihat I am licensed under provisions of Chopler 9 ADDRE55 /� �..�� NO. (tommenting with Section 7000)o!Division 3 of the Business and ��� SEWER MAP Professlons Coda,and my Ilcense is In full forca ond eHett. CITY '✓G n r n.qSS � BK � VALIDATION ,/� SO.FT.• NO.OF NO.OF CHECK License Number��G��Ua Class!� 5¢E STORIES FAMRIES - ONE-� L VALUATION CoMrattorweS����.�/ ri�a �ESCRIMIONOF WORK G'� CLC► N� ❑ s 7i�) . . Gvf��/ ADD � C/C/ , . ❑I am exempt under Sec. _❑ - AITFR B.BP.C.for this reaion REPAIR � f � � . . — �. �_� O?']a pp+,: 7 • 3 a �1 USE OF �a // exisT�Nc eioc. l oerna ❑ t!� • • , • 1 -Slgnot�re — . . . � �•�_ ." . APPLICANT TEG� FINAL � O NER-BUIIDER DECIARATIQN � PRiNi Na� DATE _ I heraby affirm thm�am exempt from tha Contractor's licensa - � - - - - � ' '�h f�S- Law for the followin reasan Section 7031.5, Business ond /+�OUESS FINAL - � - � e ( . . .'675r Profeeslons Coda): - � � �� - � - - pg N sy . . 0'j j(�_R'] , O � 8�����NG : 1, as owner of Iha property, or my employeas wllh qDDRE55 wages as rheir sole tompensation,will do the wark and � � � �- tha str�cture is not In�ended or offe�ed for sole(Section lOG1L�TY 704a,Bosiness and Professfons Code). � -- �-�- MOVMG ret.. � I,as owner of 1he properly,om eKclusively contracfing CONTRaCTOR NO. � � with licensed conlroctors Io consrrucl the projetl(Seo-� � - � -- � - - � - - . . ' . . � L� lion 7044,Business and P�ofessions Coda). ADDRESS , REOUIRED 70TAlSETBAIXFR I o7� '�k � CONSTRUCiION tENDiNG AGENCY ' � SET BnCK-- YAaD Hm/'r PROP.un7E WiDiii - ��� � O ' here6y afiirm that there is o tonstr�tfion lending agency far FRONi . ie pertormance oI�he work for whith this parmit is issued. _ P.l. ( iac.3097,Civ.C.)• SIDE �• P.L. +nder's Name �' � � � � IDMA Ref.A +nder's Addrese � � � P.C.Fee S� Permlr fae :er�ify that I have read this opplicotion and stofe thof the Issuonce Fee �S .IDMA P/C M . � � :� �ave information fs cortect.I agrea to tomply with all Counry imeerigaiion Fee ) � � : dinonees and Stale�aws relating fo building conslruction, Totol Fee (p' LDM4 Perm.N � id hereby authorize repreeenrmlves of this Couny to enler � - -- . ' the ebove•mantioned properly far inspettian purposes. . �.—�f �(_ �_y / SEE REYERSE FOR EXPUNATORY LANGUAGE ' • s • Signafure of Applicom or Agent . pa�e �� . _ .. . . . . . . � � - _ " nx ", " �^ inc v o n"' ,... � . ..�.i .� -.. = r �- - --�� - - z -r �3 00 ° ° ,'p o o � � � -, ° om `° a � I ? � a:. ,.� ° ° �o o ^ �c, �' ? 3 a- � �c �� p � .. � m ° -_ � . o '� � T ?p � r� p c o y W � V o . ��: � � � � � T ; � ` �Z „ �� � _ f� a , � _ �o � .�c ` �� ,n , � � o I c �� � n� o � _ n „ �3 _ o o c N � o � o� o � ; ...'* , D . = � : : i'� � o � o = o: -t < � � t o' -'. L.,� .� �_ = v ; i i . .. - � � - o •a o n , o _ � c o � l� o �� -.o. a � o'� � � I _ � � o � � ° ,. _.� - 3 =— ' - m' ' vo " ' i � C 7 � — t;' • ' � i - � Q � � �. D a N o r � , 2 � ! .f •c. �. vc �-. ° O , . m � D � � - ' . I- °- - : m v � . -� , -' .. r -,'j .^ C. � 1 ��� � 7 . � 6 �. ` � O. Z . I j i O i �,% J'• O' . ' � t i � w 1 i j � , . � • - I- o o �. . � ,r I v+' " - -- - '- m I � � i I �o � r-� - . 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