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HomeMy WebLinkAbout0949A WORKER$'COMPENSATION DECLARATION �� � � � .` " "-��--� - �' "��" -� "�' � � - _ I hereby offirm iha�I have a cenificate o(consenf to=e�F ����� qp�p�ICATION - FOR �BUILDING PERMIT � insure,ar a cerlifica�e of Workers'Compensolion InS�rance, o�a certified coQpy ihercetojF(Sec.38 ,Lab.C.) ,,�/ COUNTY OF LOS ANGELES BUILDING AND SAFETY Polity No. 1 ��7 aCompony ��. 'rG �,i � � Certified mpy is hereby furn�shed. FOR APPLICANT TO FILL IN BUILDING ADORESS � � � Certified copy is tiled wiih ihe tounty buiiding inspec- BunDiNG ( - � � tion department. (� ADDRESS ) � (y, T(� Dote •(i "+D Applicanl , `�r� CITY Q LP I 7 ' IODUTV CERTIFICAIE OF EXEMPTION FROM WORKERS' •,. NO.OF BLDGS. _ NPaREST - COMPENSATtON INSURANCE SIZE OF lOT � �� � ��� NOW ON LO7 GROSS SL �� -- ��-. (This section need nof be tompleted if Ihe permil is for one ASSESSOR . hundred dolla�s(E100)o�less.) � iRnCT - BLOCK LOT NO. � � p�qp gppK 7AGE PARCEI � � TE�' USE ONE M-4P I certify�hat in ihe performonce of�he work for which this � OwNEtt. NO. ��I �,p. ' �3 a --- permit is issued,I shall not employ any pe�son in any monner A,/n SVECIAI c O � so as�0 6ecome subjetl fo fhe Workerz'Compensafion Laws, - ADDRESS �/l% CONDITIONS � `J'�' U � � - CIN ZIP � � Uate Applimnt � � NOTICE TO APPLICANT; If, ofrer moking Ihis Certifitale of ARCNiTECT OR TEI. DISiRICT GROUP ttPE FIRE SSED BY ENGINEFR NO. Exempfion, you shou�d 6ecome subjet� to ihe Workers' . . /� CONSi � ZOtaE � Compensaiion p�ovisions of the Labar Code,you must forth- qDDRE55 (%�� N iih comply ih soch provisions or this permit shall be TF� deemedravoked. - � . ' "" � �� �"" � 'J�4 Jlq��S$ STATISTICAtCIASSIFI ATION APT. CONDO. Z . CONTRACTOR NO. — UCENSED CONTRACTORS DECIARATION �� �a � `��� ��� CLAS$NO. DN/ELL UNI75� � � ' � 1 hereby offirm thot I am licensed under provisions of Chopter 9 -' A�DrtE55 [i o�J No. 1 - (commencing wiih Section 7000)a/Division 3 of the Bustness and n ��� /� SEWER MAP Professions Code,and my license is in full force and eflect � [itt Y - MSS l.'��o - BK � .- VALIDATION ' 50.FT. NO.OF NO.OF CHECK �i�e�Se Nu be� �L4310� �;�.��as, S�ZE. � STORIE$ � FAMItIES�� ONE 1/ �1�1p(ff7 NEW VAWATION OJ � c'G�J��>'A CoNraC�o W Itl�o�e 1'L7'DJ - . DESCRIPiION OF WORK S 10� �� _ IUI�R.�l�G A�D : , �I • �°�3 �I am exemp�UndBI$CC. � „ AITER ' � B.BP.C.for Ihif reason � � REPAIR � s . I • •�4�C a�e: USE OF � DEMOL • ^ � T E%ISTING BIDG. ❑ �l.1 J�J�� Slenelure /��` � ....-. ACPLICAfd(� iEl. !..' CRINT � � NO. / — � FINAL O 7.2 9—�� O NER-BUILDE DECIARATION DATE I hereby affirrrt�hai I am exempt from the ComraUoi s License � � � � � � Law for�he following reoson(Section 7031.5,Business and ADDRE55 FlNAL � Professions Code): , . . . F�E ti .. .. .. . BY � � � � OBUILDING I, os owner oi the properly, or my employees with ADDRE55 ' n I wages as�heit sole compensalion,wiil do the work and . .. . ._. .. . . . y � the slr�tt�re is nol intended or oifered for sale(Setfion ����TY �� � /',_ J 7044,Business ond Professions Code). .. , . MOwNG . _ _ . TEI. ,. � Q} ��� � � I,as owner of tha property,am exclusi�ely contracting CONTRAGTOR NO. V � with licensed conrracrors lo constroct tha project(Sec- . . AD�RESs � �� - - � � - - � --� �-� ���\7 l ,n„� � �� tion 7044,B�siness and Professions Code). 1.� � ��� � CONSTRUCTION LENDING AGENCY .... SEQeaCK YARD HWY TOTAP OTP.LINE � W�DTH ��\ A�. V � � - I hereby affirm thai there is a construc�ion�ending agency for FaONT J; � rhe periormance of Ihe work for which Ihis permit is issued p.L. 0 (Sec.3097.Civ.G.)• � SiDE . . . P.l. lender's Noma � � ' 5 _rr1 tDMA Re1.M lender's Address - � . . a.G Fee�S a C7 V Fcrmn Fee � _ , .. ' . . . f certify�hat I hava read this opplication and sfata that the I�evonce Fee IDnM v/C M � obove informolion is correcf.I agree la tamply wilh all Counly � �nvestigo�ion Fea ordinances and Siate laws rela�ing lo building construclion, Taol Fee LDAM Perm.N � ond hereby outhorize represenla�ives of this Counly to enter � � upon tha 4�va•menli d pr erty for inspection purposes. � 1� �� ,�29•� SfE REVERSE fOR EXPLANATORY LANCVAGE . �� SIgn�Appl;canl or Agent po�e . ' .�/.��� .�a ", 1 '1�..�0 Q � �� f,. `�: � ,+ � + 1��. �f�" l7 '.,'. ' � � 1 �' � �� �! 7 �� I ' � �f 1 �V � n�. .= j: .� 7 + r 1 r. Tl O p� r '9 ;J. i1 �,e'�'O �' �. '� b , .� � 11� ' � ' �- n ..r_ � o. �O,: � . .o, C^r .- 1. 9 �i '� � n ,� . �� �(.,•O � ��� t t_. �r�� � � -`•, �,n� � � c ;, � •: � T � CI Y C � IJ .7 7'� ;? 'i] _ `�' '� � 'r= 1. .:Y, � 1 � � ��• I C ` r C ry O � G � C t7 . i� � �y,�. O � � � 1 � � � . D > 9 I O .. 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