Loading...
HomeMy WebLinkAbout0949A (5) 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;<anl or Agent po�e . ' * T O c � � � o U � m n I �TC o •��i ?�-'.-'�' -F�-.-z'--'_f..-"'r'I'_'_;_ . ' " .i. . � t O O � �, �7 f ,I: . ...� '. . o c .- � ry � v � _ c � r �r, ° �= � ,� c j � � �, I„ j ' �—1 ',. �� o � � �i I �O � � � n c y ,� c - � � �. 3'� �� �.� , i�. � � I �. � "Z X ,�.� - ° F� ro � - _� - '°. ;c . v C,, .rt � � i� ''°c ; oF � o � � 'o � ' .. >ol �;n� �. '� � � Ii �DI � � i � � v 3 ' ^ o c N 'o �• c c ' o .� - .- � � : � j � i ; � . . � _ � o, � a� � � G � � o a �°-� � � � 3 � c l; .o , ; �I ' �p . � � v ...n � a , . o . � . i � �. .�o . � I i � Im � f � -- --� ; �' �� � � i � r 4 ' _'__ ..I ' 1-' I ' ' ' I '• � I I I I �•. - '1" � , � � � , . .. � _ �I' :.:/ _ r. D o _ ' ' ' ° � p � , . tn I �' ; i - '�I'Z -a ,,:' ,i-c � o �.. O : � .. .. , a ' . � � � � . �; � ' �.�.' _' I '' �o O S 1 i . 1 � 1 � i � � -i•� a � _ � c � I � , o a ' I O � D - � -, -- _ �° o Z v e. a " . i e i.. = - . . � � ' 1 M, . + �'. , p O•' ' __ �,��.I ; � v: . D o' i . ._ � � . .� 7a .. _ p . � � � _ ._ p O,. � ' �L , . � _ ' ' � e�� p . . O . � . " Q O � < . .. �� - - . .... 6� m . . - . ' ' a :j .. ,.. � , -_ - . • I ! � i . . • � I � ; , . I • - .. � ' . � .. _ _ '1 - � . � I , 1 ' ._ , I . , i � , . , __ - _ � ' , i , � ' � . l. � . , . i , � .. r ' . ' ' . , I ! � � -� I , � ' . � . .. ._ _ � � _ - � . ' ' t ' y . . . ; � - . � ' , - � . A � . _. . .� . � . . - . ' :� ' :�^. O � . I ' ' . . __ � - N . ' � ' . ' ,/ • � . ..._ _ I . I � . I '• � . �� .. . . .. �. � � . • . � ` � � ,' � .. a �yo.;r� - . ;,a•..•�� , - �.� " f -. � �;;� -':�� p � � ^..C ^.O � �� C �'�� �-�� �' M m C �.� '�� � [ G q �-C � ^ � _ : - . ' � � �J � a�.:�rt. v� ❑ ����.,. �•� io �.: t • � C'a. � �.� � w � : =� M Z� f � � n � "' e,` t,..3. r .�'.j .tv' ���.^• _. . . . � � N _ r� �- _.� a�� `s A � h c _ .' C.�.-C -� = n n �. . . ! ..; �� T. 5 1.� �� H � o _ � �� i.�^. �� �i''^ ^ Y � - '� � �� i p c ��:,�y; �.�. '.�� t�¢ , n � � . I 3 M � .. C �'n d n+j p.��+ ^-`R s � S� S�C R w�^f�.'� � s C '� i . ' .� ., 3 M q � ^ � 'i '`' .. .`. �`- � O .�.. : ` 'a �. ' ` y � ' , . ., � w` ti � � � �:.`� o,��.. '� �,j� � f =�� �. w a ,`� • = ='7 ' ' /'' .3 � : e ^ � s c� cc.�'� =•''� ^'�o 0 1 : �.^ �. ." �� e �`�°.3 F '. .' I i � ': .7.' � 'i'M ,7 n '��C �'2 � '�N j �p � C� '.7'' ` i i^ = - =-w _ ' N .' ; 'C �`�' `� �j O �=�.7 '.t•w ` z ^ n O� �' n ;K• �'�`. [ `' ^ r C, Q r' ' > Z7 �G C'fj p 1 3 ^y�. �. ,� _ - � m �a A � �, , ON " w X��JSC `. C13C. L7 .< �„w,+� �J�.��h _ � - i .� ���^v .e- . � =c,: �, a a � � _ �❑ y ^ �° ' �\ - y - �N ` s•�« o o . ' „ �'�s r _ n a�� � ; =�`� " 3 - ' =• 0 3 - p m �_ � c.«v , G,F,�. �: `c �o � o �• c ., T ^ � ^ , � . ' . , N �� � i c � �4 a ; . � .. �� '^a a � �' - ' '` f � � � � . �- � ' "•C,a�.M < . � � R �� C i ��� �:� ^ ''��.`�w - �•�•• !L' - � _'i . . . . 2 � � c�n� .� a: � �. �n ..� � h� . �7 ; a _ ': O . � � � C .. y '�'1C � �' q= 3 <5 �'��� _ ".. , � - . - . � T ` � x a� 3 -- .r '3�, ' t� l;G F e �c�C a = � �� ^ �`! � . . . ' y� ,O. � y�. y n G . �'�p ^C�' � O- 3� L G �� � .� 3 _ Z:� 'S�_^ V G .'L y �_ � '�.ti �, C"e ` _ c. �e 1 �r � = � �: � ' > - '1 , � a � �' .. � '' r - � N � �_1�' : ^�� a • _ � � : - ccc F �'� �G � ��,` ' ^ o � ''a 4 �' T , o :� o _ �. � 3' . .. ` ' - :. .. a �_c � c;v < _ c.\� ��� ; ama .�' s .r`` ��� �+nC . . - . _ .. v � zw.y � o � = " ; .`' N.N o..H = =` ��� V1r � nJ :f __ _ n ^\w ' � " . �� e.- _ ^'.o ncv� �..'>�.r.� �._' , �•�- . .., . � . � „ o � �o ' �^ � �,,�.. �.N m _ � � ^:� � � �-^: ' ; c -' � : '� o 0 � - .o . � � . � ,�_ �' , r � f•` ..,�.� . - e � `i _ i- . s �e �N ^o `,:. � �C •� n � - �.� r� � "' _ � .` _ ` � , __ - .._ - . y� . �0 .. .. . . 1 7 l:-\i ti 4 T v G. i � - '�.n � . � w . � � v