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HomeMy WebLinkAbout1395A (7) , . .. .. . . _ . .. . . ... ...... .. .. . .... ... , '- WORKERS'COMPENSATION DECLARATION ��� � � ' " " ' (hereby affirm tha�� �a�a a cerriFicofe o,�o�;e��,o 5e�f — �- � �qpp�ICATION FOR BUILDING- PERMIT - ,1 insure,or a ceniiicoie of Workers'Compensation Insuronce, �'or o certi(ied mpy thereof(Sec.3800,lab.C.) • - " [OUNTY OF LOS ANGELES BUILDING AND SAfETY P❑ol�ityNo.�� Company . BWLDtNG Cert�f�ed copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 1��� � Ceit�f�ed copy is filed�wiih tha monry boilding inspec- �-� BUR�iNG� ��� tion depo�imenf. � ADDRESS .�-� O Data .. . ..APPI12ant .. � Utt La LOCALIiv ' CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF BLDGS. � � NEAREST ,__ . . . . � COMPENSATION INSURANCE � � SIZE OP LOT NOW ON LOT CROSS 5T.� 0.1� (This seetion need nol be compleled if the permll le for one - - TRACT - - � BLOCK � � t0T NO.���� Mqp BOp('� ' CAGE PARCEI� hundred dollors(SI00)or less.) . _ � ONrtJFR � Il e411 {NO. I¢� USE ZONE M4 l I ` � � 1 cerlify that ln�tha performance of the work fo�whith thh , �• _ perml�ie issued,1 ehall nat employ any person in any mannar La `.ew p r - � . 3� ONDITIONS � so as to hecome fub(ect to rhe Workers' ompan- tlon Laws. �DDRE55 p � pate��APPlieanf � - CIN i C 21P I7G� . . . . . NOTIGE TO APPIICANT: If, afler mak �Ihis Cerfificafe of ARCHIIEROR TE�• DISTRICT GROUa TYaE fiRE PROCESSE�BY O NGINEER NO. ('pry�� ZONE F- Exem tlon, ou ehould become eu c� to the�Workers' - �� 1� Q P Y (� W Compensmion provlelons of�he Lobor Code,you musf forth- ADDRE55 � -I v \. .� 1J wlth mmply with wch provislons or thls permN shc11 be TEl�1I STATISTIGAL CIASSIFlCATION . APT. CON00. � deemed revoked. . � � � ���� � � ' GONTRACIOR �Q N06b 3�- Z LICENSED CONTRACTORS DECLARATION -� � uc.�- �� � - Cta55 NO.�OwELt.UNiTS� � � � � I hereby affirm thof I om Ilcensed undar provifions of Chapler 9 A�DRESS S �Q NO. (commencing with Sec�ion 7000�of Divhton 3 of+he Bustness and . ,. .. . .. . u�, SEwER nn.°'v - Professivns Code,and my Iltense is in full force and effeet Citt G1n55 BK- � ��- •� - - - VAIIDATION ' � ' � � � ' ' � SO.FT. NO.OF NO.OF CHECK . License Number U[.CIoi7 � � SIZE � �- STORIES ��� FAMIUES ONE � _ � - � , . . . ❑ VALUATION � C�ontfottOr P � � Dafe - DESCRIPTION OP WORK. .. ...... . A D s ... � . .. . I om e■em t under Sac. �� ` ❑ , ,CITER ❑ B.BP.C.for Ihis reason - ... REPAIR ❑ ` s - - � - � USE OF .V � Dc1e: f7ci5TING BtDG, OEMOL Signaluro � � nPatiCANT � i'- O TE�. FINA `� OWNER-BUIIDER DECLARATION PRiM V Ri .N�� . DATE I���/ , . . � .. 1 hereby o}firm Ihal I am exempf from ths Confmcfor's License qpDRESS FINAL � � ' Law for ihe following reaeon(Sectlon 7031.5,B�siness ond � � Proiessions Coda�:� ��- " ' � 6Y ` � BUILDING �1.3 9.5 A � I, as owner of the properfy, or my employees wilh AD�RE55 —"-`�, �1 }�?���!,�y.. woges oe Ihair sole[omp�nsallon,will do�ha work and ���rv �:�"{ �1{�} �• • ��• . � rhe etrueture is not intended or offered for sole(Sectlon ';1 �Q 7044,Bmtness ond Professfone Code). � MOVING TEL , � � I • •U 9,2 5 � t,af owner of tha properfy,am ezc�u�ive�y controcting CONTRAttOR NO. _ with Ilcensed tontmerors lo conetrvct�ha pro�ect(Sec• qDDaESS • ° •U 9.2 5 c� � �ion 7044,Business ond Professions Code). CONSTRUCTION LENDING AGENCY SET�BACK �YARD HWY TOTAPROP LINE WI�TH � �� O 9 I�S�S 7 I here6y offirm thot Ihere is a tonstruc�lon lending agenty fo� iRONT the performance o(ihe work/or which this permi�is issued P.l. � ��� �� - � - � - -� � - �- � (Sec.3097,Cfv.C.). SIDE P.L. lendera Name J . lDM4 Ref.N - P.C.Fee S - Permit Fee .� � ' � , lander's Address � I certify Ihot I have�ead.lhis opplicotion and efale thot tha . bmence Fee �O� O lD/W+P/C M abave informotion is torreU.1 ogree ro comply with oll County ' Investigar�on Fae C� ; ordinances and Stota lows relaling�o building construtlion, Torol Fee ` lDht4 Perm.M - . � and hereby autharize�apresanta�ivas of this Counry to enter upon the above-memio ed proper�y for Inspection purposas. - � �, � SEE REYEKE FOR EX�UNATORY IANGUAGF � Signo e oi Ap limn�or Aqenl � � Do�e . . - . . ... . / �Too c o � o' o o �oo o ° oo �a o; '�' �. .�. o -- - - -- o 0 � 'o ^ c �- T ? - v �- a'-o F o 3 ., � m ° _a 0 ° 'D . p � n �G T 7 � K �f D. �r n b D � O v O N � � � 17 �j T � , � ' Z x �� _ + }-7 'O 7 = 'r p ' L � � •� ' � T �"� � o f ' i o^ � 1 � o », no o i '� -. � Di i v 3 � o c N, o 'o o'v: � .0 3 0 �, v i I . �� o _ _ � • : _ � ° � ° o-: `o o n �° c -` �.m o... o' . \. `. 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