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HomeMy WebLinkAbout0906A ..__ . _ _- - - _ _ . - _ ... � WORKER$'COMPENSATION DECLARAT�ON � � . -: - - � � �� �.,... ,. .. � . , . . _ - - � .. I hereby affirm thot I hove a ceriificate of�o�5e��,o se�f � APPII�CATION� ��FOR���.�BUI�LD�I NG� PE�RMIT�� insure,�_or a certifimte of Workers'Compensation insuronce, � ,.. or a certified ccr�y iheieof(Sec 3800,La6.C.)� ' � '" - � ��-- ��� �" � � ���� --- � � � . . COUNTY OF LOS ANGELES BUtLDING AND SAFETY , . PolicyNo .�� '- ���Company. - ---.. ---- : -- . .._.�.:.. ._. . . . . . -. _. �� ;Certified copy is hereby furnished � FOR APPLICANT TO FILL IN AooREss �-d��� .�' ' ' /C,ry!i}�4 C` � Certified��copy�is filed wiih�the county building inspeo ` gUILDING //`, ��q - - tion department. �� �- ADDRESSc,{�/ %t'/ � �J Y//�C . .. . . ...:t- _ . .... �y .. Date �. .. . ,.. Applicani'. . ..� `.� qTY .. . . ZIP � ���/ LOCALITY /� T � CERTIFICATE OF EXEMPTION FROM WORKER5 NO.OP BL�GS. NEAREST - � �� COMPENSATION INSURANCE . �� SIZE Of LOT NOW ON tOT CRO55 ST. �/2.� C �"� (This seuion need>not be'�completed if the permif is for one -:-�-�` TRA�T 7,�q'l�f . � � - �! . � ASSESSOR ;__ _ - � ��� �: hundred dollars(.$1.00)or.�ess.) . . -' � J ��K � LOT NO.��q �_ ry,p,p gapK'-� - - pAGE PARCEL � �OWNER ,J��✓G �X+-'/�� � NO.���-33.C/ USE ZONE MAP �� >� � I�certify that in the performance of the work for which th�s _ r, ��/�� NO. j� /�3 ,7 ��} permii is iss�ed,I shalP not�employ any person�in any manner _ : qD�RESS `�✓/y����=� - ��ry�} SPEqAt - -���. �so as fo become subject fo fhe Workers'Compensation Laws. - � CONDIT�ONS � .o . V . . . ., :.,: ' ._-_. . _ ....,: �CITY - ZIP :� �. Date Applicant � ��. � ARCHITECT OR r�(/�� TEL � .,.DIS7RICT GROUP TYPE �� -FIRE PROCESSED BY � ' �NOTICE TO APPLICANT If, afte makin tbre-Certificate of � 7 4 _ ENGINEER �-U/«�' ,—/`.�^� NO.,c. �^ �� CONSL�._ ��ZONE Exempiion, you should 6ecome s 6jetf ta,�the Workers' ' y y Compensationi:provisions.7of ihe Labor;'Code you must forih- � .� �i. � ,J %����s � : ADORESS L -/y7j)�,J/"YLU-�FiT�f f,.l�}fj 'O. with comply with,;Such provisons or�this permit shall he � � L��-"'- -z ,tI) �deemed revoked.� ,J TE�� �sj r�' STATISTICAI C1A551FICATION � APT. CONDO `.�;,'� �: CONTRACTOR Q � � NO.�.ZS !aJ --: — LlCENSED CONTRACTORS�DECLARATION -� � ii�. -_�C�aSS n�0._�1—owEu.`UNiiS � -- a I hereby affirm that I nm licensed_under prov�sons of Chapter 9 qDORE55 {rj�, �/�-jy�/� NO. � ' (commencing with Section 7000)o�D vision-3 of the Business and , _�� , ��� . SEWER MAP Professions Code,and my license s in fu0 force and effecr ciiv-f� �O/„/C_ " ctass m - -gK, f� �� J - YALIDATION � .. � , . � - �REFT�7B 5 OR�S 7 AMI�LIES / CO EK License�Numher Lic.Class . . �� - - VALUATION � . .. . . .. ..... . � DESCRIPTION�OFWORK � /'� , /�'/�' DD ❑ S_ ��,,��G � Contracror ��' -.. � Date / , ... �I am exempf under Sec - �f��_ _- f���.���!^ ^�� �� . �: / ALTER ❑ _ . ;�%C.E'F� � B.SP.C.for this reason . :: ;. £' sfL- /� ��GS�C=T aePa�R � . S_.._ . . .:.. _.. .. . - � �: � � USE OF i� ° a ° g ' . Date: : EXISTING BLDG. �EMOL ❑ . .. .Signature _ _ APPLICAN7 JL/ TEL. -...FINAI . . . _ � . 1 I C��.��;'l� _ . OWNER-BUILDER DECLARATION PRinIT) � � !�/- il��`�l�O..S�'��'� . . DATE . � ���1 hereby�affirm thai I am exempt from the Controctor's license . ,-- - "' � O:%,U V�i . _. ' _ - �ADDRESS �/�'%�<L. , ��:, �Law for the follawing-reason.(Section 7031.5, Business nnd � - FINAL - : -'Professions Code):�� . .'. ... .. . . . ,."". PRE EN7 ,.� By , . .". . ._ ' i 1 r^—u, ' ` �555��� BUItDING �___�Irr'� . , I, as owner of the property, or my employees with ADDRE55 /, , � � � wages as iheir sole compensatlon,will�do the work and r(� ' the siructure is not iniended or offered for sale(Sedion � ' �OCAUTY � ��J' . ` -�7044,Eusinessnnd�ProfessionsCode).�- MOVING TEL ,�(�) . - � »� � �_� I,qs owner of ihe property,pm exclusive�y coniracting � ��. CONTRACTOR NO. -._ ' �v : ' -with-licensed wntraciors to consiruct theprojecr(Sec- -���- � ����-�---���- - �� - / (� � . - tion 7044,Bosiness and Professions Code). ADDRE55 .. / � ,,9 g� � r�f� RE�IIIRED T�TAL SETBACK FROM EXIST _ �'� f �� " CONSTRUGTIONLENDINGAGENCY - - � � "�' SE7BACK YARD HWY PROP.LINE WIDTH /� � I hereby affirm ihal there is a conslruclion lending agenty for . FRON7 � ` �� ihe performance of the work for which this permit is issued � � P.L � . . ' � (Sec 3097,Civ.C.). : SIDE �. . � " . � � , . . .. � . . \ ... .. , , P.L� :. ; . . ..... . . .. . _.... Lender's Name �� - . � � �� IDMA Ref.N �' i - Lender's Address � P.C.Fee$ Permit Fee �J.� , . _� E > 10, ,5a € � 1 certify rhat I.have read this applimtion and state ihat rhe . ..,. i:suonce Fee �oMA aic fl � � � � Q a6ove information is correct.I agree to comply with all Coun�y Investigarion Fee . - ordinance,c'�nd Stafe laws relating to�uilding canstruction, _ . �Total fee -���-�-s ��.- - � � w and hereb authorize represen�hve4o/ihis County to enter '°`iDMA Perm.-k � �� � - � � . m upon abo>ve-mgP tro`ne/2A rope Ey fai mspection purpo s. p- � � � � j � /' �._�y�{.! /'������'��C�r�..7 /l��'/(/J // SEE�REVERSE FOR EXPLANAiORV IANGUACE - � . � t . I ����gnaroreofAppfimnt`6rAgent'� - q6te ' .. . .- . .. . -.- .. .. - ...- .- . . V� � N C�' d « .. � y 1. �U t,j�^�„i� ta y . . ' d r,��, s-�a °''e1 0 �"�o^„' a�n.°.�, � y � o N -i: o� c' A' �' x ...ea-O , � a O d '�.�.�� v`.,� o� � � � ''`^'' O ' . 'O� �+�N m v vj� *v'` �C ��� �-D N U �'+� O � � � y„�� U�� . � �.� �S C ?` S'. 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