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HomeMy WebLinkAbout1624A 1625A (9) WORKERS'COMPENSATION DECLARATION . � � - I hereby affirm tha� I have a certificate of consent io 5a�f � q�����AT���iV� F��� BIJ�L���V ������ � insure,or a certificate of Workers'Compenstion Insurance,or a certified copy�hereof(Sec.3800,�ab.C.) COUNTY OF LOS ANGEIES BU�LDING AND SAFETY PolicyNo. Company � Ce�ufied copy�s he�eby f���ished. FOR APPLICANT TO FILL IN nooaess �rrf�G' � ° C )% `�— � Certified copy is filed with the county building inspec- gultolNG Y j /�J fion depariment. . ADDRESS .7,.}�)� � � �:�1�d N'`� LOCALITY ✓" ��"- /�� Dale Applicanl CITY ��/jF%1 ii't� i_�f�L r'E�� ZiP ��'���!�y F CROS5557. �L-%�'��-���'. /'��j� CERTIFICATE OF EXEMPTION FROM WORKERS' j NO.OF eLDGS. � ASSESSOR COMPENSATION INSURANCE SIZE OF LOT ,�J NOW ON LOT y MAP BOOK PAGE PARCEL (TFis section need not be completed if ihe permit is for one �j �USE ONE MAP hundred dollars($100)or less.) TRACT ���� BLOCK LOT NO. �7 p� � NO. � . �� ' �, . � TEL 7 � SPECIAL � - 1 certif that in the erformance of ihe work far which this OwNER ���-/Yj �� .�d. ?°�W_�C da•✓��CNO.�J�y�"�l'G�}� CONDiTIONS ,_ � � y � ) f 1 DISTRICT 6ROUV iYPE FIRF NROCESSED BY � permif is issued,I shall not employ any person in any manner ADDRE55 �� �t � ^ 7 ����y� 1''v CONST. ZONE � � Dpie 10-be ome sub�a Ato icanWorkers'Com ensaiion Laws. �° n � �� ���� �J� � � P �,+ K � - Cf1' tfN�F��✓'J rl't'`` �i�.�T�' Zi7 �- ���% � _ u _ pp STATISTICAL CL/1551f1CATION APT. CONDO. AR'�.y��ECT OR 1LL 7Y =NOTICE TO APPIICANT: If, afier rnakirig rhis Cerrificate of ENGIN� �O. _ CLASS NO- `-� oWeLL.UNiis_ -� �Exemption, you snould 6ecome subjeci to the Workers' ---��- � .Conipensation provisions of the�abor Code,you musi torth- A�DRE55 SEWER MAP - ith comply with such provisions or this permN shall 6e <-4 .:deemed revoked. CONTRACTOR �`'^ � � NO. dK. NG, VALIOATION � IICENSED CONTRACTORS DECLARATION � � ��� UC. -�I hereby affirm thoi i nm licensed onder provisions of Chapter 9 AnD3E55 �-NO. VALUATION (mmmencing wlth Seclion 7tl00)of Division 3 0{the B�siness�nd . ��.LiC. �7 -.d-� �Professinns Code,and my license is in full force and effect. � CIIY !Ct SS 4�,S�,C�' � - SG1.fT�. NO.OF NO.Of � CHEIX License N�mber Lic.Class SIZE STORiES � FAMIlIES ONE . .. NFW � - ` �t�:/: p �. 'Contrnctor Date DES RINTIDN OF WORK ` ^ � I am exempt from the licens�ng requ�remenis as I am a ?�-J-�1 �,;c'�j�E�f� �� X��"� ADD ❑ ( -y' � � $ 4 I�censed architect or a registered professionol engineer / �1 y � AL�ER� ❑ DA E� /� /'�� ading in my professional cappcity ($ection 7051, {��'�'"/r`9 �3,96?/v� F`Z � ,,m-�- � REPAIR i c � ���� i.� . � Business and ProFessions Code). USE OP ,`.?�c7 j�" ., �. FINAL " � �' � � EXISTING BLDG. '��"'f�' U� � DEMO. �� �� �- . 8 li<.or Rey.No. _._Date - APPUCANT TEL. Y ; a..��'� � � OWNER-BUIID"cR DECWRATION � (vRINT� � - �- � NO. � � .I here6y affirm thai I am exempt from ihe CoMractor's License , � - . .Law for the Poltowing reason (Section 7031.5, Business and ADDRE55 . �Professions Code): - vRESENT � � ;,��_ QBUILDING � -,- . I, as owner of ihe property, or my employees with ADDRESS. wages as iheir sale compensation,wi�l do Ihe work and - + " � � ��� - LOCALITY - the structure is ner intended or offered for sale(Section � ,#.� � F��;,�� 7044,Business and Professions Code). MOVING 1E�. � I,as owner of the property,am exdusively mniractiny CONiRAQOR NO. �� , � with licensed contractors lo construct the project(Seo- n.i'�i-.'3� . . � tion 7044,Business and Pwfessions Code�. ACDRESS �� REQUIRED TOTAL SETBACK FROM EXIST � - � CC�NSTRUCTION LENDING AGENCY SET BACK Y�+RD HWY pROV. INE WIDTH � , I hereby aff;rrn thoi�here is a consiructlon lending agency for FRONT "` � . , the performonce of ihe work for which this permit is Issued � P.i. � Cj ' '<.F�.,�Y3ir7 �� � � (Sec 3097,Civ.C.). SIDE � � �. � Pi Lender's Name /�J � � � '.P.C.F e$ /L'� J Per ir Fee ��3���� . . . Lender's Address__.__ . �j � - � - . ' . � I certify ihat I hwe read this application and state tha*ihe Isso �e Fee p°-5 C'� - . � � � above informatlon Is correcL I agrae�o<omply�n+lth all County Ic�esrlga�ion Fee � - .� � ordinnncns and Sta�e lows reloting to building consirucllon, Total Feo � � � and hereby outhorize represe���otives cf ihls County to emer -- � � .. - ;�� ��Jon the q6ove-mentio d prope.rty for Inspeciion purposes. -� � � Q V��y�����.� �l.�.I p�.y� T//�-�� SEE REVERSE FOR EXPLANATORY LANGUAGE � L _� �s � Signat��re of Appllcanr or Ageni Dote � l� -0 O � c � . --„_'.'�^^' � `iq (D. 9 . �ro � � fl � t =o °� n� � �-� � o,� CJ �- F N "�'' (P o ?- � ^ 4.,,. 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