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HomeMy WebLinkAbout1748A WORKERS'COMPENSATiON�ECLARATION - pppppp � �s � �� � ii���p �q . � I hereby affirm thai I have a certificate of consent to seff . . � ��_��'�/������ �o�._,��.'����� y�K��� _ insure,or a certificate of Workers'Compenstion Insurance,or � �1 ■ �� a certified copy thereof;Sec 3800,Lab.C.) COUNTY OF LOS ANGELE$ BUILDING ANO$AFETY �i3/o-;",�,'1 Sta42 ccnn, r+znd - PolicyNo. Company � � cerrified co FOR APPLICANT TO FILI IN n�oaess� '� �>• r's'1t�",uP`T '�t. py is hereby fumished. 1 Q7 - � Certified ropy is filed with the roumy huilding inspec Bt11LDING �7_�� Le tion departmenr. nooRFss . 1�i2ho;nany Gt, iocAurv N�u�-`11`fi ti2oha S' is b-j, NerResr oo�e Jl1.i�5;� Appu�o��� � � �� �� cirv :�a�lnut ''?i73�3 zia 91739 ceossst. �'o�!1�sa iine 17r. � CERTIRCATE OF EXEMPTION FROM ORKERS � NO.OF BLDGS. A55E550R COMPENSAiION INSURA�CE SIZE OF LOT NOW ON LOT MAP 800K PAGE PARCEL (Th�s sedion need not be completed if ihe permit is for one ���..� j. USE ZONE MRP f{` L`'�.� hundred dollars(5100)or less.) � " TRACT .�J-J.�V BLOCK lOT NO. . NU. //� i � TEL. " SPECIAL � I<ertify tha�in rhe performance of the work fer which�his � owNFR (�,�:'l�X'�.�LS ?�iOGCi.F7uY'�`t No.S��F-i.°it'7� coNuliloNs � permit is issued,I shall not employ ony person in any manner �; DISTRICT' GROLIP TYPF �. FIRE PROCESSEO BY �+` ADDRESS 8t?1£.' CO ZONE gg; so as to become subjec?io ihe Workers'Compensation Laws. ,,� �" u�.G -� O.yi ,�� ;�, �Date Applicant � CITV ZIP ., ^�,,,- STATISTICAiCLA551fICATION APT. CONDO. °+1 � ARCHITECT O t > TE 2 � -�'�' NOTICE TO 4PPtICANT: !f, after making ihis Certificate of � ENGiNEER �'%{=x12.YC� i,ZG?Gc' ..�'�p N��'Q'K,i'��.u.,x-�+'�C ���ASSNG=�� DWctL UNITS_ '� �Exemption, you should becorne subject to the Workers' � — - � Compensation provisions oF ihe Labor Code,you musf forih- qDDRC55�-2�3p %�.`JSE `3'�.y u2.Ti'�'�n8 ����1 SEWER MAP � wilh comply with such.pro�islons or this permit shall be TE�, VALIDAYION deemedrevoked. coNTRncroe �1a1?a Poo1s 362-1779 gK. FG, NO. � - LICENSFD CONiRACTORS DECLARATION - uC. � I hereby affirm thot l am!icensed under provisions ot Chapter 4 AD�RES�-�1�� �i..�Z'8R.^.1S^Ul�i.O Np,�°99�,7 VALUATION �(commencing with Sectlon 7000)of Dlvision 3 of the Business and .r ,� n �;�. ?�4 y�n Professions Code,and my license is in full force and effect. : CITY��+•�CV111c�i;tS., �_7 �. CLASS�-�J 5 �-•x�- � -S(:.FT� NO.OF NO.OF -�LHECK License Nurnber 2����7 u�.c�ass �-53 size -5�f�a sroRies FaMiues oNF � � <7_oha Pool b- : n i�r�ir.r; ool a�d Ncw � conrracto� '' �,�17/31 uesckir�TioNOFwoeK P � � � �, � ..❑ � �y ADD � ` . . . I am exe 1 from ihe li ns ng requirements as I om q SUa .✓�-C:� ��� ,�j�c7..�� licensed nrchitec±or a registered professional engineer ALTER ❑, FINAL . '-' < � E �' �4 . acting in my professional capacity (Secfion 7051, RFPa�R �ATE — �--� ' �� �Business and Professions Code). USE OF � � �.!. � �'_ :�`�� � - � - EXISTiNG BIDG. DEMOL ❑ FlNAL � Lic.orReg.No. _Dote . APPLICANi .� TEL a gy -���` _ ` .. OWNER-BUILDERDECLF>RATION (PRINi)�iUY:B POOiS Np,7��-.f.71. � I hereby affirm ihat�am exempt from the Conirncloi s License , -=�,n Z r r,� . .�.Law for the fol�awing reason(Section 70?1.5, Business and - ADDRF55 Z ?���1 ' f_C:7_s tli'.. Z' � ni 7.^ Pwfessions Code): } PRESENT ❑ �- BUILDING - �. - I, qs owner of the property, or my employees wifh ADDRESS wages os their sole compensation,will do ihe work and � '- - - � � ihe slructure is not intended or offered for sole(Section �OCALITY - � � " . - 7044,0usiness and Professions Code). � MOVWG TFI. �� � ���t,�� � � - � I,as owner of the property,am exclusively contracting COnIiRaCiOR No. � . , � with licensed coniroctors to mnstr�cf the projed(Sec- ADDRE55 � tion 7044,Business and Professions Code). � �� �� �. . REQUIRED TOTAL SEIBACK FROM EXIST CONSTRUQION LENDING AGENCY � ser encK YARD Hwv pR�p.iiNF wi�rri I hereby affirm ihat there is a construcrion lending�ogen<y for FRON7 �l - ihe performance of fhe work for which�his permit is issued P.L. `�`n�ry fJ . . (Sec 3097,Civ_C). � SIDE ��wL,�r�� Lender's Name F I � /� �/ i � P.C.Fee$ Gi' �° �� Permit Fee �Qf'"' � _ � � _ Lender's Address_._____ � _. _.____ Q� � - - � w I certify ihai I have read this application and state that the Issuance Fee �j'�� � Qabove information is correct.I agree to cemply with oll County invesrlgo�lon Fee f e � . � � ordinances and State laws relating ie building construction, Toml Pee /����J � - and hereby authorize representativas cf ihis County lo enter � � op(on the above�mentioned pr perty for inspectian Jurposes. ' � a `„ �, _ll�Cl�r/(�/ SEE REVERSE FOR EXPLANAtORV LANGUAGE _. '_Ff= aJs � Signat e of Appllc�nt or en-/�� 6ofe . - . � � �. A a s+�w � Q L � '0 �9 � � 4 �� � R r n-p C�9 q,. O �f1- C1 'S . 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