HomeMy WebLinkAbout1276A 1857A 1668A � WORKERS'COMPENSATION DECLARATION � � � � �� �- � � , �e�aby affirm ihat I have a certifitote of consent to seif APRLICATION FOR BUILDING PERMIT insure,or a ceriificole of Workers'Compensotion Insuron�e, orv�.ce�ted copy thereof(Sec. ? , COUNTY OF LOS ANGELES BWLDING AND SAFETY , "'^-..:. . ;C� � -�.. �:j,ab C.„` ,.:_.(. , ,.,., ':� . PolicyNo. �' '- Company � ' � '.�. :. . . . - � 'Certified copy ia hereby fur isbed. z. � :�. . �."F�R APPUG4NT TO F4LL W � aV�ID�NC' � ' �� �� Cerfified copy is filed with e c4un bU�ilding inspec- gU1tDWG . "' „ .;. '� ..'< A��ESS'�� � - �- � �ho1F depart ieni.� . l � f! { ADDRE53 .. � . � . ' � LOCAUN. . . . , � t �� t �� ..Date � �"_ � �APPlica ' ��' .'F!� CITY�`�: .. , ZIP CROSSSS. �� � . ... ,. — � � . . . � .. . „� . Y � CERTIFICATE OF ExEMP O FROM WORKERS' � � �� � ' �"1. Y � � NO.OF BtpGS. ���. ��-� q55E5SpR � . ��� COMPENSATIO I SURANCE SIZE C1F LOT � � ��-- ��NOW pN LOT " . MAP BOOK � � PAGE PARCEL �" (This section need not be corr4pl�ed if the permit is for one �- � �� � � VSE 20NE nwa �.� g ��� V .. hundrod dollars($7�0)or lesa:� 7��' BLOCK LOT rv0. NO. ,�• . . �. . . . . . . .. . �L �� SPECW. „d �.. I tertify that in ihe performance of fhe work for whith this OWNER` - � - � Np, ' `" - CONOiTIONS � � �perrrrit is issued,1 sholl nof employ any person in ony manner � ��� �� � � DISTRIC7 .GROUP TYpE FIRE PROCESSED 8Y } � w as to 6ecome s�b-ecf lo Ibe Workers`Com A��` �� ` ' � �� � CON,ST. 20NE ., � � penwtbn laws. . ' . „. � ,. . f;_�' � . . . �.Date � � � A Ilcont... . � � c�n�:. < . .ziF ., :. .. ..� :... ,. � PP . . . . STA715TfCAt CL45SIFICATfON APT CONDO. O � NOTICE.TO APPLICAN7: If,.after muking-fh'rs�Certificate of ENGjNEER� - ' NO. � � � �Exemption, you should.be�ome subiect ro the Wofkers' � � � C44SS NO. DWELL UNIiS_ 'Compenwtion provisions of ihe Labor Code,you musi for�h- - �� � - �� � W witbrcomply with�such provisioro or This permit shal! be A��� � ' � � SEWERMAP � - � t,,. � deQmed revoked._.• . . . � CO�viRaciOa� .�. � "�.�.. . .:tF1 : � : ' .�' �� LICENSEDCANTRACTORSDECLARAAON�� . -.. . M1�. . ` ..�. eK. PG, YALlDAT10H �= 1 hereb�affirm thof f am licensed under ravisions of Cha ter 9 ADDRE55 - � ` ��' � . Y P P �. VALUATlOtI �`�:�!� . . . �(mmmennng with Section 700�}of Owision 3 of tha Busineas o�d� �� �LL, � [IC. � � � �: � Profess�ons Code,nnd my litense 5 in full,fprGe and eHetf.- . ��ty � � ��� . ' � � � � .. . •- '' SGI.Ff:- �NO.C?F NO.OF . CHECK : '�.i..I.:;�� � .Li[enseyumber � ��.�``.'i Lic Clou `-�x, SIZE �� SiQRIES fAMIlIES ONE � - t .. � - �� �. .�. ..:.,,.. � �',�_ ,`:..�: �� � DESCRIPTION OF WORK .' .•:�- :. �� NEW � S h �',��.a,��.� ��1 � � Controctar �-^'�' ` a^%` Date . . �D ..� � ,��ti-��:-. ❑1 am.exempt u der Sec. �:` . ..�- � . - °.:� � � . . . . .. rr ; . . . � , �: . . .. ,.. � �:.. � ALTEB � �PINAL . . . ... !�,�.�.(,.L,i-i..; �� 8.8P.C.for thi repsOn " - � RATE � � . . � _ �� . . � . REPAIR � �!�_ U5€OF� � .0 ( � � . . . __ `� ate: EXISTING BtOG. . . . pEMp� � B NAL . ... •-� . Signcture -� ..,"� .,-� � - . � APPL�GWf � � iFl . y � ER-BUILDER DECLARATION . � PRIN7 � - ...NO. . � l C„-./�`,. � I bereby offirro f am e:empt from 1he�Conimdor's License� � -- - � -� - � .. Law fw the f lo�log reason(Secfion 7031.5,Business and� ADDRE55 = � . � . ��� � � � � „ t+r a�;r. . Profeuions e: - � � �. - i(i,�� ;;,'�,i}r`: oe���o,�..-�---�� 1, as Q er af the property, or my employees with qppg�,5 , ... - _ �.wc�ges ns their sals compensntion,will e{alhe rsorkond. .. � �. . .. . .. . . � � . . . . . , � �,��= 3 �ocaun ,• • �: :kG�c,. � � .the snucture is not intended w offered for wle{Section _ ._ - � � � -� � � 7044,9usiness and Professions Code). � � � Idpv1NG - � �� � � � � h�,� � t"+��;�j y�� - � � � i,as.owner of fhe property,am aac{usively contracfing NTRAROR � NO. � � � with��licensed�ontractors to construct fhe project..(Sec- �� . �. : �. ; . � . � �tion 7044,Business and Profassions Gode).� �� � � �. .. . ��. . . � � REQI}IRE� ... . TOiAL SEIBACK FROM EXIST. . .. . 1 ; '�;(;+[y CONSTRUQION IENDING AGENCY �gq�K YARD Hwv pRpp,uN � wIDTM , ' � , . 1 haraby a4fu.m fhat there is a conshuction IenSling agency for � pqpNT . � . :y r�a�t���, � the perfwmante of the work for�which this permit�is issued p,❑.� '�. tSec.3047�Civ.C.). � . � . . - � 51�- . . . . ��.c'��, ' q r.� J,•�i�1.... � Lender's Name�� � � � ���t� ��:„ �� ��Lender's Address � . . � . � P.0 Fae �1..�f . Pe�m�r Fea . "` ,.:�� . � / r r�e(-�C� �.'.� � � . . . }r.I�MT.'L:r.e: I cartify that I hrove read t s ppplicotion and state that ihe �'1. � �,' '�t' T . �ss�onca Fee � � � . .'< akwve�.inform ion is�Cm 1g9 rea to mmply with�oll Caunly � ���os�i��p�Fee � � � � � ordiriances a d Sta1�Ap rafating-W buiiding tonSFrudiOn. � � � � af� , ���;�.- . . . G and hereby. ihori ee resento ives of thia County to enter To�o�Fee � _ �� upon ihe ab� �e-me o prop r1y for inspection purpoFes. `-= r �-� -- -" � r � � f ; r. , i, , � �.~� -v-t� �` � ( ;.�,.� SFE REYERSF FOY'fXPUNA701fY LANGUAGE' � . � � ..S�yr�f re of Applicanrbr Agem- . pata, . � � . �t t - .. . .. . . . . . .. . . � . .. ' "' ' �'�,�'� • - _1, 1 , - -' ` �, ��1 ' ; � . �� - 1 � � � . `�� �l � � 1 1 � � • ' �1. + . �� . . . .. l.. "� - . ' ' . � , ..� . 1 • �, 11 . ., � . ' � . � � , t, �` ` , ' . '. . . , . . } . , � . . ' .. . . � � .. . ' . . . i. , ' ' - . � '� 1. .. ' � ' . . .. � � � f , . _ , r ' � � �� . . . � . 'l �1 . . . , . '" . 1 , � � , �" _. . . _t� ' ` •� ', It .` �, ,1' . ` 4 '��: . . . , . � . . � _ �� a : ,• t 1` 1 1 , ',�� ' , _ , � , � - .` � , .. ' ��, �, ',1 �; . � ''i \. ,`` 'f „ . ' . � 1 _ . -' 11 ' i. ` ` . , �� � � � - ��� �� ` � � � � ��`' � �1 �� ` � ��'� �� ' 1 4 ~1` . 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