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HomeMy WebLinkAbout1599A (9) , WORKERS'COMPENSATION DECIARATION ' + insureboraFcertifcarteofWarken''Compensatfon��g�,o�a` — APPLICATION FOR BUILDING PERMIT �� �� or a certified copy the�eof(Sec.3800,tab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY POol7cy No. Company � 6UIlDING _ Cer�ifled copy is here6y furnished: FOR APPLICANT TO FILL IN t `� ADDRESS � Ce�fified topy is fi�ed wilh the county b�ilding inspec- BUiLDihlG lion dapa�tment. ADDRESS Od �� � 1N1 � �1E. iocnun '�1 NEAREST Dote l�pplitaM CIN, MD A Q�� ZI7 ' -- � CRO55 ST.� . • CERTIFICATE OF EXEMPTION FROM WORKERS' ' �j'�4 Q�: eiOw ON�tOis� dt^lE Mqp BOOK PnGE 7ARCEL COMPENSATION INSURANCE SIZE OF LOT (This section need not be tompleted if ihe permit is for one Q • ��. � u5E ZONE n.wP I � � hundred dollars(E100)or less.) TRAC7 S 1 BLOCK lOT NO. TEI. - SPECIAL S- I certify that in the per(ormance of the work for whith Ihis � ER Q }�F)A1 I�LZ� NO. '� CONDITIONS Q. permit is issued,I shall not employ any pe�son in any manner Q p'�'� � ��' a oi5i GROUP ivee FIRE CROCESSED BY � _ so os fo become sub�ect to Iha Workeri Compensotion Lows. �RE55 � K 1 G �e.�C.. O Su� �1bp � CONST. ZONE � CITV �+V lf,l3 ' •�ZIP Dale ApPIfCOnI � ' ' �� '� $TATISTICAIM$SIFICATION APi. CO DO... O ARCHITER O c �j e TE•y� C�� U NOTICE TO APPLICANT: If, ofter making this Cerlifitata of ENGINEER M�•J��� 11�i1^��• .b O MSSNO...pL�.L_DWELL.UNITS�� - W -Eaemption, yoo should become subject to the Workers' r ,I p����� _ �2 Compensolion provisions of fha labor Code,you m�s1 forth- ADDRESSZ?+T+Z,IvEW '���V q,N�f.l-�X-�►'+ SEwER mAP with comply with s�th provizions or this permit shall be ��" = deemed revoked. - . ' CONTRACTOa jlw�'YOA� !�l TNO. l �3 S 8K. vG, VAUDATION LICENSED CONTRACTORS DEQARATION � ' � UC. ' � I hereby affirm that 1 am licensed�ndar provisions of Chop�er 9 ADDRE55��I��Oq�N�� O. �7b� VALUATION � (commenting with Secfion 7000)of Divisio�3 of tha Business and �� � �', � UC. Professions Code,ond my�icensa is in full force ond effect. , Cltt VIt3� � C1A55 �� s �� �a ► SO.6 ?, NO.OF q NO.OF ' GHECK - - litensaNum6er LiC.C�a55 , $IZ � $TORIES' 4 FAMIUES "ONE OESCRIPTION OF WORK-"C+ ���� ' 6��L� N� ❑ s �1 5 9 9 A� Controtlor Date • �1L Lb trA¢J . aoo � �. . . . . � �I am exempt under Sec. ' B.BP.C.for this reason ' REP RR � DA EL �—� + � �� •J�� �J.$.3 Date: • USE OF DEM L ❑ B NAL • •�5 1 3 8 3 c=.i � EXISTINCa BIDG. Y . SIgf101UIB ' � AP�pR NTTP�i{�LG �lL��OlZ �I• NO.�- •j,. O 7�2 2`S S OWNER-6UILOER�ECLARATION � 1 here6y aifirm�ha�I am exempt from the Controctor z Licensa ADDRESS�g Z l G���— �V�Nh ��� � - law for tha following reoson�Section 7031.5,Business and Professlons Code): _ PaeSeN� ' � � BUILDiNG -� I, as owner of tha property, or my employees wifh AODRE55 \ wages as their sole compensotion,will do the work and ����n, . `� 1_`� Ihe slruclure is not infended or offared for sala(Saction ';. 7044,Bvsiness ond Professions Code). MoviNG 7Et. ' � � . _ �l';��'�� . � I,as owner of the properly,am ezclusively contracting � NTRACfOR NO. � . \ • with licensed tonirottors to cons�r�ct the pro�ect(Sec- ADDRE55 � tion 7044,Business and Professions Code). �. - REQUIRED TOTAL SETBACK FROM EXIST, � CONSTRUCTION LEN�ING AGENCY - � Sei anCK YARD HWY pR�p ��NE WiOTH . ' � I hereby offirm that tbere is a tonstruction lending agency for � FROrvT the per(ormonte of the work for which this permit is issued P.L � � ZSec.3097,Civ.C.). � SiDE . P.L. Lender's Name� ��l'i'tl���['��f Ulf��,CO� lender's Address���T��� P•C Fe Perm�r Fee � � � i tertify thet I have read thls application and stote thot iha - Issuance Fee � � obov ' 'on is cor tl.I agree to compiy with all Counly Investigmian Fee iq�[' . ntes and ta w relating to 6uilding consvuctlon, � � 7otol Fae y�l ' reby r sentotives of this County to enter C�l,. . n ha above- i properry for Inspec�ion pvrpoees. - ��� �� 'L�'L2�aCJ SEE REVERSE FOR¢XPUNATORY LANGUAGE _ ure o m or Agenl Dote � �� \� a - , o 0 r ` T- 2- 'p � �"� ��1�` �' . \ � 'm : 1 A• n . �� T c � a o �'� n � �, ; � . .0 i �� n A P '3 4 �C� � T�' ��: �• �,O � �. O. � O ��j ���� � o �C;`� i+ O i ' ,�. �1 r � 3 c e -n in o 7 ° C�7 '�• r {� -- . � � .'+ " N O t7 ^ � �p. � �� P .O. 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