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HomeMy WebLinkAbout1645A Y�ORKERS'COMPENSATION�ECIARATION �� ��� � � � � - . _ �� '��� �� "" ���-� -' � " �-�, - � I hereby aHi.m ��a�I hove a cer�iiiw�e of�a�=e�f�o=e,f - --- - -- � APP-LICATION � FOR�BUILDING PERMIT � inwre,or a cerr�fica�e ot Workeri Com ensation Insurance, or o cen�f�e copy thereo�,((S,yec.3800 b.C.) . COUNTY OP LOS ANGELES BUILDING AND SAFETY PolicyNo. d�ponr 0 �' � Ce��fied copy�s hereby lumis ed. FOR APPLICANT TO FILL IN suuowG /'� ,/�/� � �/� 1� ADDRE$$ � O`� /�(G�+'�/ Cerlified copy is filed wilh ihe county building inspeo- BURDING 1 � . ��o�deporfinenL . ADDRE55 l-� d. ', 'A-rn t\,T ' Da1C�Applimnl CITY �� MC/�U (�i-� ZIP �p�,q��Ty I�/} TIFICATE OF EXEMPTI N FROM WORKERS' NO.OF BLDGS. NEAREST �.1 l� r.t� '� •/�� COMPENSATION INSURANCE • SIZE OF LOT �� NOW ON LOT � GROS$ST. �J .J \O� v� ("Fhis seUion need nol be compieted if ihe permit is for one ASSESSOR hundred dollars(5700J or less.� � - TRACt � BLOCK � LOT NO.- - -� M,qp gppl( - PAGE PARCEL . . - I I TEL � USE ZONE M4V }. I certify Ihol in the performonce of the work for which this - - OWNER , NO. C�� � f� � / a permit is Issved,�shall nof employ ony penan in any manner qDDRE55 � !�/ S�' SPECIAL� _ O so os to bemme subjec�to the Workers'Compensotion lows. _ 1 CONoinONS � U - �� ' - ' CITY I�m���O !ST 21P . � Data ApplicaM . O NOTICE 70 APPLICANT: If, o(te�making this Certificate of ENG NEER �R T� DiSTRICT GROUP ttPE / FIRE PROCESSED 8Y � Exemp�lon, you should become subject to the Wo�kers' _ . _ . , _ .. . - � � - CONb'r�� � �. W Compensation provisions of ihe labor Code,you must forth- ADDRE55 �� a' with camply with such pravisions or Ihis permit sholl be � deemed revoked. � � ' ' '• � ' " ' � � ' TF���� / O Sinit5nG4t iFI�TION . AVT. CONOO. Z CONTRACTOR - CC�i NO. UCENSED CONTRACTORS DECIARATION � ��. ��� CLASS NO. DWELL UNITS � I hereby oNirm thot I am litensed under provisioni of Chopfer 9 � A�DRE55 �.�U: � NO ,� ��R�P � (mmmendng wifh Section 7000)oi Divislon 3 of the Business and r �, UC. n 2 � Professionz Code,and my license is in full force and eHect. Cltt�1 /�- - QqSS l.-/ VAL��ATION Sq.FT.� J NO.Of NO.OP CHECK ' - BK. �� PG. - � licensa Number Q� lic.Closs�`i � SqE. . S10RIES' FAMILIFS � oNe - � � � • ] VALUATION� � Conlrottor�_Ca,l ���j Dota . _ �ESGRiMION OF WORK e` � lI� N� ❑ s (O� , . . J°t ecr� � e er � AD° � �1 am exemp�onder Sec. AUER�-� 8.8P.C.for this reason �� U REPAIR ❑ s Dale: � USE OF. . . .- . . a E%ISTING BIDG. DEMOI , $ignCfUre - . _ APRIGN /. . -TEL Q qC FlNAL OWNER-BUIIDER OECIARATION PR�N � � S� e �' / d DATE�(�-L� I he�eby affirrtl that I am exempt from tha Canfratlor's License ADDRESS rt�U f� 6� A�n� Law for the following reason�Section 7031.5,Business and FINAL . � Prafessions Code): _ � _ . _.._. . PkE EM . . _ . . ... BY . ❑ BV4D�NG , � I, as owner of tha property, o�my employees with nDDeE55 wo9es os their sole mmpensation,will do the work and - . _ . . - . �he structure is not imended or offered for sale(Settion ����TY , . 7044,Business and Professions Code). MOVING � _ __, . TEL _ . _ .. � . �� 6�Jr A � I,as owner of fhe p�ope!ty,am exclusively co�lrocting CONTRACTOR NO. with litensed coMroctors fo conslruct the projact(Sec- - ADORESS - --� � � � �� � � � � � fion 7044,Business and Pro(essions Code). • CONSTRUCTION LENDING AGENCY . .. , SE 8A0C YARD. HWY 10iApROP IINE - Wi�TH -� ---- �- � � . � ��b a O O I hereby affirm 1ha1 there is a consrruc�ion lending agency for FRONT � e 6 8�n= ihe perfermanca of the work for whith this permit is issued p.t. . � � (Sea 3097,Civ.C.). SiDE r.t. D9.19-88 lender's Nome �- �-� - '-���� -' � � � .� IDMA Ref.N .. . . lender's Address _ . P.C.Fee f Permu Fee . . ' . . I ce�tify that I have reod this opplimtion and slote that the �aauance Fee � V l➢MA v/C N � � obove information is conect.1 agree ro comply with otl County ' - Imesrigarion Fee �,` - � ordina es end Sta1a laws relating fo building tonstruction, To�ol Fee � v� LDMA Perm.M on er by ovthorixe represematives o(Ihis County to enter -- n e abova-mentioned roperfy f speclion pu�poses. „/J' .�� =J��� SFE REVEKE FOR EXPtANATORY UNGUAGE , ignomre of AppGmn�or Agem po�e , . .. / � _ - ,..— _ a a . — -- ' �� . � , ,� _,.-,- � 1 . _�. z` I, "� �� ..�- ��'" ;, o � �; '�'� �� � T� � ;� � � r �1 ,+ --��j � o:'� ��. o. �.. 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