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HomeMy WebLinkAbout0902A (4) . �WORKERS'COMPENSAiIpN DECtARATION _. . . . � • � � - � � Insoreborac�ertificatalofWarkerseCompenstf�°;��;a�°e3o'; � �-�� - � APPLICATION� F4R BUILDING��PERMIT - a tertified copy thereof(Sec.3800,1a6.C.) COUNTY OF LOS ANGELES � �� BUILDING AND SAFETY Policy No.� Company � � � � � � Certified co � � � i - - - . BURDMG - py is hereby fumished. FOR APPLICANT TO FILL IN nooRess'�. � 'i � �Certified copy is filed wHh the coun�y building inspec- ' BVItDING [� ,Q � � . lion deparlmenl. � �� � ADDRE55 J�(J� � � LOCALIN � ��.�. , . . . � . .. . � . NEAREST Dole �AppllcaM� � � � - CITY�� � ZiP - CR0555T. C - � - CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BtDGS. A55ESSOR - � - � - COMPENSATION INSURANCE � SIZE OF LOT .. - � NOW ON LOL MAP BOOK PAGE PARCEL (This:ectlon need not 6e completed if ihe permit is for one u5E zONE MnP �/ ' hundred doilars(S10p)or less.) � � . . TenCi � �O BLOCK l0T NO.- �' � NO. ��3'..�Y'-r � �, TEL:�� �Y7ry SPECIAL . , . y I tertify Ihat in ihe performance of fhe work for whlch�his OWNER (t �� CONDITIONS � ' ' Q .permif is iisued,I shall not employ ony pBrson in ony manner DISTRICT, GROUP 7YPE FIRE PROCESSED BY� ADDRE55 CON57. ZONE so as to become subject to the�Worker'Co sation Laws. � �� - �� � � O Dafe ' � - Applican - vqv\ ��TV ZIP � � 51ATISIICAL CLASSIFICATION - �APT. CON�O. � W V ARCHITECT OR - -�- �� . �TEt.. NOTICE TO APPLICANT: If, ofter moking Ihis Certificale of ENGtNEER NO. IXASS NO. ��DWELL.UNITS_ a �Exemption, you should bemrtie subject to ihe Workers' ' � Compenso�ion provisions af the Labor Code,you must forlh• � ADDRESS� -� - � � - � � SEWER MP.P � z wilh comply with such provisians or Ihis permit shall be � tg, - -VAIIDAT�ON�, deemed revoked. . - . � - CONTRACTOR� - - ' '- �NO. -� BK� �'• ' � - .�LI�ENSED CONTRACTORS DECIARATION � ���. _ . : � . - - I hereby affirm thot I om licensed under provisions o(Chopter 9 :�::. nDDRESS �. � - �. �- - � .- NO.-� VALUATION � - , �- (rommencing with Section 7000)of Oivision 3 of the Bosiness and. - ��� ' �, , Professions Code,and my license is in full force and ef/ect. CITY . CLA55 ' S � � . ' - SQ.FT. NO.OF NO.OF CHECK ' . - ' License Num6er � � � � Lic Class - � - 9ZE STORiES � FaMiueS ONE - . � -� � � � - OESCRIPTION OF WORK NEW ❑ E � � Confmctor " - Date ❑ � � � - - ' � ' � I am exempt from the licensing requiremenh as I am a e� ,V�� � � -- A�o� . _ . licensed archilecl or p registered professionol engineer__ . . ._ . . . . AUER .❑ � FINAL � . ocfing in my professional capacity (Sec�ian 705I, - � ' REPnIR � � DA7E j� ��/ � � 9 � - Business dnd ProfeSsions Code). , USE OF , ❑ � Q 2'A � EXISTING BLDG. � � - DEMOL � FINAL� , Bv #. . ..,1 3 Lic.or Reg.No. ' Dole APPLICANT iEL � � , �- � �- OWNER-BUIlOERDECLARATION ' - f�RWT�- — --� � - � tu0. � ��- • • 1 hereby offirm that I am exempt irom the Contrador's License ��� a ., . . . . ���..�'��g".`5 Q "law for.the followfng reason(Section 7031.5,9usiness and ADDRESS �' � �� � � �/jC�T � •�• � _ - Professions Code): � � veESetii , � � �.5 Q�' D . . BUIIDING . . . _. ... . . . . . . � . I,�as owner of the property, or my employees wifh ADDRE55 I 2 0 3-8`� wages os their sole compensotion,will do�he work and _ : � : ; LOCAL�TV . . --- . . - . .--.. �-� -the sirocture is not intended or affered for sole(Section "� -�-"--" - . � � 7044,Business ond.Profeesions Code]. MOVING . � 7EL � � � � �� .I;os owner of fhe property,am exdusively coMrocfing � CONTRACTOR n10. - � - �� . . with licensed coniractors to canstruct the project(Seo- A�DaE55 � � - - lion 7044,Business ond Profess7ons Code). �-• �� ��� - ��- � - - � � � - - � REOUIRED 70TAL SETBAIX FROM EXIST. - � � CONSTRUCTION LENDING AGENCY SET BnIX YARD HWY PROa.lwE WIDiH - 1 hCreby affirm fhot there is a canstrottion lending ogenry for � ' FaOM � - � � �� the performance of ihe work for which fhis permit is issued v.i. � � .�Sec.3097.Civ.C.1. . - . . . . Si�e . . _ . . ........ .. .i � . . ... . . . .. P.L _ lender's Name � ' Lender's Address � + P.C.Fee S Permii Fee /�'� O .. . � • . . � I cenify�that I have read this opplica�ion and state thot the . issuonre Fee � v� � above�nlormation is correcl.I agree to tomply wilh a�l Cooniy . . Inves��ga��on Fea � - � � �� � - �J - � � - � � � ordinances ond State laws relating to bullding conshuc�ion, 7oiol Fee �l d•...�1� ' - ond hereby ao�horize represenlolives of this County to enter _ _. , � . .� - upony .abpve•me fio d�prope 1 fo/i ction purposes. . , . (� ` ��P�.�,1 - SEE REVERSE FOR E%PLANATORY IANGUACE � Signoture of�ppll nf or Agent Dore � � - i . - @� ._ y � , c� T m o: ..._ - o a rn �+m m n m ° � � o .°r. o n � m o a p ,? '. , T �, o Tn o x v n� �;. �°aa w� o m m � ' �' R� Q G m P � 7 O. ... p � Z3 :'� �6 , O -n 2 a n � o a. � ir-. � 3 ; n� 3 0 � � . j-' O O S � 3 0. 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