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HomeMy WebLinkAbout1347A (7) WORKERS'COMPENSATION DECLARATION � � I hereby affirm thot I hava a-certificale of consent to salf APPLICATION=FOR.�BUILDING PERMIT � insure,or a certificate of Workers'Compensation Insurante, � or a certified copy thereof(Sec.3800,lob.C.) _ . . COUNTY OF LOS ANGELES � . �BUILDING AND SAFETY Policy No. Campany � ' " � � � - � - ' Certified copy is hereby f�rnished. BV�lDinlG Z,f 3 T ti. _ .r11 �� � ❑ FOR APPLICANT TO FILL IN no�aess r � vi,o-v�c„ � Certified copy is filed with�he caunry buiiding inspec• BuaDiNG �t1 L � lion department. ADDRE55 333 AC LOUIITY. - W �+�o-1�� f�Lw . ♦ �1 �G NEAREST Data Applicant Cltt�i\A 8�/D A� ZIP (k CROSSST. � CERTIFICATE OF EXEMMION FROM WORKERS O-D�9L6G5. ASSESSOR . � COMPENSATION INSl1RANCE SIZE OF lOT IT O S NOw oN l0T MAP BOOK vAGE VARCEL . (This section need nat ba compleled if Ihe permil is for one µ u5E ZOME MaP hundred dollars(EI00)or less.) - TRAR � BtOGK LOT NO.'yf �_1 NO. �2..d`�� � ��TEL: � � � SPECIAI I ce.tify that in the performance of th'e work for whith this OWNER J ' p No. C�D CONDITIONS � � �or. permit is Issued,I shall not employ any person In any monner � --- .- ._.. _ DiSTRiCT GROUP TYPE �' FIRE PROCESSED BY � - so as to becoma sobjecf fo the Workers'Com satlon Laws.. ADDRESS � as -a.be��e . �U � CONSTr� ZONE �� � . _ . . ... . . . ...'___._.. w"`�V � /� Dafe ApPIICOn} • ' ��TM f�/ Z�P STATISTICAI QASSIFICATION APT. CONDO. �F NOTICE T •APPUCANT: If, after making Ihfs Ce ficote�of NGNEFR�R �/ - NO. - � - � -� V �Exemption, you should become subject lo the orkers' CW55 NO.��WELL.UNITS a Compensation provisions of the Lobar Code,yov musl forfh- ADDRE55 SEWER AMP y wiih comp�y wi�h such provisions or this pe�mit shall 6e � � � Z deemedrevoked. ' TE�• . gK,._ .p� VALIDATION � � CONTRACfOR >LS� ryp, LICENSED CONTRACTORS DECLARATION i�C. . � I hereby affirm thaf I am licensed under p�ovisions of Chop�er 9 ADDRESS NO. VALUATION (tommencing with Seciion 7000)of Division 3 of the Bvsiness and ��� � - � � Professione Code,and my license is in full forca and effect. CiiV CLa55 S ��(�� , • � � 5�.F7 NO.OF NO.OF �/, CHECK License Number l(c.Class SIZE STORIES FAMILIES�/ ONE . DESCRIPTION OF WORK N� f � - �1 3 4,7 A CoMracto� Date � I��� ����� . ADD � - k• • � f • � ❑I am ezempt under Sac. q�TER � FINAL {� B.BP.C.for rhis reason � � -- REaAiR�� DATE � Q� - I •�3�7 5 Da1e: USE OF DEMOL ❑ FINA •e .J Q'�5� EXISTING BLDG. BY Signotore APPLpRjNTi NO. �^ - �S.2 7"$b OWNER•BUILDER DECIARATION _ � I hereby affirm thof I om exempl from 1he Controcfors Licensa Law for the following reason(Section 7031.5,Business and noortess . C Ct. �� • � - � � � ' ROfessions Code): " � PRE N - �� � - �� I,as owner of�ha property, or my employees with AD�RE55 7� woqesastheireolecompensa�ion,willdotheworkand � � the strod�re is nof infended or offered for sale(Sectlon ����T�" , . _. . _ 7044,Bvsiness and Professions Code). MOVING TEL. ,� I,os owner Of 1h0 property,am exdusively conlracfing C NTRACfOR NO. . wf�h Ilcensed contractors to construct the projecf(Sec- qooRE55 tion 7044,Business ond Professions Code�. . REOUIRED TOTAL SETBAIX FROM E%IST. � CONSTRUCTION LENDING AGENCY SET BAGK YaRo HNn PROP.LINE �✓��TH , I hereby affirm that Ihere is o mnstivtlion lending ogency for fRON7 . . the performance of the work for which this pe�mit is issued P.L. �SeC.3097,Civ.C.). � SIDE . . . P.l. . . .. . . . _ _ lender's Name i lender's Address P.C.Fee f Perm�r Fee I certify Ihat I have read�hls application�ond srme rhot tha � i:suonce c�, I V. � a6ova information is conect.I agree lo comply with all Counfy Investigation Fee � � ordinonce3 ond 51o1e laws relating lo building construction, � Toiol Fee (� • ' and hareby authoNza represenfclives of this Coonty to emer . upon tha abova-myntioned property for inspaction purposes./� � � � � _ . . - . . ` / � SEE REYERSE FOR EXPLANATORY IANGUACE Sig tura of Apptim 1 or AgeM Do�e . .... .. .. . � . . ,mt Z o . ,.�I`o . : �' � �- � ', '� G� G1 W o n. � ,'. -'"'�+� o p. O ? C�, � "'�p � �, �, �4 m O.- 7 C �.� c9. ,t� . � � r� n 7 C� O 'C) -C' ;� �� ' , �O O O � n v� e0 , a p .K7 ... 'O� i � � n p �^.,p. o�, � �.G � O•.. L . � ,�, �. �- o n. �' C�a �� s � '3 m.. M � " � �� . :� � N C 0 O W Q p� p o ; 7 •1 '� �. O d - js tQ v� Ci .p ..-" � ` �' Y � r� � O � a„ O� �.� � ��, �� � • � ,� w .w � C�y o � �o � c, �' � a Jo a :,.. , .. 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