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HomeMy WebLinkAbout1587A � � - • �.f WORKERS'COMPENSATION DECLARATION --� � � �. -: -�- - � -�-' � � , � � I hereby affirm ihat 1 have a�e,�;F,�o,e o<<o�5e�f,o se�, - � ��� � APPi.ICATION FOR BUILDING PERMIT � insure,o�a certificaie of Workers'Compenso�ion Inswance, � or o cerri(ied mpy thereof(Sec.3800,Lab.C.) -� � � . Pol�c Nq��ompa�y S%�7� f?/f(/O COUNTY OF LOS ANGELES BUIL�ING AND SAFETY �Cer�ified copy is hereby furnished. FOR APPLICANT TO FILL IN BUiIDING g • � t aooReSs .J Ceriified copy is filed wiih ihe tounty building,inspeo BUnOwG nc� lion deportment. ADDRESS �3 L..� ���M��U � ��e � � JO � Appliconf � CITV /// ��/Q ZiP �7bJ tOCALITY CERTIFICATE OF EXEMPTION FR M WORKERS' ._ .. . . r+0.OF BioGS. _. NFqREST ��' �y � COMPENSATION INSURANCE 512E OF LOT NOW ON LOT � CRO55 ST. [,{,i[ (This section need not be comple�ed if the permit is for one n55E550R � . . hundred dollors(5100)or�e55.) ' TRACT - BIOCK LOi NO. / ' /�IqP gppl( PAGE PAR�EL � � TEL.g/I�WI� USE 20NE MAP I cerlify that in 1he performance of fhe work(or whith�his OWNER O�yQf NO. 0 3 r,,o � � a; permit is issved,I shatl not employ any person in any manner pDDeE55 .2�j�j2.� �s�t�/''��ND ,�1 SVK�n� _ . 0 so os lo become subject to�he Workeri Compensalion Laws. -- Q CONDITIONS [� CITY ��D/�0 ZIP /�76� � Dale Applicont O ARCHITECT OR TEL. NOTICE TO APPLICANT: If, aFier moking this Certificote af Di5i2iCT GFtOUP 7YPE fiRE HiO�55ED BY U Exemption, you should became 5�bje[f l0 1he Workeri ENG�NEER NO. CONST. �E Compensa�ion provisions of Ihe Labar Code,you musl forth- ADDRE55 �- ith comply w�th such provis�ons or Ihis permit sholl 6e � ' N deemed revoked. ' �O C OR � ET�. mg �C Np. —7� TATISTICAL CU1551FICATION . APT. CONDO. Z IICENSED CONTRACTORS DECLARATION � i��. CLn55 NO.��L�WEIL UNiTS , . I hereby aHirm that I am licensed under provisions of Chapter 9 aDORE55��•w'SrA7C S7 �n10. ,r.r� ��R�P , (commencing with Section 7000)of Divisio�3 of the Business and ��� Professions Code,ond my license is in(ull forte and effeU. GITY IU - � cw5�3 -� BK � VALIDATION ��'✓✓✓ SQ.FT. NO.OF• NO.OF CHECK License N�mbe�r1�.�} Lfc.Closs C 3� SIZE � STORiES � FAM�LiES� ONE • 6[►�"'�" +�'•"'-'�+�Da�e_��� - VALUATION Coniroctor E DESCRIPTION OF WORK N�7CVE EJ�S'71i✓(i' _ N�'`�_ ❑ ' = s�fs"� / AOD � , �I am exempr under Sec. ' ' _ r ❑ AITER B.BP.C.for Ihii reoson � p � J � /�OS/T�'✓ REPAIR � f Dole: O USE Of ` `� �EMOL E%ISTiNG BLDG. ❑ $ignelule l� . APFLI�.4NT. TEL q�� � ONE ER-BUILDER DECLARATION PRINT LA���'F NO./a/ 733� DATE �z C I hereby aflirrrt�hm I am ezempt from the Conlrocror's License � �� � � Law for the following reason.(Setlion 70J1:S,�Business and /+DDRE5�3• �''�JT����- � FINAL �1 5 8 7 A Professians CodeJ: , . . . pgE¢N _ . . . . . . - By ' �• • • • � 1 ❑ BUIIDING 1, os owner o(the prooerty, or my emoioyees wi�h nooaESS woges os their sole compensa�ion,will do ihe work and ��q��TV , f � • •6�,7 J� the structure is nof in�ended or offe�ed for sole(Section � 7044,8usiness ond Prolessions Code)., , . . ,, MOVtNG_ _. . . . TEL. . _ _ � I,as owner of tha property,om ex[I�sively[onfrocting fONTRACTOR NO. • � •6�.7 J c� with licensed controcrors�o cons�roct tha project(Sec- - ADDaE55�- -�� � � ' � Q 9,� ��—II 8� tion 7044,Business and Professions Code). CONSTRUCTION LEN�ING AGENCY � �sEQencK vaeo r+wr T�TApRpP UNE wioTH � � I hereby oifirm�hor�here is a construttion lending ogency for fkONT � the performance of the work ior which rhis permit is issued P.L. . - ($ec.3097,Civ.C.). - �- �- SiDE � P.l. Lender's Name '� LDMA Ref.N lander's Add�ess � - P.0 Fee f Vermi�Fee . � 1 terti(y thai I have read this appllcation and state that the Issuonce Fee �. tDMA PiC M obove info�morion is mrrect.I ogrea ro comply with all Counry In.esGgo�ion Fea ordinances and Slate lows relating to building tonstruttion, To�al Fee IDMA Ferm.N ond hereby outhori eprexntatives of this County to enter � - upan the a e• � d � ert inspection purposes. .._ � � . � �/ . . __.. _ ___...__. . . . . . . _. 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