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HomeMy WebLinkAbout1480A (8) . WORKERS'COMPENSAiION�ECIARATION C��"� �/.j V ��/7 � - .insure6orarcenittoteof Workers'1Compensaton��,�;a��f � � -APPLICATION- FQR BUILDING PERMIT � ar a ceniRed copy thereoi�Set.3800,lob.C.� COUN7Y OF LOS ANGELES BUILOING AND SAFETY PolityNo � Compony ' � Certified copy ia hereby furn�shed. FOR APPLICANT TO FILL IN BUILDING � � , C ���� nooaEu � Certified copy ie flled wilh�ha coumy building inipec- � BUIL�ING lion deporlmanl. . ADDRE55 Z� 3 � � �9L dM.�/v Dale APPIicaN . . . � .. �ITY � Y N O.s/D � ZIP C 7V� IOCALITV CERTIFICATE OF EXEMPTION FROM WORKERS' " - - . . NO.OF BLDGS. NEAREST � COMGENSATION INSURANCE � . 512E OF LOT NOW ON LOT I CROSS Si. (This seclion need nol be mmpleled i(the permil is!or one . ,+�r7 . ASSESSOR . . hundred dallors(E100)or less.) TRAR �T/ BtOCK LOT NO. /�nq7 Bpp1( PAGE PARCEL TEL USE,yQNE, NOP i Y�l r I certify�hat in tha pe�farmance of ihe work for which fhis � �NER 1- �iN� ND. �� �..Q,. permi�is iss�ed,I shall not employ any pe�son in eny manner qDDRE55 d r US/� 7�r�p �� �CinL p� so as to become sobjetl to the Woikers'Com ensation lows. � / �/ /� CONOITIONS p 9 � GIN O (SJ�D �y 21P "/��� � �°iB--F-�PPlicant AR[HITECi OR TEL�9 � NOTICE TO AP ICANT: If, offer moking�this Certificale of �lp�'� DISTRICT GkOVP TYPE FIRE PROCESSEDBY O Exemplion, you shoold bemme sub�ect to tha Workeri ENGiNEER NO. �Q / NST. IONF- :�C V Compensafion provisions of tha Labor Code,you musf forfh- pDDRE55 Y� a with comply wi�h such provisions or this pe�mif sholl be . '/r TEL, STATISTICAL QASSIFICATION APi. NDO. tn deemed revoked. CONiRnttOR /v G P NO. +� Z LICENSED CONTRACiORS DECLARATION r�i�, . M55 NO.�owEtL UNitS I hereby oNirm Ihot I am litensed under provislons of Chapter 9 ADDRESS a Vl..NO. ��R�P (commencing with Section 7000)oi Division 3 af the 8usiness and ���. . Professioni Code,and my license is in Full force ond effecL CITY � � C1A55 ��� ��� ��� BK � � VALIDATION � � SQ.fT. NO.OF Np,OF CHECK Licensa Number - � Lit.Class � �" ' SIZE STORIES FAMIUES - ONE - . ❑ VAIpATION Contrattor Dafe � �� � DESCRIPTIOp� WORK �S7A LL �^ N� S /, �� �1 om exempt under Sec. �Q��w �N R�b �� ' ADD � � ,. � AITER � . . D � I S�D REPAIR ❑ s � z 1 4 8.0 A 8.8P.C.for�his reason . . pa�e; � USE OF y EXISTING BLDG.S�G L(/ MJ'L ���� � � � � SignatVEC . APPLICANT �� !'� Ei. flNAI � • •3 0,5 0 OWNER•BUILDER DECLARATION PRWT I7 NO. OATE � t hereby affirm Iha�I am eKempt from the Contmtfor's License � � •• •3 Q 5 0� Low for the following reason(Settion 7031.5,9usiness ond- ADORe55 FINAL � �� � Professions CodeJ: - � e N � � � BY �9.Q�_q�8 � � BUILDING I,as owner of the properly, or my employees wifh ADDRESS •��^ges c:!hclr sole conparso'lon,will do rhe wo�k ond ���TM � ' ��()�p _ T-/�•/ the structure is not Intended or offered for sole(Section � )0 � «�'Suf"'� ��•/D'8�'. 7044,Bustneas and Vrofessions Code�.� - - MOVING - � iEt. l� . . � I,os owner of the pioperfy,am exclusively controcring CONTRACTOR NO. , wllh licensed conrcactors�o mnstruct tha project(Sec- ADDRESS . ... .. .. ji� �� UK��l'nQ . tion 704A,Busfness ond Prafessions Coda�. f ���� CONSiRUCTION IEN�ING AGENCY - � - �si�sACK YARD �HWY T�iAp�p�INEf W�OTH 1 hereby offi�m Iha�there is o consvuction�ending agency for FRONi � . the performonte oI the work for which this permi�is issued . a.i. . . . ' (Sec.3097,Civ,C.). SIDE P.l. Lendar's Noma � � � � � �<�, L�MA Re1.M Lender'e AddrE51 � � - P.C.Fee S-� Permu Fee. ' I tertify that I hava read�his applicolion ond state that tha bmonm Fee f d �� LOMA P/C M . . . obove information is correct.I agree to comply wl�h oll County Invesrgar�an iee �f �p � ordinances ond Sto1e lows relating ro building construdion, Torol fee �v'V� IDMA Perm.M � ond hereby aurhortza representatives ot thts Covmy to enfer - -� upon ihe abpv -menlioned pr�pe for in�pecfion purpo�es. �.+� � �/�l�g SEE REVERSE FOR E%�UNATO�Y IANGUAGE ` S noture of ApplicoM or AgeN Wte � � - � � . Z '� a o , � � o _ v � � A o ^ „C o n-o �N o c o z �, _(- • o �� n N o � 4 D � D � . N C .F O � � �� �A dJ ,p v �- C . C N O r m � o O m O . i0 . � =��1 C>> �= • � �' C � � . � n � o � a a o D . o � ° 'o _ c� y 3 � o ` Z o � n j j O C � ? � G � �� � . aiy 0��'. 9 O j . p' . • �p � � Q � ?� .G d �� ^0 > > ,�m � � . , r . �io R, m,t > > .c . �o - . � , q o ' X �, u� < o � o , z � �? � o f c ? 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