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HomeMy WebLinkAbout0813A (4) _ . _ _._. _ ._ - - _ WORKERS'COMPENSATION DECIARATION � '�� --� - � �� . � I hereby offirm rhat I hove a certificate of tonsem ro self � ,�,�,e,oracertificotaofWorken'Compensoiion�n,�,o��e, APPLICATION FOR BUILDING PERMIT • or a cenified copy thereof(Sec.380p,�ob.C.1 ' - -� 3/B COUNTY OF LOS ANGELES . BUILDING AND SAfETY � 7ddrJ�9A5-279-04��Pony Nationwide ❑ nooae"ss 620 Pantera Drive Ce.;ified copy is hereby fumished. fOR APPLICANT TO FILL IN �� Cerrified copy is filed with the mvnty building inspeo- �". BUItDING tion deparfineM: AD�RESS Date R�j�R 7 ApplitaM P Qt � .. . . ZiP ioGAUTv . CERTIFICATE OF EXEMPTION FROM WORKERS' � �� � � - NO.OG BL . � � � NFARESt . COMPfNSATION INSURANCE ' � SIZE OF l07 NOW ON tOT CROSS ST. ' (This seciion need not be completed if the permif is for one , quEupg _ _ 1T1Cf5 hondred dollars(EI00)or lesi.) TRACT BLOCK LOT NO. MAP BOOK�� � PAGE PARCEL TEL. U ONE �P �t 2•� I cedify ihot in�ha performonce of the work for which this owNER N � ! —yY- permit is issved,I sholl not employ any person in any manner poDRe55 gO�7 ���A�- -� � - - �� - � — so as to bemme subjed to tha Worken'Compensaiion laws. CON��nONS 0 � .. . �� '� CIN Z(P V �te - ' A II[onf � ARCHItECf OR TEI. DISTRICT GROUP ttPE FIRE PROCESSED BY_ � .ziYICE TO APPUCANT:pf oifer�moking�this Certificale of ENGiNeER NO CDNST. - � 20NE � � Exemptlon, yov shovld becoma sob�ect to�the�Workari 1� . � Compensotio�provisions of ihe tabor Code,yoo mvst fonh- qDDaE55 � W wiih compty with svch provisions or this permil shall be �-�-- �� ������- � �� - d� TfL. STATISiICAI CLA55�ICATION APT. C NDO. � deemed revoked. � �� CONTRACTOR O. Z LICENSED CONTRACTORS DECIARATION� � � � i��;� - � - �-tASS NO. DWELL UN�TS � I hereby affirm Ihat I am litensed under provislons of Chopter 9 AD�RE55 . (commendng with Section 7000)of Division 3 of the Bvsiness ond _ . . . .���, . _ SEN'ER AMP Professions Code,and my license is in full(orce ond effect. , p7y CtqSS B --'� -BK� � - - - - �� YALIDATION� SQ.Ff. NO.OF ND OF CHECK �icense Numher 510 5 6 0 - ua Clase R s�ze 14 0 9 sTott�es 1 FAMILIES 1 ot�e THE ANDEN GROUg 8/5/8 7 - oesceirr�oN oF woaK ' "Ew vawanoN conrrocror ate �S � 462 $r' ADD , I am ezempr under See. G1rd 2— AITER� � P 0 8-1.3 A 8.8P.C,for this reoson SLAB ONLY REPAIR � f � � #• • • • •� oo�e: use oF oenna ❑ I+ •7 U,2 5 EXISTWG BLDG. . - Signature � .. . . . � ' ^P�iCaNt TEI. F�NAL /�/ OWNER-BUILDER DECLARATION • PRWT -.DATE ls � J D . • • •7�2 Jr c=i � �I hereby affirm thot I am eKempt from the Contractor's Licensa � � �-j{S dbOV2 � � - � - � �ow for Ihe following reason(Section 7031.5,Business ond ADDRE55 FINAI O B.� �T"'$7 � �f055i0n3COdBJ: . . . .. ..... . .. PRE EN sY / �.. ' . .. . . . . . . . . � t BUILDING I, as owner of Ihe property, ar my employees wifh ADDRE55 woges as their sole tompensation,will do the work and ��TM � . � . tha slroctvre is nof intended or offered for sale(Setlion - � � 7044,Business and Professions Code). � �-- - - � � MOVING - TFI. - - ��� �- - �� -� - � � - � I,as owner of the propeny,am exdusively contmcting GOMRAQOR NO. . , wi�h Itcensed contracmrs to conztruc�the project(Sec- - �--�- - -- � � ---- �-�--- ---- - -- � - � - -�� tian 7044.8usiness and Professlons Code). ADDRESS �� � � CONSTRUCTIONIENDINGAGENCY � � -'�Qgq�K YARD NWY TOTAp�SE�TpAINEFR WIDTH � � � - I hereby a(Firm iho�there is o constroction lending agency for FaONT � � the perio�manca of the wo�k forwhich lhis permil Is issved P.l. - - � � (Sec.3097,Civ.C.). SioE � . . . P.L. _ . . . lender's Name Citibank � � � IDMA Ref.S � Lender'sAddress444 .S. Flower. L.A. 4��7�. PC.Feef Perm�tFee , .1 certify�hvt I have read thin applicatian and tlofe�hat iha . Ivuonce Fee .�'O•5� IDMA P/C M . . above in(ormotl is corcect.I agrce fo comply with all County � i�„esiigaiian Fee ordinoncee a tma laws relating ro building consiruttion, _. Toiol Fee 74•25 I�MA Perm:N -� - � and hereb orize representotives of Ihis Coonty lo aMer � ' opon th tianed properry for inspectlon p�rposas. � � � SEE REVFRSE FOR E%►tANATORY UNGl1AGE S�gnmuro o Applicanr or AgeT D_� . . .. . . . . . . . 2 0 - o _ .�, , ' � �- � �� _G�� a, � m ��� � i v "�'• o - � ` � � Q � v, �m oA a �� 'a �F ,v��_� \ ; r ��7 9 N O'� a -�O p it -..d`. t m w.�, �O � O ^ � �G. '� '1+ 1` O `n � ., ��.. Y V t ��., �. �3 � p f, o -�o p� ic `• . r .,. No � � �� �?r ,'� � 1� ;'~',� • u� n �' a roo � o��' . oo ' ` . , '" .a �, '^ o � o �9 m o .^. < ° +� Z O 0 o c 7 f� �. � � � O 6 p. � . - O � ,� .' P C^ � 9 !� ^ ���\, � , . ei• ' j� Q G ' ,� CJ � � O � p � `. . "^'��j . , 'I '. ^ 't 'O � - s � n j 4 M „ N '\ I , �{` L .,yf ,, G~ f� �? � r� n < ,� � m p t` •,.. �- q ; ,x � J a G 1� M p �-. 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