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HomeMy WebLinkAbout1594A WORKERS'COMPENSATION DECLARATION . . f - �} I here6y affirm ihat I have a tertifimte of consent to self � LS ��,��a,or a certifitata of Worke�s'Compensalion lnsvrante, �P P L I CAT I O N-F O R �B U I L D I N G P E RM I T o�a certified copy thereof(Sec.3800,tab.C.) . COUNTY OF.LOS ANGELES__ ��'i. . BUILDING AND SAFETY PolityNo. �Company BUiLDiNG � Certiiied mpy is he.eby furn�shed. FQR APPLICANT TO FILL W - aooRess a�9oZ � Certified copy is flled with the cooNy buildi�g inspec- 8UIl0ING I . , tion deparimeM, � . . A�DRESS � .� ,�,�p " LUCAIIN . NEAREST /.' . Date Applfmnt CITY W P ZIP CROSS ST. l�n� � CERTIFICATE OF EXEMPTION FROM WORKERS � � NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP BOOK � AGE PARCEL (This settion need not be tomple�ed if the permit is for one use ZONE nwP /aV..-� �� , hundred dollars(E100)or less.) rancr e�ocx LOT NO. � No. . � TEt. �n � SFECIAL �- I certify that In the performante o/Ihe work for which this OWNER � Np. 7 C71. �� � CON�ITIONS 0- permit is issued,I sholl nat employ any pBrSon In any manner ' ' � - - - /� �� DISTRICT GROUP TYPE FIRE PROCESSED BY 0 _ so as to become sub�ect to Ihe Worke,s'Compansation Laws. ADDRE55 y y I �� CONST.,1// ZONE � . . . , . . �.. .. 1' `.J Date -� � � Applicanf - ' � � CIN. .G �- .. ..ZIP / STATISTiCAIClAS51FIG4TION APT. NDO. � O NOTICE TO APPLICANT: If,ofter making Ihis Certificate of ARCHITECi OR TEL. _9 � � � �V ENGINEER -NO. � ��qu N0�-`/ DWELL VNIT$ W �Exempflon, you ahould become sobjecf to the Worken' p, Campensation provisions of the lobor Code,you most forfh- . .. . u1 ADDRE55- - � �� -� ��------ �- -r SEWERMNP with.comply wilh such provisions or this permit shall be � � deemed revoked. - � �pMRAC70R .. NO. �� ��BK. PG,- VALIDATION LICENSED CONTRACTORS DECUIRATION �i� I hereby eHirm thot I om licensed ander provisions o(Chapter9 ADDRE55 NO. ��,VAIUATION �- (mmmencirg with Section 7000)of Division 3 of the Business and �� ��� � . � Professlom Code,and my license is in full forte ond effetl. GiY CW55 ���E�QQQ -� ,, . . " Sq.Fi NO.OF NO.OF CMECK .-..._ . _. . Li[ense NUmbef �LiG C�oss SIZE . Q STOR�ES FAMIUES � ; ONE ' . � . . - . . . _ . _. /. N�._❑ E - - . . CoMfattof D�ta OESCRIPfION OF WORK . � - ' ' � � ' . c . ADD� . -.... �I am exempt onder$ee. ALTER � � FINAL - - ^� ����.a � . B.&P.C.for this rcason . . .... .. . .. . . ... ...-- REPAiR � DATE�—�'�-�� ���.• . . a ' , . � . . . Data: USE OF . � . DEMOL.❑ � FINAI . . ewsriric aioc. — _ _ ar I • 1 1 1.7 5 Signafure ' . . . . ' APPLICANT TEL. OWNER-BUILDERDECL4RATION �WT S .NO.S � y ' -" - � 1 hereby aifirm that I am exempt from the Contracror's License � • ' � � �.�'S� law for the followfng,reason(Section 7031.5,Business and ADORESS 1 �- - - � � � 0�.30-83 � ProfessionsCode): � . � vueSeNi ' . ._ ... _ . . . .. . _ . \f"1 BUILDING _ __ .___._.. ___ _ _ . __.. __.. n�� I, as owner of tbe property, or my employees with A�DRE55 wages as their sole compensation,will do the work and . . ' . � . . � the sfructura is not IMended or offered for sole(Setlion -- ����TY . . . . . .. .__. ' . . .. 7044,Business ond Profession:Coda). MOVING TEI. .. . . � I,as owner of fhe properry,am axclus(vely[ontracting NTRACTOR NO. ' - . � . with Iicensed conlroctors fo canstrucf the pro�ecf($ee- ADDRE55 � tion 7044,0usiness and Professions Code). =� ' � � . � � REQUIRED TOTAI SETBAIX FROM EXIST. CONSTRUCTION IENDING AGENCY SET BnCK YARD HWY pR07.LINE WiDiH ,► . ' � ' I hereby offirm that there is a con:truction lending agency for . FRONt � �- � � - -� � ' . - - . the parformance of the work for which Ihis permit is issued p.L. . �SeC.3097.Clv.C.). � � SIDE . " � � _ . . _ . . . .. P.L - . . _._ ._._._. _. _._ . . .__'_. .. .� .. lender's Nome � , __-\�-��� —.: ,.. . . . .. . . _ .. __ . . .. . P.C.Fee E Permit Fee ��ar Lendei s Address . � - _ � � � ..I terti that I have read ihia a lication and sfate ihat the . . . � : . .� .. - ---.. . .�. . �U. .�O. .•.. .':� � . .. � . . ._. . fY PP Iasuan<e Fee � � � obove informarion is correct.I agree to comply with oll Counry Investigarion Fee . � -ordinances and Sto�e lowa relating to building constroction, -� � Torol Fee /��•�J � and hereby au�horiza rapresantativas of this Counry to enter ., . upon the above- tioned property for inspec�ion purposes. � � - � - �� � � �- � - - � ��-�- � - - � � ^ O.�� , SFE REVFRSE�FOR E%PIANATORY UNGUJICE .__ . . , , SlgnaNre ApplimM or Agen� pote. . ..m� . . - ' . - . . . . . . _. ... . _ . .. .. . . . . / i __.. - - � ,: . .- z >? o0 0 0 � a o ° mR � o o �� o� m � '-' -�?- -o� – - - ,- o q � � a � a e ; � . .�I_ _; mo - w � � 3 0- � o-g . ir o � r, � m � a ° c'o o � ^° m �� � ° o ° o D m' � �,o °� n° 9. � v �: - + � i , , Z x m,� F� �n � o �� `° � o n i i ' ' �+ �� m' o f c � c� � � - � �� o' °I ° :�, o a i � i � ° � o � ° '^ -C •c - m o v � v -� 3 0 �. � t �c g p M . _.. � ;? � o � �_ -• o_ U � ai � ? a — , � � o .� m ' � o o ! o. - ._.� - 3 - ; � ° • � , { v� �� � N � 1 C � � '� ro _�� � � � � a � - �i � � �, Y � o � , _ � a v � � ° — ' « o ,- - � Z .. 0 � � � �, , _ « � � ;� r r A y 6 :�t v 1 � ' � � = � � Z n, n o � 3 : D � . ° I � ° � � � o a, � e i, " � v . 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