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HomeMy WebLinkAbout1594A (9) 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. FOR APPLICANT TO FILL W - aooRess a09oZ � 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.) � TRACT BLOCK LOT NO. �1 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 forlh- . .. . y 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. . �Set.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 representatives 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� . . - ' . - . . . . . . _. ... . _ . .. .. . . . . / __--, _-- z o . ._ o I � ,. _p -9- '1 :„� c� ��� Q � �, `� � � �' nv �a o a�, o �r• n, � ,� ', ,i 0 O 7 n n N O � ' V p O �y � . •n N O -F p Q 9 �^. �.' � p -'� C � tf -'' a -n N O (p fi • 9 O .i" P p'. •p' "' � � +. �• � r 7 O p � O'O. t0 � � (l 3 ��' 3 q� � . p; = p a m a' � o D a �i N o -o � e_ �� 1� j 7 O O S � m O O j�� w � � Q� O O + ..� , O p � . m p lp '" I �O '� O Qo� p _' j n. �m � ,? i N . 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