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HomeMy WebLinkAbout1551A (9) )1'ORKERS'CO!P.FENSATION OECLARATION I hr�rby o����m rhal I hevr���,,,�;�o,�oF�o�,��,,o,��� APPf.ICATION FOR BUILDING PERMIT � msure,o.a cen�lita�e of Wor4ers'Compansalion Insu�once, cr�o ccrr�lird ccoy�hercof(Sec.3300,Lab.C.� COUNTY OF LOS ANGELES BUILOING AND SAPETY Palicy No. Compony BU�tC'NG � Ccri�l+ed copy is hcreby fur��shed. FOR APPLICANT i0 FILL IN ADD7E55 � ,CrrGlied cepy�s f�ed with ihe counry huild+ng inspec- BUi1D�NG ' lion Acpnrfinenr. AD'J�E55 _���1/� DOIC Applicant CITY {JI��O/�I��,� 71V' �I/Ei l IOCAtITY .0 NO.OF BlDGS. N'.AREST CERTIFICATE OF EXEMPTION FROM VJORKER$' S�ZE O�lOi NOv�I ON lOT CRO55 ST. ti • �}[ CO1dPEN5ATION INSURANCE -�— �This seci�on necd not be tomplcied if Ihe pe�m�1 is for one ASSESSOR ' hv�dred dollors(5100)ar ICSS.� TRACT OLOCK LOi NO. /J�AP P.00K PAGE PARCFL O`h'NER C ��' f USE ZONE �N } I te!rlily ihot in ihe�crformoncn.of the�ork lor wh' i is �� n. permi��s iss�ed,I sholl not employ ony p son any nnn . 6 S°E�iA� U so as l0 6eco ,su�[t lo Ihe�'✓o�k i Om�rnsali n La �DDRE55 p� sV PCa�!ei��. �.� CpNDITIONS �) �d. aTr n� i3a, ziv C� � �/ Do1N Appli[ant ARCHITECTC+' TEL O J1 NOTICE TO PPIICANT: If, a(�er m ng this Ce�����ca of DISiRiCI GROU7 TyCE F14E PROCESSED BY �"' E.emp�ion, you should become subjen �o �he Wa ke�i ENG�!.FfR N0� CCY$T, . 20N W Cemp�^•.�'icn provisiars cf the labor Codr.,you mus�(orth- pDpRF55 • � �" wi�h comply w'�h suth provisions or Ihis permii sholl be TEI. $TATISiICAL QASSIFICATION AVT, COt+00. Z deemr.d revokpd. �04iRACTOR NO. — IICENSED CONTRACTORS DECIARATION �i�. RA55 NO. DwEIL.Uv1T5 I hereby ollirm thot I am licensed�ndr.r prov�s�o�s o�Chcp�er 9 A��RE55 Np. �w,���P �tommrncing wi�h$ection 7000)of Dirision�of the B�siness ond liC. Professeons Code,nnd my license is in lull Iorcr,ond elfect. CiiV Cta55 BK � VALIDATION SO.FT. NO.OF NO.CF CHFCK licensr.Numher Li[.CIo55 SIIE STO4iE5 FA.MIL�ES O�E VALUATION an DESCRIPi104 OF WCRK �,� N'w ❑ 3 CoNraclor Dalr. ACD = `" ��� , �I am ezempt under Sec. . � � ALTER B.BP.C.for ihi�reason REPn!R ❑ s . ' DOIC: �SE OF DEI.tiOL E%ISTING OICG. � :�� 5 J� l�i AFMIGiNi TFI. $ignalurr. FR:NTI NO. FINa e • • OWNER-6UILDER DECLARATION DAT �/, �' � ' � I he.eby aff�rrtl iha�I om ezempt from�hc Controctor's Litense law for Ihr.(ollowinp reoson(S^ction 7071.5, Businrss and /OCoE55 FINAL � • �U�.G; Professions CodeJ: _ .__ , a�ie_!n� B1' a . c — ❑ BU'LDiNG � "��^— I, os owner of ihe p.cpe.ty, or my employees with aDo4e55 .i agez as ihr.i.sole compensonon,will do�he work and �� � �1 0� ,i—";S the struc�ure is nal intendcd or o((ered for sole(Set�ion �aA�iTY 7044,Business ond ProFessions Code). fAOVING TFI. � I,os owner o(the proper�y,am e.cl�sirely contracrfng CONTRaCTOR NO. wilh licensed tonlractors to conslrucf Ihe prajetl(SeO . qD�RE55 iion 7044,Dus�ness and Professions Code). CONSTR�GTION LEND�NG AGENCY SEi�Bq�K Y�RD NWY ���Apppp�iNE� W!D7FI I hereby af(irm thar ihere is a cons+ruction Ir.nding agency For f RCu� Ihe performvnce o�IFe work(or which Ihis pe�mit is is�ued n.t. (Sr.C.J097,Crv.C.). SICE v.�. Lendei s Nome lDMA Rel.M Lender's Address P.C.Fee S Pe�m�e Fe. J I crnify ihot I ho�e read Ihis appli tion ond sro�e ihot Ihe Nwonce Fee � l�"M P/C M , above informm�on is corre .I ,�e td Comply wilh oll Counly � in.es��ga��on Fee ord�nOnCCS Ond 510�9�a s relati g�o uilding conskuction, To+nl Fee IDti+A Perm.M and here authorire r p.esem iive of�h�s County�o enter vpon�he above� nti f or ins ncfion purposes. ��q) � � _ 7'�Y(l�/ SFE REVERSE FOR EX�IANATORY LANGUAGF � naNre ol Apphconl�r Agr.M Dole ,-- � f--- 'i,�1, � ' , _ �N� . �. -7-��``..1- - r,•_�_�,�, � � ' .` ���r;,;'` c- �:: , �: , . .`1 " . �y" . �� ` = �� , ➢, . .S r 1 ' � '1 � S. t � f.. q � O ,.-.�";, .� �U � , _ �� l: .� ;`,`• .'� ��I ,� . .l j � � ;� �, } � ,� • `•' ; , �', '� .� � ' . CY 'c i ' 1 'C •(1 � ��! ('. 1 �� . 1. . 1, r '' ''�i�'���,,�, ,'., , ��.: ; ? �� � ,`� = �` , 11 Zy ,i �r �1 C �: �( �~�rtC 1\ r , + �L. i �(`,, ` . 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