HomeMy WebLinkAbout1760A (10) IWORKERS'COMPENSATION DECLARATION ��� ��
I hereby affirm that i have a certificate of tonsent to��t APPLICATiQN FO��ll�L[9�11VG PERMIT
insure,or a certifitate of Workers'Compensation Insurance, �
or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS t�'r E�p � �e; �,,��I {N(1�-/�1� �
Policy No. Cnmpan � A� `-" ���. '
Y . .
❑ Certified copy is here6y fwniahed. FOR APPLICANT TO FILL I ��_
❑ Csrtified copY.is filed wifh Ihe touny building imp�- �I���
� tion dapariment.. .. -. � A�DRESS I 3 � - �v,r',t ��/-
ZIP I��S
CITY � ��C/ IOCALIN
Date A�IicoiN P�p.OF slOGS. NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE�OF Loi Now oN�07 / [RO55 Si.
COMPENSATION INSURANCE ��R
(This section need not be completed if the permif is for one TRAQ ��� eLOCK LOT No. µqP BOOIC PAGE PARCEL
h�ndrad dollars(;10p)or leu.) TE�
OWNER Q �Q �' /p�p � � 5�'�N�E MAP �
1 certify fhat in the perfwroWlca of fhe�ork for whicFi thia ;` ��L
parmit ia iuued.1 sM�all not employ any perw�in any ma�ner ADDFESS/33'.� (' �f[/iC'.� �iV• � �pNDITIONS O
so os to become subject to the Worken'Compenaation Laws.
. - cm � /y ziv /? v
Date Applicani � ARCHITER OR TE�� DIRRICT GRWP TYPE FIRE y �
NOTICE TO APPLICANT: If, aher making ihis Certificate of ENGINEER u/,I/C.T itd O. ,.,",�„� ZONE �
Exemption, you should become wbject to tha Wwkers'
Compensotion provisions Qf the Iabor Code,you must fw�h- ADDRE55 � �h� �' w
with Comply wifh Such provlsloni or this permii sholl be TE�� STATISTICAL GUSSIfICATION qPT, CONpp, �
deemed ravoked. � CONTRACTOR N0. Z
LICENSED CONTRACTORS DECLARATION t�C. MSS HO.�kVFll.UN�7S -..
I hereby affirm ihof 1 om licensed under proviaions of CFwpfar 9 ADDRE55 NO.
{commencing with Section 7000)of Division 3 of fha Business LIC. SEWER MAF I
and Profeasions Goda,and my license ia in iull fwce and eHect ��TY ��� BK. PG. VALIDATION '
50.FT. P�.OF NO.OF CHECK �
liwnse Num6er Lic.Closs SIZE STORIES FAMIUES ONE �I
YAIUATION �
Contrpctor pote �ESCRIPTION OF WORK N� s �G c a �n �
❑1 am exempf�nder Sea �aP /.d/+(/�! L!/.G C! ADD ❑ � , z}']Q p A� I
ALTER ❑ ;� •'�
6.8P.C.for ihis reawn / �� ' <<'vF REPAIR❑ s ••� •
°p�e` ExlsT�c stoc. oenna❑ I ••4 3 0 0
Signature ����'7i 7Et.
OWNER•BUILDER DKLARATION �(�IM} /PQ, /P.L}�.}/vo pp i/// �' FIN/LL • !�►U 3,O�O�
I hereby affirm that I am exempt from the Contratlor's Licensa . . �p� �Q,1 7—$9
Law for tha following reason(Section 7031.5,8usineas and ADORESS/��'�S /g-'CO �iV« L iv, F��
Professions Code�: . pp�N1 gy
� BUIL�ING
I, os owner of the property, or my employees with qpDRE55 � ��
wages aa their sole compensation,wil�do ihe work ond �
the srr�cture is not intended or offered for wle(Section ����n" .
,_,/7044,8usiness and Professions Code.} - MOVMG 7EL �C^�
�� I,as owner of the properfy,am exclusively conlracting ��R'4CTOR Np.
with licensed contrecfors to consiruct fhe projecf(Sec- pDDRE55 ^
tian 7044,Busineu and Professions Code.) n y�y �
CONSTRUCTION LENDING AGENCY REqUiRED YA� �, TOTnt SETBAQC FROM � EXISS. �(//`✓"" �
SET BACK R P ll E TH �
I hereby affirm ihot there is a consiruction lending agency for FRONT
the performance of the wwk for which this permit is issued v.l.
(Sec.3097.Civ.C.). SIDE �
P.L.
Lander's Name
� � LDMA Ref.N -
Lender's Addreu P.C.Fee f Permi�Fee �
° I certify that I have read this application and state ihat ihe Iss�ance F e V IDMA PiC N ►
� above information is corcett.I agree to tomply with all County invesfigarion Fea 7�
ordinoafes and Sfafe laws relating to 6uilding tonatructlon, Totol Fee / ' 0 0 LDMA Per�,,.q
Q an eby uthori r �saMatives of this County ic emer
$ up, f�-m ti d p',ro_perfy for inspection p rpose
�d��C _�� SEE REVER6F FOR FXPLANA70EY IANGUAGE
in Signmura of Applimni or Agan1 f
. �
�,_ �
91 G O G(Q�n� N O
,.:C Ct 0 f�� y O G� � v '
���'A O E O� E r✓F. N t�.0 � 6 .
N� O C a� � � C p y G
•=� �o m s`a;,c n Z v iv '�.c v, � ; N
�s �° �aa' �v+z�a� ;2 00 3, � O W
�u c��i�$� ` '� o�'m 'l y� i>a U m� � \ r 0
acpsoa myi�p hss. Qv �o x � .n �'= Z
m�C om�a�V Ny•N�p..r 3�?ti$�cia p �... 6 0c Q m
Y N
r L O II m Y'_ m G r� �, a� L% U i' �.Y ;,,' w L p N 6 M�' D p � �G
^�03 Ec, � ''.O m� m 4✓N� a=La�-; `� m�m v; � �?
A�- �aov,o�i�,o�v mo�uc� o �'r.00`o,E �po`� =°'-+
� ~UN°c���c°�m�,•` �dE34' �ov`o,c.'O >II� �'��m��� � v'
� m oa����an���c� 'c°rav m� m�' Q'� m�� e1� � �
�G G T W m OEO O= N� !`+O O N C O��`p.pC`CG N OtJ N� �.�J 6 .
.CUM .G i ; wG�' 41 �
r`L ��yo�-��y=�m mw m �.°G`Q o�i; r�� oc .-a c�cuE �°' @
(� O �T`Y Y� 07 n�� �at'�V C.�C C O Ot C' � N'N..]O Y 6 7C �
Q ic r� a M�i� 4 4�D �ab �Ct'. O+t.v �G � m vr c�u m
�j 4 0� o�,°:M.. i�m c a c. o p w E�,E"_v =s ui �n v y� aa ,� � '
OG N ' O!" C, O..C=m E U:. ' 6 C dp O r.-C._
.m�3o'�o�m.°°c.om`x�". + � cmnaty�� 3oy�oa�o �
�� o U m �U c 4 ,c c m o� o o.- a l.'� aa'es d+.✓��-.� o �� c
`,1y m� N V' d G' ,y„ O �.1 n O 4 p O 6 � S C � �O.r Q' 7! v+L ti O 6
�`° m'�'u,`���c.�w mEo� �j�,'-La"'=c`�-�c�� GN� ��� p m y0
R U 8
ffl�� w��om��� 0c� �wr�inm�a,�m� 0.w��a,~��;,aY'+� '
�•+ 00.�N��UO���t70i���c� E.� OpasN Op `✓ , .
?� 3cac�^��ppppoda« �°' a;aqi..�a=r -
�w A a6 af �_ � al � N � 6'� .
� l�l.J N N� O.61 p�m� T Cy� 3.zr,m-� .
'r mm'asnt Cvrocn
m°Pa+c• m`°mao`ooUz°s ' '
c. � m.c..,
summc�,. . . ,
-a .
.� , �
, �,
. r�
Z
�
O � '
��
N
Z
' �
' �N .
a
0
� C�
. ' ' �� o '
$� , � \
��
. � � �� , 1
_. o p �
,= o � \� ..
� � $� o
, o � o �o°- u-
a � y � \ � ca ` o � ��a as °
a ia_� Z.�
. '. . 6 � � �b a i �� � , �• � G 3?; � `'°'is d ie✓
� (� m � W i0 y � G � 7 �G
- J 7 �.T.. . p T� o '�rn 0� � y� �'y
. o. c �o \;\a°,, . m m ,' �
� �� O OT i p' ��C p 9 �A G �
O 2 p� dN m a \u d �°y, ¢N W W
Y '
' = G ✓ 0.�j, �� .A� � \ jN
N G,
J �^ A C E " m '°� ' O � V a`o
.�
6 p Q � � 6 Q O �G �� , O-
� �C. p m r �w N.�
. ~p , 6 `� r p' � � Q,�
M m ~ V
� Z LL
. y." 7