HomeMy WebLinkAbout0723A 6527A (4) J WORKERS'COMPENSATION DECLARATION �7
lf 1 hereby affirm that I hove a certificate of consant io salf APPLICATI�N FOR BUILDING PERMIT ��
(� � intura,or a certificate of Workers'Compenaption Insurance,
' or a ce�ifiqd.copy theroof(Sec.3800,lab.C.)
. Pollcy No. ;A$(fgQ Compony FATSMnNP 7TLS_ COUNTY OF LOS ANGELES 6UILDING ANC SAFETY
� Certified copy+s hareby F�rr,�.had. FOR APPLICAN7 TO FILL IN BUI�DttvG �
❑ ADDRESS 2�6$� $� �r'$jilN$
� Certifiad topy is filed wifh ihe counfy 6uilding inspQo- BUIIDING a�i�.l g• ��8i ��� �.� �� g1765
, tion dapqr}menl. A�DRESS
Date =;'��;=�.`"`�Applicant � . . � CITY D=`�� �� ZIP 91765 �p�qLITY
:'CERTIFICATE OF EXEMPTION fROM WORKERS' SR.E OF lOT NO ON lOt � CNa055�57. ],}$R$jaj('s�.R LA�I$
���� '- . COMPENSATION�INSURANCE
. �(This settion need not 6e[ompleted if the permit is for one TRACT BtOCK LOT NO. �ESSOR �
hundred dollars(=100)or less.) �+P�� PAGE PANCFL
OWNER BYERMA��Z �B NO. ���� �ZONE 7� ' ' .r V
� 1 certify ihol in 1ha parformance of Ihe work for whith Ihis � - �� ��� " �'"�
.. parmit is issued,I ahall not employ ony person in any manner , �,: . , SPKiAL W
'so oa to become su6ject to the Worken'Compenwlion Lawa. A�DRESS 770 PINHYALLS - coNomavs "'�
cin. 86LDi0t nv 917$9 y,
Dofe ApPliGanf ARCNITERp� TEL. �
NOTICE TO APPIiCANT: If, cftor making�this Certificate of N INEER .Cl�� .TO��N NO. ��/�� DISTRICT GROUP IYPE fIRE PROCFSSED9Y
Ez�mption, you chould become su6jecr to the Workera' r ��T�I Z� ��� o�
Compansotioa prOvisions of the Lobor Code,you muet forfh- qppRE55 7�8 g• p���.� ��r � J Q;'
wllh comply wNh such provisions or this parmit �hall bv TEL. STATISTIUI CIASSIEICI.TION APT. CO �
dsemed revok�d. �ONiRaCTOR Np, ' �
�r`;;.
LICENSED CONTRACTORS DECIARATION ���, CAASS NO. - DWELL.UNITS
I her�by offlrm that I am liurwd undet provlslons of Chapter 9 ADDRESS �7� $. �x�� r,o. 21�33724
(wmmencing wirh Sxtion 700D)of Divieion 3 of rhs Businea and ��, ��p�P
Profeaions Code,and my licanea ia in fuii force and effaer. Cliv CW55 Z BK � VALIDATION
� SQ.FT. � NO.OF Np.OF CHECK
licensa Number 38572b i;�,�i,u 81 sae '� STORIES � i ies oNe
� �7 VALUAT�ON
, p� �• - ' �-f DESCRIPTIDN OF WORK N� qG �l ,_j:;.�,
Controctor Dme �••� { � � . -
�I am�xempt undar S�c. �i� ��� ADD LJ � r� �.�i.L::f
AITER � •,4,i,• i' -
i:. C tr
8.8P.C.for this nown i_. � 4 � REPAiR ❑ f .
- - Datr � .3 USE OF ,�,.,c..-��= DEMOL .t,+��.e.i.G i
� EXISTING BLOG. ❑ �
Sip�OtYr� � - APPLICANT ; ,'�..'" : _ 4 ,i TEl .' HNAL �,���,4.n�.J?!
�OWNER-BWLDER DECLARATION PRi�tT � NO.-- DAT� � � ..
. I h�nhy afNrm that I am���mpt fiom 1hs Conlractor i Lic�nu :' � „ �� _ _ _ . ,_.. - y,G,�,j„-',y;i�.
Law foi the followinq nason(Section 7031.5,6u�lnee�and p��R�� � � � FINAI
Profeolona Cod�): 8►
� � BUIL�ING
1, a�owner of Ihs property, or my amployees wifh A�DRE55
� wogs�a�their wls campenaatlon,will do the work and
th�struauro is not imendad or offered for wls(Seclion �aA��TY
7014,Busineea and Profaisions Code). MOVING TEI. `"��
' �� I,as Owner oF the property,am exclulively cOnirocting CONTRACTOR NO.
wlth Ifcenaed comracrors ro conatruct the p�oject(Sec- qODRE55 - �
tion 7044,6�sineu and Professions Coda). � f
WNSTRUCTION LENDING AGENCV SET BACK YARD HWY T�T'�'�OP.LINE WIDTH F"y'R�+�
I heroby affirm that�here is o conatruction�ending agency for FRONii , �'-�- �!�p���
tha perfnrmance of the wo�k for which�his permit is iasued P.t. 'T���.�'
. .,
(5ea 3097�Civ.C.). SIDE °' . .,.�� •.: .i•`,t..•...�•Lf
P.l -
Lender's Name
/., .' �r F LDMA Raf.M d.Ci:�/a,/.�;
m Lender's Address P.e cee f y( v�.ma ree
� I carlify Ihat I have read fhis applimtion ond state fhat the IuuancaFee IDMA P/C k , ����•�••�' �
above informotion is mrrect.I o9rae ro comply with all Counry i��es�� ��on Fee -
�$ ' ordieances and State lawa ielating�o building construction, � Torol Fee �'�����:�(, tDnnA 7nm.M �,��•�����
' and hareby puthorize eepresentatives wf this Coumy�o enter
� upon iheJoLiove-mgMioned property for iospetlion purPpyes._ � , ���'����"����+��.
^ .' �•; ... ..!!� E; � SBE iEVNSE FOR EYM,lWATORY IANGUAGE �� E '%1 f� `
,� Siynafwe of Applicani w Agen� � '.po�e . j t � '.. �
Y �