HomeMy WebLinkAbout1222A 1223A (9) � . . N/f)RKERS'COMPENSATION DECLARATION � � ^ � I yere6y affirm thot I hova o certificate ot consenl to.a�� qpp��CAT10N F�tt BUILDING PERMIT � 1 ipsure,o�a ceniticote of Workers'Compensation Insurance, or o certified capy�haraof(Sec.3800,lab.C.) [�UNTY OF LOS ANGELES BUILDING AND SAFETY Polity No. Comppny � Certified capy is hereby fum�shed. FOR APPLICANT TO FILL IN ������ f ' ADDRE55 Z ZZ/p /n+ 1 R� � Cenified copy ia filed with tha county building inapec- BUILDING "� liondepartmenf. . ADDRESS �z2/� 1 J� j � D���y/„ (� �ryM1 Dale Applicant CIiY y�14'M�N(,� /,�� ZIP LOCALITY ���++0� �� CERTIFICAiE OF EXEMPTION FROM WORKERS' NO.OF e�oGS. NfqREST COMPENSATION INSURANCE SiZE OF LOT (�� NOW ON toi CRO55 5T. �i,p��r gQ /Vl� (ihis section nead not be completed if the permit is fw one T�� � BLOCK lOT NO. ��R hundred dollors(S10p)pr less.) � MAP B001C PAGE PARCEL TEL U ONE hV•F I certify that in the performance of fhe work for which this ON�NER �I � . Np, ryp � 3 permit is isaued,I shall nof employ ony penon in any manner qDDRE55 S Ma.��' L'7 �—1 ���A� �' w as to become subjM to the Worksri CompensWion tows. �0 CONDI710N5 3 6 Z, � �Da�e���+ Apptimnt CITY ZIP 9/7 8� V NOTICE TO APPLICANT: If, uhar making thie ertificote pf ARCHITECT OR TE�� pO DISTRICT GROUP TypE FIRE VROCESSED BY � ENG�NEER �UI ,Pj NO.S// '�� � Exemption, you should becomo subjecl to the Wwken' . �1 COr1Si. ZON GOmpananlion provisions of the labor Code,you muaf forlh- qDDRE55 /� J W wi�h comply wi�h such provisions or Ihis parmit sholl ba � TE� �- deemed revoked. . �pryT�p,�{p� / NO. STA7ISTICAt CLASSI�ON qpr. CpNpp. Z LICENSEDCONTRAGTORSDECIARATION �K_ QASSNO. DWELL.UWtS I hereby offirm thot 1 am licensed under provisions of Chapter 9 ADDRE55 � NO. (commencing witM Saction 7000)of Division 3 of�he 8usinass ard ��� SEWER AAAP � Professions Code,and my I�canse is in full force a�d effxi. C�iv CL455 � VAi1DATION SQ.FT. NO.OF IVO.�F CHECK 8K. PG. License N�m6er Lic.Class 512E �U6 STORIES '� FAMILIES ONE Q VALUATION � Ganhactor Date DESCRIFt10N OF WaiK NEW i�d O U O� z� 2 2,L A ADD ❑I am exempt u�der Sec. ��r � � �+� Y� AIiER � -: #• • • �,%3 B.BP.C.for thia reawn ,n•��� V�� REPAIR � f • ,� �,7.�� Data: EXISTING BIDG. �� ❑ i Signoture A���i TEL. FINAL •• j 6�i.f''�� � OWNER-BU4CDER DECLARATION PR�NT �' DATE �� � 1 hereby affirm that I am exempt from the C.ontractor i License � G u G y—C G Low for ihe following reason(Setlion 7031.5, B�siness ond A�DRE55 FINAI Proieeaione Code): .. . gy � � BUILDING I, as owner of the property, ar my employees with qppitE55 „L7� ' woges as fheir sole compenwtion,wlll de the work and [ 1hp slrutlu�e is not intended or olfered for sale(Sacfion ����TY 7W4,Businesa and Vratexions Code�. MOViNG 7EL. �' ♦ �� 2 1.J,ti � I,as ownar of Ihe praperly,om exclusively conhacting CONTRACiOR Np. � y,.,�.ry #• . . s . 1 � U�x,_._ with licen�ed to�tractors to construc�tFe p�ojett(Sec- qDDRESS tion 7004,8usiness and Professions Code). RE�UIRED TqL SEiBAIX � °L G a V O CONSTRUCTION LENUING AGENCY �7 gq� YARD HWY pRpp,�INE WIDTFI I hereby offirm thot ihere is o construction lending ogency for pg�T • •C G C����C'� �he performance of the work for which this permit is issued p.i. (Set.3097,Civ.C.)• SIDE 0&2 9—8 8 Lender's Name /✓O✓�^ P.l. L�hAA Ref.� m Lander i Add�ass P.0 For S •� ve�m��c� i� � � 1 certify that 1 Iwve read thia applimtion and state Ihat ihe Issuanco Fae a� WAAA P/C N above infortnotion is correct.1 agree to comply with oll Counly Invaitipanon fes �`�� 'q ordinances and Stole laws relating to buildinfl construclion, To�al Fee O LDMA verm.N R and here6y authorize repreaentativec of ihis Counfy to enter � �po�the obove-mentioned property for I�spettion p�rposea. m —29—�jg Sifi RfVFRfE FOq EX►LANATOItY LANGUAGE $ignCNr �Applicant or Aq�n7 p�e "'��n ,. . i, .. « t. ` �` u m � . . �. ^„C c, � . ^L M!'�ti. � C [� C y-S: �^ _ C. � � .�; _ �`f,',\ U L t`� +� .� _ � c J i '� ? _n « � � �,�; a `-'n � �. a. o� � %i O ~ e_y ' :; � 7."�. ' y. S •C. . �+ � � � � `r w � . :. t� _" � c ,"r, '+ " `�M ..Y. C -' �.i .r r 4.G C V � � . � `�- r. � .� `ti��^ ... �a, c o ,. 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