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HomeMy WebLinkAbout1228A 9552A / WORKERS'COMPENSATION DECLARATION � �J � � 1 hereby offirm-t6at I,hove a«.,,�,�o,e of�o�,B�,,o,e�f qpp��CAT14N FOR BUILDING PERMIT msure,or a cerlificale ol Workers'Compensotion In ront :,� or a cenifiad copy rhereof(Sec 3800, tOUNTY OF LOS ANGELES BUILDING AND SAFf7Y Volicy No. Company � Cenified copy�s hereby fornish FOR APPUCANT T�FILL fN BUILDING • � Certifiad copy is Tiled�w'h f n �rr��ir}�c g � j ADDRFSS a a,�s �. tion depanmant. �[�i 9 ,... E „� Z-Z C � /2 DaH. . _.... . I' .�. ��O��� CITY � l4{� is 1 r� � 'Q ZIP LOGUTY CERTIFICATE OF E%EMPTION FROM WORKERS' SIZE OF LOT �'���''S' NEAREST COMPENSATION INSURANCE C NOw ON LO7 � CROSS ST. (Thi��sc�ion n�od not b�comploqd if the psrmif if for ane tRA� � 7g g�aK lOT NO. ��R hund��d d011an�SI00)o�IBfl.) .. . NNP BOOK � PAGE 7ARCEL I c�Nlfy thoi in�he performence of the work for which thie �ER � �i��" '7 ��,y oy- �/��� p�p, �Da�3� permit ie is�ued,1 sholl nor amploy any pe�son in ony monner qDDRE55.� � l� Q J 1� � ��� �µ � •o os to becoms�ubjen fo ths W om n�on lawa. CpNDI710N5 ��Dote��Applicont CITY • ' � fJ� ZIP � (/ U NOTICE i0 APP(ICqNi: If, oh mCkln �thi�GrtifiCole of ARCHITECTO (� T ./ Q.' fl N INEER � ANy � p �STR�R G&OUP OP�T zRE PiiOCP$SW 6y Q Exrmption, you �hould becoin� wb�ect to the WaVwn' �� !D �� � U tompo�scllon provisiona of�ho Labor Cods,yov must forth• qppR�S 00 O� �� i wlih comply with euch proviaions or this po�mit �ha14 60 . �� � - � . ..-..... .... .-... .. ..... .h���� ..��y SfAT15fiCAl CIASSiFICATION dromad reroked. �pNTRAnOrs � �. 00. y IICENSED CONTRACTORS DEUARATION.. 6N�� , ��'� _ Q�. � Z 1 Aora6y affirm�hae I am lieenaed undar provitions ot Chepfor 9 �D�RESS ,-r fNp� a��� ��«�UNiTS (commencing wirh S�pfon 7000)of Divn�on 3 0l�he Buunwt ond . �D .^ � ��C. SEWER MAv Rofeanions Code,ond my ficsnae is in full face ond effect. Cii cu55 YAl10AT10N 50. NO.OF NO.OF CHECK �' �'. LiconN Number � L�io.Glacs SIZE �7 STOkIES � FAMIUES ONE CAntro[to� �ESCRIPTION OF WORK w C Jx/Vt NEW VALUATION z 1 2 2&A oo�a /c s 2&'S on7 � ❑I am exempt under Sec fp 7.3 �� ❑ � #• • • •L 3 AITER ❑ I •�2 4 3 8 . B.B P.C.for t hi3 roown RFPAIR � : USE OF ❑ �C 4�;�O u ��8� EXISTING BLW. DEMOL �� Siqnaluro APPLKANT ` • 7E1q. �a�G_�$ OWNER-BUILAER�ECIARATION PR�NT p�p,/� � FINAI. I hereby affirm thot I am exempl from the Contractar's iicense DALF� 2 �d Law fu�he foUowi�g reasan(Set�ion 703L5,Businau aod ADORE55��1(I �. O��A�� !{ C v. Professions Code): �� � � �.� (, as owner of tha a � BU401NG � p� pe fy, or my employeea wifM ADDRE55 wagas as thai�wle compansation,will do the wo�k and � z 9��2 A ihe strocture is not intended or oflered for wle(Section ����T�' 7044,Business ond Rofessions Code). MOViNG TEL. � 1,os owner of the property,om eaclusively contwcting CONTkAROR Np, �r r � � � �� wi�h licensed contraotors ro construct the project(Sec qooResS iion 7004,Business and Professions Code). � 2� �9��� RE(]UIRED TAi TBAC CONSTRUCTION LENDING AGENCV SE7 BACK YARD HWY pROP.UNE WIDTH � � � � ���i,.�� I here6y offirm Ihot there ia n construction lending ogency for iRONT the performonce of�ba work for which Ihis parmii is issued p.i. ��O,�`�9 (Sec.3097.Civ.C.). SIDE P.L. Lendar's Name 'J O�•1 D LDMA Ret.k m Lender's Addresa P.C.Fea S �Z �ermi�Fee •L 0 V � 0 `��] I tenify thaf 1 have reod this application and atole thot the Ig �0. � iaaua�c�Fee �r �' V DMA P/C M o above informa�ion is correct.I agree to comply with all County ��„�i;��ion Px S ordirwnces and Sio�e lowa�elotiny Io building construclion, Taiol fae � o ori representatives of this Counry�o enter � •3 d �DMA Verm.Y �j s � uPon fha abo n�ion proper for ins - n purposes. � �,, ��/} � � � � ... 4" `. �/�I �J LFi RlVfi�fi fOR EX►LANATORY IANGU `�� (I . V nmu.�o pplic or Ag�nr po�e `��� . v s v� .4,� � ' - f �;p c.;' i � c� s �� � . 4=l , w � i fi � G y.�� '+, c �n .. X�..� t d � v'r, . � o_ c ..,-.�- � �o +c '�`•. � «� owy ^ ,, � i:r� '�-•� : !�: �H �,v, t. ,,, v � ., a� -�n. � . . '% � ` S v ^ � � SO '� �w�C. �.��C'�:.� y c V C O •Cj� ^' R-� " F`� � l ~f`� ~` >, 3 N'N�l �'�''1�" y T S' L' J�'�C ��� U l., iJ � x �.� ` ��,i .` a 4 � v -' � ,,�- � -•. E C) � � �'v� d cL � v J, � s a " . 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