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HomeMy WebLinkAbout1094A WORKERS'COMVENSATION DECLARATION \ insure,borafc�ertitica�elofWorkerseCompensffonlnsuroncesolr � APPLIGAT6��N FOR BUiLDING PERMIT �' a cert�fied copy thereof(Sec.3so0,�ob.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY �cy No. Compony eUILDING Cerdfied coPy is hereby iurnished. FOR APPLICANT TO FILL IN A�DRE55 ��� � Cenified copy is filed wilh the toonfy building inspeo BUIIDING /� /J n �J_� n /� iiOn departmenf. ' ' . ADDRE55 / �� S. /C L /"�/(�(��J' /�GC. LOCALITY �.4�.�.-� t-L/�./� 9' / � NEAREST Date Applicant � ' CITV ZIP Y CROSS St. CERTIFICATE OF ExEMPTION FROM WORKFRS' - NO.OF BLDGS. , ASSESSOR COMPENSATION INSURANCE S�ZE OF LOT S ISO NOW ON LOT MAP BOOK PAGE PARCEL (This section need not 6e completed if the permit is fo�one USE ZONE NOP ��7 `f� hundred dollars(8100}or less.� TRAQ /J BLOCK LO7 NO. �'� � / iEL tL �/ �/ SPECIAL y� OWNER S/l(� �.�p,�T��IT �rT� CONDITIONS I certify thoi in the per4ormance of�he work for which this V permit is issued,i-shall nof employ any person in ony monner p l/1J DISTpIGT GROUP TVPE . FIRE 7ROCESSE�BY , so as to became subject to the Wo�kers'Compensorion Laws. /ODRE55 �s K B �✓{,r !�K, !O �� cONSL r 20NE O ��/� 0 zT Date Applican_ • a�^' GTY �� � Z�P ��7G SiA715i1CAL CLASSIFlCAiION APT. CONDO. V NOTICE TO APPUCANT: If, after moki this Certifimte ARCHITECS OR iei. q � Ezempfion, you should become 1u6jecf to iRe Worke ' ENGINEER NO. QA55 NO. �-i OWELL.UNITS__ N Compeasation prorisions of the tabor Cade,you must forth- qDDRE55� �� �� � �- - SEwER hWF Z with comply wilh such p�ovisions ot.this permit.shall 6e TE� � deemed revoked. CONreaCrat � NO. BK. PG, � YAUDATION LICENSED CONTRACTORS DECLARATION � IIC. I hereby offirm ihat I am licensed under provisians of Chop�er 9 ADDRESS �� �VALUATION (cammencing with Sedion 7000)af Division 3 of the Business ond � ���_ Profass�ons Code,and my license is in foll force and effed. CITY C1A55 s ���� SQ.FT. NO.OF NO.OF CHECK Litense Number Lia Clau SRE ��O U� STORIES FAMIUES ONE _! S Contractor Date ' DESCRIPTION OF WORK D G•��r NEW � � / G �/OL2cSP�� ADD � 1 am ezemp�from the liwnsing requirementz as I am a licensed archirect or a ragiftared protessional engineer AITER � FINAL � � octing in my profes�iona� copacify (Section 7051, REPAIR � DATE � Business and Professions Code�. USE OF � EX�STING BIDG. DEMOI � FIN L Lic.or Reg.No. Date APPLICANT TEL �d gr QWNER-BUIIDER DECIARATION PRINT) �E /� NO.07��Zq �1 0 9 4 A 1 here6y affirm tha�I am ezempt frord the Connactor's License aooRe55 T�S S. /!r ek ,�I V*r /c6(_, �" �� Law for the following reospn(SeClion 7031.5, Business and tt���►��� . Professioni Code):' PR �- -I, as owner of the propeny, or my employees with nooRE55 - � � �31.5 0 woges os�heir sole compensation,will do the work and LO�uTY •��TJ��J��c�i the siructure is no�in�ended or offered for sale(Sec�ion 7A44,Bosiness ond Prafessionz Code). MOVWG TEL. � I,as owner of the properfy,om exdusively mntracting CONTRA[TOR NO. �2 2 2�8,� wilh licensed mniractors to consirucf the project(Seo- qD�RESS � tion 7044,Bus�ness and Professions CodeJ. REOUIRED TO7AL SET9AIX FROM � EXIST. CONSTRUCTION LENDING AGENCY Sei BACK YARD HWY PROP.L!NE WI�7H . � I hereby a44�rm thar there is a mnstrocrion lending agency for . FeOrvT Ihe pedormance of the work for which this permit is issued P.�. � (Sec.3W7,Civ.C.)� SIDE - - v,i. Lender's Name ._ . . .. _. . . ,�} $ P.C.Fee$ Permii Fee ,f�� Lender's Address o//J I rerfify fhol I hove read lhis oppiication and siote that Ihe Issu ce fee /•JV Qabove information is correu.I agree to comply wilh pll CooMy Inrestigation Fee an /�) . ordinances and Staie lows rela�ing to building mnstruction, Toial Pee ,3�.�ryU � ond here6y authorize representotives of this County to enler m upon Ihe obo�e-mentioned properfy for inspecfion purposes. � X�,/, //((/YV L�J �2' L2- 8� SEE REVERSE FOR EXPIANATORY LANGUAGE ', �gnoi�re of Appl�cont e�� Dote , �� N .a s y� V� � 1. \ ���41 ��✓� T* � u. �� '^ O � O� 0� p v ��"�� a N 'O d g�„r'+,� y !. o ? � �k, .p, � � G r� ':t o� S�� m.�N.a�u � �'o o �� � m 3 �n u ���'~ C.3 r��o� �'L, '��� ' °�m»;� � � � +� O a.-.a.a `�'�, °`n"g' o..:��� °b' e N�y. 3 xy.u'�~�'�6� o '�f+ * '-es Z �O� Ai.�i .'iOld�"-+:�QV� � mmoTOMOINti'„� � � m �'f1 *' � � 9 ° °""s�3 '� �d� e '� cat—�� 3 .•7 m .. ^�s 3 � °� M�o�o�a'm o v Q m °�' �o'u m�N� ,� o �V ��s� � O O v '�3 oi 3 m � ���u G.� }��` C��'�^� ti. �'� � �O � w d v' N d Z'�� �" $ u�,c� °' N'�'n md o3 ds°o�� a ""`� ao� �c$3 °' � �s o �a.+� "''� E �n o�"s �.°r F a''i"� -nc, �,,�'a o o d c.* �� � � rd E� �����°�� x � � � o ° m �..°e d K �o � ���a�w � � a, o a'r, �.�;;,m St�d°m � o-°o 0 0 3 T°'' m L « x a �„- o a,N � s;c� m �.$' � o c-o V -a�� o'N s s o�s� m `�'� � � �d�� w �d«�� y`^ o-¢,� e �.a.� � ,c . p „ � � a a x mK W6 � m '-�� o+o+. �� a t � �.'�.°., m o� � m.°.1 �d N-°ac.-:a:« � ` ��3 � �� a o,z,¢.a o y x x�•S�. `� w G x C �.a cn k, [, .. � G ��° � •�,o; a� 3 d o � �'o � o �t, ° V " cy s.,`�t?t v� °' �a m ..-.+z,� $ .`�.m o,o 0 0 =t �•4 . � W p� � p v.a� �� m a c m o p �o.�S ° � v ��m o� � o �v�i� � mq � A o `� L �' s�.q � � �' �'.. � .. m p" o v�•:L .,��� $O o _L� � �:� K D d O .d�'2 'y . ..,^ � ,r�,� X � 6t y'Q'� �o� NQi.i�fi-rw � �t �� �p,II � ?O m 4.� t3�� ay�V 5�p+,E o a�, � „� �' .,,�,n x� c ° o � �,ro�'''o � 3 a� � =o »- ,. x E o c �,c W '" -n ,d,n,,a $��'3 Q . 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