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HomeMy WebLinkAbout1610A (17) f � ' eeettt WORNERS'COMPENSATION DECLARATION � � I hereby affirm Ihat I have a certificote of consent to self .. , . insure,or a terlifiCate of Workers'Compenstion Insurance,or APPL�CATIOi�1�-FOR �B!lILDING �PERMIT a certified mpy thereof(Sec.3800,tab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Pol�cy No. Company - � Certified copy in here6y furnished. � --� FOR APPLICANT TO FILL IN ADDRE55 0 �0�'� �/� � Certified copy is filed with the county buildin9 inspec- BUILDING �^ Q�j fion departmeM.� ADDRE55 �(�f LOCALITY '"�[��^^' dll�i.f' NEAREST V�j�,��.��fi�� ��� Date �Applimnt Ciiv Z�a —i� Ip7 CRO55 ST, � CERTIFICATE OF EXEMPTION PROM WORKERS' � NO.OF eLDGS. �j ASSESSOR Q�8(, PnGE O Z pqRCEL � � COMPENSATION INSURANCE SIZE OF t07 K NOW ON LOT � On�/ /r�qP BOOK v �This section need not be compfeted if the permit is for one USE ZONE MAP � _ hundred dollars(Si W)or less.� TRAQ e�ocK ioT No. �� No. •Z 3�'� } 7EL o �.l' SPECIAL a OWNER � ,.7� �� �J�W CUNDITIONS I certify that i the performonce-of the work for which ihis � � �ISTRIC7 GROUP TYPE FIRE PROCESSED BY -permil is issued,I shall nol employ any person in any mannei V AODRE55 .f�C�cT� �E �[ S���G Q so as to betome subietl lo ihe Wohers'Compensation laws. O f� � td . . . ,;.. . ..._ ._.._. . �f ..i� /� Date Applicant � . CITY � ZIP StAT15TKAtttAS5ff1CAfN3N..- . .APi. �CON00.� - (~j � ARCHITELT�R ��TEL. �NOTICE TO APPUCANT:�If, after moking-this Cerfifimte of - g'�� � � .U"Q � � �� W Exemption,� you should become suhjeci to the Workers' ENGWEER NO. CtA55N0. OWELLUNtTS 6. Compensation provitions of the La6or Code,you muat forth- qoDRESS Z?��� � ��r,j' �� � � �� -� N wifh comply wifh such provisions vr.this�permif shall be �` SEWER MAP � i deemed ravoked. .. ,.. , - - CONTRACTOR (� , -- p�p. - BK. V PG, __ YAIIDATION I � L�CENSED�CONiRAGTOR5�DECtRRAi10N�� � � � � - �- ���. � � I hereby affirm that I am licensed under provisiom of Cbap�er 9 ADQRE55 NO. yqLUAT10N � i (cammencing with Section 7p00)of Division 3 ofi�he Business and i�C. A ' Profeuions Code,and my license is in fult force and effect. �. CiTv - � -� - Cu�.SS ��- T � V�.� - � , � � ' SO.FT. NO.OF � NO.OF CHEIX. liCenSe Number Lic.Closs SIZE 2 STORIES � ' FAMILIES ONE - � � �ESCRIPTION OF WORK �{ N� ❑ $ � Confra[for � � Date � � 1 am exempf 6om ihe licensing requirements as I.om a � �� � � � licensed architect or a reqistered professianal engineer . : .... . �.... . . . AUER � ��N���� � � �� ' ���-��- � I otling in my prafesaional�capatify (Section 7051, - REPAIR � DATE I� y �i Business and Professions Code). USE Oc �� �Ma � FINAL - EXISTING BIDG. 8 Lit.Or Rgg.N0. DatC � APPLICANT,`' TEt. �p Y OWNER-BUIL�ER�ECLARAiiON� � � PRiNi W NO. 5{ "' � I hareby offirm thaf I am exempt from the Confractar's Licanse � Low for the following reoson(Section 7031.5,Business end AD�RE55 �� �� �Pro 9:�0�$coda�: �t b'1,0 A auaoirvc I, as owner of the properfy, or my amployeas wilh ADDRESS wages as their sole compensotion,will do tha work ond �� �.�• •,� � thestructure isnot intended or offered for sate(Section ���A��TY � ��� •3 Z 50 7044,8usiness and Professions Coda). nnOVING 7EL � . � - CONTRACTOR NO. - � I,os owner of ihe propeny,am extlusively contracting • � •3�Z 5 0� wifh licensed controctors to consiruct the project(Sec- qD�RESS Q 2,2 2��8 z tion 704A,Business and Professions Code). . REQUIRE� TOTAL SETBACK fROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK_ �AR� HWY� PROP.UNE WIDTH 1 hereby affirm that there is a consrruuion lending agency 4or FRON7 the performance of ihe work for which this permit is issued p.�. ($ec.3097,Civ.C.�. . ' . SIDE .. P.L. Lender's Name Q _. . � $ Lender's Address P.0 Fee S Permi�Fee �/ • �0 � I certify that I have read this opplimtion and state Ihat the Issu ceFee i�� � � above information is correct.I agree to comply wilh all County Investigo�ion Fee �J 0 ordinances and Sate laws relaNng�o building ronstruciion, an s0 ond hereby authorize represenfotives of this Co�nty ta enter Totol Fee J�� q upan�he above-menlioned property for inspection purposes. � SEEREVERSEFOREXPIANATORYLANGUAGE � Siqnalure of Applicont or Agenr Da1e �� N C wQ A i VI ,rQ t� N aD d O 6 d .�ys �� O `�" . 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