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HomeMy WebLinkAbout1423A � � . I ' WORKERS'CC��MPENSATION DECIARATION µ � ��, � � I hereby affirm ihat I have a certificate of consenl to self APPLICATION F�R BU � � insure,or a ceni(icote of Workers'Compensation Insvrance, ���I� or a certified topy thereof(Sac.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � Golicy No. . Compcmy � ❑ Certified co is hereb f��oi.t;ad. FOR APPLICANT TO FILL IN euaou�� , pY Y ADDRE55 ZOBOG /CpCK jr PO/�T/�%V. . ❑ Certified copy is filod with the co�nty building inspec- BqppREu aOBO /?Oe�ry poin�T�N. � lion department. . Data Applicant aTv W/1WGr'TCPOSTi!{.) na 9/789 �,��rv W.4L�u7' I NO.OF 8LDG5. NFAREST I � CERTIFICATE OF EXFMPTION FROM WORKERS' � SiZE OF lOT NOW ON LO7 CROSS 5T. /P�49r�f'ees"A}�-- COMPENSATION INSl1ttANCE� i / �?-� ASSESSOR ! '7 (This section need n01 be complBfed if the parmit is for One TRACT 37(7 BLOCK LOT NO.�/ - �y�p,p gpp� �Qp pq� �z� PARCEL � hundred dollars($1W)or less.) TEL Ti¢ O owNea�AzUY[!Kf /SN/.//�vIA NO. 2 �EZOI`ff �M1AP I certify that in the performance of the work for which fhis r � �� parmi!ia iasued.I shall not ampby.ony pereon in any manner AD�RE55 2O8O�m /�C�' pQfj{/'T LN� SPECIAI � } CONDITIONS d so as to becoma su6ject to the Workera Compensation iaws. O � C4TY WA'�I{�(/T ZIP ��78y . . . V Data Appliconl . pRGH1TECf OR TEL DISTRICi GRWP NPE FIRE VRpCF$$Ep BY � NOTICE TO APP�ICANT: If, afrer making this Certifimte of ENGINEER NO. �Q�T ZONE �r Exemption, you shauld bewme subjed to the Workeri � 2 �� c� �Compansation provisicns of the lo6or Code,�you must forth- ADDRE55 � � �� �++ with comply with such provisions�w thia permi# shall be tE�. STATISTiCAI CL4551fICAT10N qpT. GON00. N cleemed revoked. CONTRACTOR NO, - Z LICENSED CONTRACTOR$DEUARATIQN . �C [3A55 NO. � DWFi1.UNiTS I hereby affirm thm t am ticensed undw prOvisions of Ghayter 4 AO�RE55 NO. (commencing with Sectipn 70pQ)of Division 3 of the Busineu LIC. 3EWER MAP and Profassions Coda,and my licensg is in full fqce and.effett CIIY Cu55 gK � VpLIDAT{ON SQ.Ff NO.OF NO.OF ' COH EK License Num6er �ic.Clau - --� �� � STORIES FAMIUES � DESCRIPf10N OF WORK � N�, � VUVATIpN co�f�a�,o� oo,a : �! n a - ❑I am exempt under Sec /'fbA'77�/V OF dN�RCO!✓f �� � � CFAM�L j� RO�M ALTER ❑ z�� D Z�A � B.&P.C.for this reason REpA1R❑ ; Dme: use oF fiiilaG6 F+RNI/t EXISTING eL�G. Y�YBLLJ�Nf� D�p�Q ����i�t i SignaWre APPLICqNT h T/ � ._.. OWNER-BUILDER DECLAR.4TION (PRINT)�/1Z4yU.r% /,r/,Nk n� _ ��� p�� ,� �L I���9 3.�O I here6 affirm thot I am exem t from the Conrracror's license =� v P AODRE55�OBOG �Qpc(�y��.N, a�fr�iVu7• ��n��J� r •'9 3 0 0� law for fhe fo4lowing reason(Secrion 703}.5, Business and N � Professions Code): . . . . . . . PRESENT By � �Q,,� Q—$9 � 1, as owner of iha proparty, or my empbyees with p�p�E�S Nl wages as their sole compenaation,will do Ihe work ard i�iiry � rhe strudure is not intended a offered for sale($ection � r 7044,Business and Wofenions Code.} MOVING iEt. ' - f ❑ I,as owner�of the property,am axclusively controcfing COMRACTOR NO. . � with IitBnsed[OMmtlOf!10�tOneirod fhe projett(SeC- ADDRE55 � � � � tion 7044,Bualness and Professions Code.) CONSTRUCTION LENDING AGENCY - SET BAEK - �ARD -HWY TOTAISETPAAC1cEF� WID7H � I herehy affirm�hat there is a construction lending agency for FRONT � ihe parformanca of 1he work far which thia permi}is issued P.l. . (Sec.3097,Civ.C.j. SIDE � - P.l. lender's Nome � . . .. . 4.... IDMA Ret.R P.C.Fee S Permil Fee i � lender's Address � I cartify thot I bove read this applicalion and stafe fhat fhe � Issuonm Fee LDMA PiC M gabova informatian is correct.I agree ro comply with all County Invesngarion Pee . •�,/� , � ordinances and State laws relating to building construction, � romi Fee � (! LDma Perm.N � ond hereby authorize representatives of this County fo onter . upon the a6ove-ment/ioned/property for inspe[tion purp es. � ���,�—.(i-��f�, ¢ �� B SEE REVERSE FOR EXR/1NATORY IANGUAGE , Sig�nc�l re o��anf or Agenr Data .. � 'y � � . o m � �boa�N .o . -0'�o °o dmo c5 ci �m� o'�__ o9Q ����UQ a � 'G s"y m� 'ti C�3 7,y c O S °� G . �..=:�;i�7�m�� mnv.5da'� a�v oi$� v. m 3 N s �- o A �xh. .=m . �'a p �'i � O W y �u c���o��,x ,c�� .�c.�v 03 m`� v"'inU w�� O rr.�am °t�NH p��° N.�?rxm �m�. 7ooc�1O� Z N�!'1,t�W.�E U ✓' � m� .N.O 6• C`v >' ��„'a N= �+ V C �.,C� � � ..OtLOQ.�..Y_.maT�-Cm L`.~U'C� � N �Oin Oq ' . %p; Emm 3 �.'', o:pw- 4''.�W acmm-~3�n Twm�p�m e.�''on � � �S~ �d O�D O c 0" ,�.. o'�O 6'OG c � �7 ti o aGc 07 E 'G p._ K5 L qy � . ., �� mO0/ WWCG�C� dy� ��w � ¢ tn't ��^ V� Cy� N � �' . . o � o m � m �$m � m'� o �a�a m �, _ 'o m N V m W.... r"�� O"as LS'i. 7 N,> C Zv-!--L.$�r..y �m c,c,voi.°r'FL-- � ��� 4im¢ Lwo 7 Z p�� YEm ��oc�o�=�:° mc o ,�.a�n �°n�T"` Q-C"'� "'o r�� w.T ���v =� � � � ��o �o � o�� p c o� � ��.;N � Q O m C 0� tf �^�m ,�'�3 Q Gpy"� C�_.. 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