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HomeMy WebLinkAbout1053 (9) � '�"� WORKERS'COMPENSATION DECLARATION � � insurebor�afcert'ifca,teofWokesr'Comtpensotionlnsora e" APPLICATION FOR BUILDING PERMiT a�o cariitied copy rhereo4(Sec.38W,�ab.C.� COUNTY OF lOS ANGELES BUILDING AND SAPETY Pacy Np, Company BUItOING T' n � Cenified copy is hsreby furnished. FOR APPLICANT TO FILL IN qppR65S � � � 2� f � Certified copy is filed wi�h the couny building inspec- D RESS 0 V�fl !'� � „"' ' _ �ion deparlment. C �y ApPlicont� CITV V ZIV ���J �.p�ITY q,.��rn_9-rw CERTIPICATE OF E%EMPTION FROM WORKERS' NO.Of B�OGS. NEAREST , COMPENSATION�NSURANCE sie oF iOt raOW Orr LOT CRO55 ST. (This SBcHon neYd not be completed if the pBrmit i!iq one TR� ?�BLOCK LOT NO, � µqp BOqC PAGE PARCEL hundred do�lnr:45100}or{ea.) /� 7E1. Q .l � pWNER Y"• NO.- ! � �� lISE ZONE � f D�J 1 cerlify Iha1-in Ihe performante of tha wwk for whicfi thia .��' � ermif is iaaued,I shall no�em lo on enon in an manner y r� ���A� - P P y Y P y nooaess b(C� U O � CONDITIONS so m to b�o wbject m ths W ri Com nw�ion lowa. � V�f arr z�P �1e N�� i4PP���°�� qRCHI7E DISTRIR GROUF TYVE FIRE D BY O� � NOTICE TO APPIICRNT: If, aNer making thks Certificate of ENGINEER TEL � Ecemption, you sho�ld become eubjed to the Workeri N� "S. t-j_� ��� � V , Compensalion provision�of ihe lobor Code,you muat foHh- qpppE� O� li,. d�- '. wlth tompFy with such provisions o� thii psrmil shcll ba TEL .t ! STATISTICAt MSS�FICATION APT.� CONDO. N '�, deemed rovokad. � � CONTRACTOR �� NO.�'7 7 . � ! Z ��. IICENSED CONTRACiORS OECtARATION ��t_- C�fj-, Cllss HO�—i—DwEtL UNITS__ � i t fiereby oft'um thot I am ticanwd under provisior��of Ctapter 9 AWRE55 21i�i(� Yl�'� �. 3 7�T� �R� _ . ... I (commencing wilh Saction 7000)of Diviaion 3 of the Buainess and � .LC..- - �- � � - � Professions Code,and my licensa is in full forca ond effect. CI7Y ✓ C1.455 e� f� � � VALIDATION �j SI p1_Z./ (�,�(a so.cr. Z No.oF ra.of cr�cK I litense Number �` l .Closs� SIZE STORIES FAMIlIES ONE �( �? -v�u�no++ _.___ _ i Wv��(�� � _ ConMa[tor � " �"ti�" e 0 DESGFtIPTIOrI OF WORK ��... S I��U_ L. /��O Aoo y �1 am ex�mpf undw Sec. /f q�TER � � r������� 8.8P.C.ior rhis reaaon �`�� 0.EPAIR � s us�oc Oote: EXISTING BLW. ��� �^^� �as3 Siqnorure � .. � � FINAL ��� r��. ` OWNER-BUILDER DECIARATION �PUN . A���� �EL,,���� ���- � DATE 1 hare6y offirm Ihat I am ozampt from the Conhactor's Liunss AooaE55 �L�� N'K' �/�IKW� • t�� FlNAL �� �� law for the toliowing mnson(Section 703t.5,Boeineas and � �� / Profeesiom Code): .. . . .. . ... . . . . �.....� ..• 3(r.�'S � BUILDING I, as owner of the property. or my employees with ADDRESS wages os their sole compenantion,will do the work and � �Q"��� Me shottore is noi Intended o�offarod fo�wle{Secfion ��`��� . 76/1,Business ond Aofeszions Code). MOVING iEl. � I,as owner of the propeny,am eaclusively cont.ocf�ng C NTRACTOR N�� � with Itcenaed cootraclas to consiruct fhe projecr(Seo- � qDDRE55 � tion 70�4,Buainess ond Professions Code). CONSYRUCTION IFNDING AGENCY SET�BACK ��kD HWY T T���NE WIDTH l hereby affirm�ho�there is a cnnakuction Iending agency for cRONT ihe performance of Ihe work for which this permit is issued P.L. (Sec.3097.Civ.C.). SIDE P.L. Lender's Namo � IDMA Ref.� � Lender'a Address P.C.Fee S Pormi�Fee � $ I cerfify that I have read Ihis opplitatio�and state Iha�fhe Issuonce Fee � ��+P��y � o6ove informa�ion is corract I ogree to comply wi�h oll CountY investiqation Feo / —7 q ordinanms and Stote laws relminp to buildinp conurottion. To�al Fee 2Co �/ �DMa v.�+.Y and here6y outhorize ropresenroiives ot rhis Count to/ente� � n obove-m^entioned p�spection urposas. ��1J ' fE!REVFMfE fOY iXMANATORY LANGUAGE Sigrwture d Applicant or Agent Dala '^'^ :^.,` c: ' c. - �c; "" �,.. w c� m w � .� - y _ . p_ .� i �,R u r`.��� � = c � � ^ r�t�C u � y.��` , M -: v i�'` '= `�r, � .3 00 i"'`•.. . ` ..t:. � v�i « � .�, ~ + . . �� Z''i- L p`�' ��M 'y '� ,Y�".�. �C �-C.y..k : �' 'c '. � � i O O . . ~ �`� ,. G� 4� r .. y.t C O ` 1 . .. c ''• c, i �� ..v e o �; , ..k a ii . �; i�`� . . 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