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HomeMy WebLinkAbout0957A (7) � WORKERS'COMPENSATION DECLARATION ^ � 1 hereby affirm that I have a certificate oF tonsent to self qpp��CATION FOR BUILDING PERMIT � insure,or o certificaie of Workers'Compensation Insuronce, or n cartified copy thereof(Sec.3800,I.a6.C.� COUNTY OF lOS ANGELES BUILDING AND SAFETY PolicyNo. Compony � Cor;ifiod cOpy�a hereby furnished. FOR APPlICANT TO Flll IN BUILOING � noo�ss 0�'['i !3 rt.� � Certified copy is filed with the county building insper g���p�� tion deportment. ADDRESS p �/ N ! oAD Data ApplicoN � CITY O/ M ZIP f �(� ` �('j,/�. . IOUtITV CERTIFICATE OF EXEMPTION FROM WORKERY � NO.OF BLDGS. NEAREST COMPENSATION INSURANCE� StZE OF LOT NOW Onl L � CRO55 ST. (Thii section need not be comple�ed if the permit la for one ASSESSpg hundred dollan(5100)or less.) TRACi BIOCK LOT NO. Mqp gpq� p,qGE PARCEI TEL. �T � I cartify that in the performance of Ihe work for which this ��E * ' 'v � �P��'�� 2� ryp' . permit is Issued,1 sholl not emplo ony penon in ny manner qDDRE55 09 ,t .r SPECIAi �� so os to b om �ubjetl to the u ke ' fion Lawa, - CprypRipHS 0 �� / CIIY / ZIP /%�� V Dafe - Appliwnf ARCNITECf ON TEL. �7.' NOTICE O A PLICANT: If, pfter oking this Certificole Of N INEER p�p DISTRICT GROUP TYpE FIRE PROCESSED BY p Exompfion, you should becom�subjed to�the Workers' CONS� ZONE F- Compenwfion provisions of tho Cod�,you muU fonh- � �U wRb comply wHh euch proviaions a thii prrmit �FwH be ���� daemad revpked. � � �NT��� � STATIS ICAL CLAS$IFICA110N qpf. CpNpp. Z IICENSED CONTRACTORS DECLARATION uC. M55 NO• DWELL.UNITS I hareby affirm�hal�am licanxd undar proviaiom aF Chop�er 9 A�DRESS r.p, � (rommancing with Sactlon 7000j of Division 3 of tVq Bualneµond ��G � SEWER MAP Professions Codv,and my Ilcense ie in full fate and effect. C�iv CLA55 YALIDATION SO.FT. NO.OF NO.OF CMECK BK. PG. ���n license Number tla Cla:. SIZE STORIES FAMILIES � ONE z U Y.��A YAlUAT10N co��.a�ro� o,�o DESCRIPIION OF WORK r+�w ❑ s �9 0 0 �• •• •2 3 �I om eaempt under Sx. � Q , � • •�2 9 4 ALTER B.BP.C.for this rw�on R��R Q S • • •3�,q�1� oofa: us�oF EXiSTIhIG BL�G. ^�, r e.�, �t ❑ p y,2�—g'7 Siqnatun '�'P�I�T �L. FINAI � OWNER-BUILOER DECIARATION ��NT � + N .9/ Id/•/663 � : p,dTE � I hereby affirm Ihat I am ezampt from Ih�Conhxtor's liten3e � - � , law for Ihe following reoson(Section 7031.5,Bualness end ADDRESS,Z09�f�r�,tW/ . _ C�. �/Ip HNAL �' Pro(eteiont Code)� p By � � I, as owner of tho rp pr or m em lo ees with BUiLDING P P �Y� Y P Y ADDRE55 waqe3 aa ihair aole compensafion,will do the work and � Ihe structure i�not intended or offerad for wie(Section �aA��TY � 7044,Business and Professions Code). MOVING TEi. � 1,as owner of the proparty,am exclusively contracting ��TRACTOR NO. � with licensed controctors to construct the project(Sec- qDDRE55 �� tian 7044,Business and Professions Code�. �� CONSTRUCTION LENDING AGENCY g�gqCK YnRD HWY T�ApROP��NE WIDTH �i1 � I here6y affirm�hat�here is a construction lending agency for FRONT 1��� the per(ormonce of Ihe work for which this permit n issued p.�, ($et.3097,Civ.C.). SIDE P.L. Lander's Nome LDMA Ref.tl m Landar'a Addresa P.C.Fea S .2. aermi�Pee � � I certify that 1 have read this application and state that the . Iss�a�ce Fee IDMA viC M obove information is coirect.I agree to comply with all County Inre»�go��on Fse � ordinances and Staie laws rslating to building constructlon, ioral Fee & d hereby authoriz representativea of�his Coun�y to enter ���m�* Z u on e o 4me io�ed r perry for iny�ction p� � , � / SEE REVFNSf FOR EXRJINATORY LANGUA6i Siqnatvre of Applimnt ar ApeM ro _ _ � . ` � y � .. _ � i .i ,:. �, � � � � � = :� a �� ; �.� � � ��^: �- i , .. ' c-- ` _ � : � 3 � o'c'� �'-h y � 4 �: ;n L � . y " : '� " y ti.�' y n Q� '�� � `�+^�,� v C �; v ti r� ` � �� � : ' 'r C � � V`�.. `.' y�: 7P ^ �;�. _ y� � �,a ^ 4 l`.,w V . � : rr .'. t-~ l =.' f, •, �, T J• ~ . � 3. v �. _ : � C^+.i � p� � 1 �II v Y _ �� � � � �..; .. � ..Z �y� ^ - � C.i: y m . � � . F. . i ,� � � r c � L;�-. �a y � '� ,-;, •. .. '� ti ` � � ; I ,? 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