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HomeMy WebLinkAbout1059A 3728A 3729A (7) WORKERS'COMPENSAiION DECLARATION • � .� � . �- I hereby��firm that I have a cerlificata of�o�,e�„o,e�f � - APPLICATION��FOR �BUI�LDING PERMIT 'i^ture,oi,�certifiwfe of Workers'Compensation Insurance, or a cert�ffed copy thereof(Sec.3800,lab.C.) COUNTY OF l05 ANGELES_. _ . �BUILDING AND SAFETY P❑o1lcyNo. Company eUiIDiNG • Certiiied copy is hereby furnished. i FOR APPLICANT TO FILL IN nooeess �.��� ��R � Certified copy is fi�ed wilh the tounfy buflding Inspec- BUILDING �/1 lion deparlment. ADDRESS �-t - IOCALITV C NEAREST Data Applimnl Cltt ZI7 CROSS ST. - � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF eL�GS. ASSESSOR � . ' COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP 800K PAGE PARCEI , (This section need not be comp�eled if the permit is(or one ^� u{5��ZONE �P ` �� TRACT3�� BIOCK LOTNO. .J.� �"�� SPECtAL ` hundred dollars(5100)or less.) . . h cy y � I I cerli that in the erformance of 1he work(or which this , OWNER I � - O �..�� CONDITIONS 1 fY P DI 7RICT GROUP TYPE FIkE� PROCESSED BY � � permit is issued,I sha�l not employ any person in any,manner ' -� CONST. Zpn�l� y �i i A�DRESS lJ � so as to become subject�o the Wo�kers' ampensation ows. , 1 �O '."7 3 .�t"( C�Q w . /-�/�!� CIN 1 ZIP , �S �� l V Q Date!l��Appli[an} . -f� STATISTICALCLASSIFICATION, .: APT. CONDO. �- � NOTICE TO'APPUCANT: If, ofrer maki this Cerfificote of � ARCHITEROR " W �Exemption, you should become su cf to the Workeri ENGiNEER 0.�3 '�J`-�7� QASSNO.�DWEtL.UNITS + [1. Compensation provisions of the labor ode,you must forth- , qDDRE55 7 -- �� �� SEWER MAP . , y � � wi�h comply with such provisians or this permit�shall be 7E1. � deemed revoked. � � CONTRa.QOR NO. BK. ' FG, VALIDATION LICENSED CONTRACTORS DECLARATION , LiC. � ' I hereby affirm that I am licensed�nder provisions of Chapler 9 ADDRESS NO. VALUA]ION�� ._ (commencing with Section 7000)of Division 3 of the Business and� � LIC. :\\ 1f„�-� , - " Pro(euions Coda,ond my license is in full force and effett. � CiTV CLA55 �b��` . . . SQ.Ff NO.OF� .'^ O.OF CHECK � � � licen3e Number liC.Class SIZE STORIES��IU.. fAMILIES � ONE ?1 p S 9 A g P � Conhactor Dale DESCRIMION OF WORK AD ❑ I v/ �� � a �'z 3 , ❑I am exempt under Sec. � q�7ER � FINAL Q �/� . � " � Q 2�Q B.BP.C.far�his reason L � � REPAIR � DATE-� e = Data: � u5E OF . DEMOL.❑ .-..FINAI� - ." � �2�O O c� E%ISTING BLDG. - gY y,� - Signature AP�PRIMT U(i nio. - . - 0 1,1 7-8 4 OWNER-BUILDER DEQARATION � , ' ; I hereby aifirm thot I am exempt irom the Controdor's License . _ _ __ _ _ _ , ._ Law for the following reason(Section 7031.5,Business end ADDRE55 Professlons Coda): � PRE ENI . O � BUILDING --� ��� 1, as owner of�ha property, or my employees with ADDRE55 wages as iheir sole campensation,will do iha work ond � � � � , _ the strucrore Is not Imended or offered for sale(Section ����N --- . "� " - �- " � � 704<,Business ond Professions Code). � MOVING TEL , � ' - I,as owner of ihe properfy,am exclusively contracting � NTRACTOR No. �3 i 2•8 A with liCensed cOntroctors 10[o�struc�the projed(Sec- ADDRE55 k• •�• •2 J tion 7044,Business and Profezsions Code�. -- -- - � � . ' 2FOUIRED TOTAL SETBAIX FROM EXIST. CONSiRUCTiON IENDING AGENCY � SEt sn[K YARD HWY pRpp��NE wi�iH I •�• •�J� I hereby offirm fhot there ie a conshuction lending agency(or � FRONT -- � � - � " ' � �he performance of�he work for which this permit is issued v.l. , > " • •a 3 1 � _ �Sec.3097,ci�.c.). Pioe _ - 0 6 0 7-8 4 � lenders Name ' � � P.C.Fee f `O 1 Permil Fee �G��� � � Lender's Address � ' �`' , p �� • U! � �cer�ify that I have reod this applicotion and state that the . ,l j� Issua ca Fae ..SO v pl pl • J � a6ove infwmation is cortect I ogree to comply wilh all County � in.esrgaro�Fee � . / _ __. . , _. . � � ordinonces and Sta�e iaws relating to building consirotlion, � Totol Fee L•73 � �� � ^� iY and he�eby au�horize representafives of thfs County to enler � J� � � � - upon t�abova-menli/nydi�p/rEperry for inspecfion purposes. - � -- ��� - - � �U-' � � 1%!/l•GG� � C-J . _ .. - . -. rH. . a � rY1-e��� SEE REVERSE fOR EXPIANATORY IANGVAGE 5' ture of Applimnr or Agent �e � ' / -� � . 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