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HomeMy WebLinkAbout1684A _ .WORKER$'COMPENSAlION DECLARATION . . � - � � .� I hereby-affirm thot I have o ce�lificote of consem ro self . � APPLICATION FOR� BUILDING PERMIT�� insure,or a cerfi(icote of Workers'Compens�ion Insuronce,or ' a certiiiedcapy rhereof(Sec.3800,Lab.C.) : � - COUNTY OF LOS ANGELES � BUILDING AND AFETY Policy No. Compony � BUILDiNG J � Cerrifed topy is hereliy Fumished. FOR APPLICANT TO FILL IN ADDRE55 ���J b a/L 0. (.tt k� '���Cer�ified copy is filed wirh the county building fnspe[- BUIL�ING �7 �3 �1TA ti0ndepartment.- ADDRE55 O�� � S�/'//� //1� IOCAIITY �Q/kQ !�� NEAREST /�� � d Do�e - Applicant � CITv��� /J/yR ZIP CROSS Si. 'Q Q t/lR.1A � CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR � COMPENSATION INSURANCE ' SIZE Of LOT NOW ON LOT � MAP BOOK PAGE PARCEL (This section�need not be compleled if Ihe permit is for one - U E Ot�E nMP /O 0 ,7�� � hundred dollars(5100)or less.�' • TRACT BLOCK lOT NO. � NO. d�J } TEI.�-p -^,� 60 SPECIAL ' . a I certify ihat in the performance of the work(or which Ihis � OWNER M �M�S. Q f�1t/l�c+e'N0..7/g"-�c� O CONDITIONS . - Q ' ermi��5 issued,I shall not em 10 an erson in an � DISTRICT GROUP TYPE FIRE PROCESS D 6Y P P Y Y P Y manner... � . V ADDRE55 �3O f CONST.� � �`�� O so os to become subject lo the Warkers'Compensa�ion laws. � 1.6 [7� `� �� � /���� Af�lnde 13 ` " '-"�Dafe��y�Appli[ant �—�"r . . CRY ZIP STATISTICAlCLA551fICA710N APT. CONDO. ~ NOTICE TO APPIICANT: If, after moking Ihis Cerfificate of - ARCHITECT OR iEi. � W Exemption, you should become subject to the Workers' ENGINEER NO. M55 NO.�DwEtt.UNiiS d � H Compensalion provisions o4 the lobo�Code,you musl forlh- �- - ADD2E55 �� � SEWER MAP z ith compiy with such p�ovislons or this permil shall be TE� deemerJ fBVOkPd. � � ' CONTRACTOR N0.3 BK. PG, VAIIDATION ' LICENSED CONTRACTORS DKIARATION � tIC. I hereby af(irm Iho1 1 om licensed under pro�isions oF Chopler 9_. AD�RE55 /G�U• C �NO. 3 VAIUATION (commencing with Section 7000�of Division 3 of Ihe Business and ��� ,e, - � Professions Code,ond my license is in full force and eifect CITY � C1a55 �'� S ,�V� � SO.FT. NO.OF NO.OF CHECK ' ' license Number Li[.Closs SIZE d S70RiES r FAMRIES ONE � Contractor Dale DESCRIPTION OF WORK ^! NEW S � I am e�empt from the licensing requiremen�s as I'am a � � �0� ADD� licensed architeci or a registered professionol�engineer., _ , _. „ AtTER � FINAL � „ aciing in my professional capacity (Section 7051, REPAIR � �ATE ��'���Z Bustness and Professlons Code). USE OF � FINA ' " � � � E%ISTING BLDG.� A M/� �L✓� - DEMOL ❑ � Lic.ar Reg,No. Da1e A7MICANT p r TEL. BY 1 - ! � � OWNER-BUIIDER DECLARATION -� " -'fPRiNT)�00 L- - - N0.�3 —Op � I here6y offirm that I am ezempt from ihe Contrattor's License r l`Jf � , Law for the following reason�Section 7031.5, B�siness and ADDRE55 ✓ � ..S' I P�fessions Code): ' pgE��Ni � suaoiNc �,(g3o $1 6 8.'4 A I, os owner of Iha proper�y, or my employees with A�DRF55 wages vs their sola tompensaiion,will do the wcrk and - � • � the strvdore is not intended or offered for sale(Section' � �OCnuiv /+/!t - j�;•,• •��� 7044,Business and Professions Code). MOVING 1EL. . 2'�V 5� � � I,as owrier of rhe property,om exclusivety coNroding ' CONTRnCTOR NO. � ��,��• with licensed commcrors to consuoU the prolect(Sec- qDDRESS ' •,' �2�S O� tion 7044,Business and Prolessions Code). � � --�� - - � - � � . 12EOU�RED TOTAL SETBACK FROM EXIST. ' ' CONSTRUCTION IENDING AGENCY SET BACK YARD HWY pROP.IINE WIDiH O 2 2(�.�$2 I hereby offirm rhai there is a constrvc�ion lending ogency tor faOM � " . the performance of Ihe work(or which Ihis permil is issued v.L � ' (Set.3097.Civ.C.�. . . SiDE � . . � . P.L. Lender's Nome �' y � ' $ lender's Address P.C.Fee S Perm�i Fee �3"U�7�U , � w I cenify thot I hove iead�his applicmion and s�ote that ihe I:suonce Fee �.�V aobove informotion is correct.I agree to compiy wiih all County._ i�ve.+�ga��oo fee .. C . . ordinances and Sfote lows reloting to building construction, a d � sd � � and hereby outhorize repieseNatives af this County b eMer imal fee � � . m ' 'upon the above-me���/JJ��..��ned operty for inspeclion purposes.' " . � - � < f_ ,�{� (a� /�`' SFE REVFRSE FOR E%PLANATORY LANGUAGE - � S�g�arv�e o�Applicont or Age�� Dme ' - � �� m T n 2 n+ '++ ; �N �rr r =0 Oc S 7' � •O . O . ;C CNJn O O �� na � .n' �-n •2' � ' . 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