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HomeMy WebLinkAbout1000A � WORKERS'COMPENSATION DEQARATION � " ' �- . " � !�,��eba�°a`�e�,<<o',aofwoke5"�om'Pe�,a°o�s��;��o��e` � : APPLICATION FOR BUILDING PERMIT or a certifie8 copy thereof(Sec.3800`,Lab.-C}.-) �� � CpUNTY OF LOS ANGELES BUILDING AND SA ETY Policy No. Company 1�19 p �y /', � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN nooaess �0 �b` �(.l Ct- �/�>/�G • • �� Certified copy is filed with the county building inspec- BW�DwG � , � ti0ndeportment. ADDRF.SS � �/n.� tocnun � Q � on� ��� 2— c"a�ossSST. r� �.� ' (2tv G Da�e Applicant qN I � Ziv 1��C� � CERTIFICATE OF EXEM7TION FROM WORKERS' � NO.OF BLDGS. I nS5E5SOR COMPENSATION INSURANCE SIZE OF lOT NOW ON LOT 1 MAP BOOK PAGE PARCEL (This section need nol be completed i(the permit Is for one � u ZpNE �+P ] ] h�ndred dollors(EI00)or�ess.) TRAR BIOCK LOT NO. � � �,I NO. U �1J 7 —t- TEL h� p O SPECIAL } 1 cer�ify thet in the performance of the work for which this OWNER MC�^� ilc9 •�S='� No. p�vl g� 0�� CONDITION$' d permi�is issued,I shall not employ any person in any manner r, '�1 - - oisteici G20uv ireE FlRe PRpCE55ED BY Q so as fo become subiecf to the Worken'Compensation Laws. ADDRE55 o2t Tt� 1 N IG �� roNS� �� e„ /� � . � . . . � . . �CM-' � rP� i�/ 3 Y ��� ,O Date APPIi[ant �. CITY � . .. .. ` ZIP. ... $TATISTICAlQA551FICA110N APT. CONDO. U NOTICE TO APPIICANT: If, after m6king this Cerfificate'o4 ARCHITECTOR�,\ � '�.TEL�. � .,-... . . �/ „ ENGINEER: � ��YR1W�'�I�N�VL+=.�.� NO. �.' �CLASSNO. �- DWELL..UNITS W �Exemption,�you should bemme��subject'�fo�the Worken' �- c . .. - . , tL Compenwtion provisians of the Labor Code,yau must(orth= - � ADORE55 ��.Jl�`���' � �'. � '��- � � SEwER nMP � ith comply with such provisions or ihis permit shall be 7EL. deemed revoked. i � . . BK. PG, VAI�DATION CONTRACTOR �G �•� /}�.INO. IICENSED CONTRACTORS DECIARATiON � uC. • I hereby affirm thet I om licensed under provisions of Chapter 9 A�DRE �. b� NO. �0 t'7 yqLUAT10N ' (mmmencing wiih Section 7000)of Division 3 of rha Buslness and uC. � Profeuions Code,and my license is in f�ll(orce ond ffetl. CiTY ! i ,u. v CIn55 f p1� Q Q � SO.FT. N OF NO.Of y CMECK Li[ense Nu ber� � a�� Lic.Class � SIZE �� ST RIES i FAMIUES ONE ► , - �c he. � � �/sj s Conira[tor � �afg I DESCRIPT N OF WORK S �7.J N� ❑ �I am e.empt�nder Sec. � � � ��R � FINAL � �J , � 6.8P.C.for this reason REPAIR � DATE / ���J Data: � USE OF p�p� � i1NAt / � E%ISTING BL . BY �/,y�� � APPLICANT TEL. v(F+'.] Signature OWNER-BUIIDERDECLARATION I PRIM l � � NO. �O4 I hereby a(firm Ihat I om exempt from the Conlmclors License I �� ► Law for ihe following reason(Sectlon 7091.5,0usiness and A�DRESS � Profeesions Code): � PR - � ❑ . BUIIDING I (� F N " ' I, os owner of 1he prope�ty, or my employees with ADDRE55 �� O Q O A wages as their sole compensation,will do the work and . ����TM S U{�2 �tA:� �/�LM14. the strvct�re is not inlended or offered for sala(Sectlon I — �. • . • •.� 7(144,Business and Professions Coda). MOVING TEL. � �, � I,as owner of Ihe property,am ezclvsively contracting � � �RACTOR NO. . . _ � • �8 Q 5 O . with licensed mntmUors ro consfruct tha project(Seo- qDDUE55 tion 7044,9usiness and Pro(essions Code). I . • e� $Q 5 p� . REQUIRED TOTAI SETBAIX FROM EXIST. CONSTRUC710N IENDING AGENCY � SEi BaCK YAR� FM1YY PROP.LINE Wi�TH I�� � I hereby affirm that there is a construction lending agency for FRONT �1 U � �Q � r ` - � - ��•�2�$4�� � the per(ormance of Iha work for which�his pe.mit�s�ssued + p.�. oC , tSee.3097,Civ.C.�. SIDE - � -..P.L. � lender's Noma �j � ( P.C.Fea f Permit Fee � /U• � . . lender's Address c � I tertify that I hava read this application and state Ihal the � � Issuance Fee �,,) O �, �� a ve fnformalion is mrrecl.I agrea to comply wiih all Counly I Invesiigaiion Fea `) - � � dinances an Sfa1e laws reloling fo building construciion, Toial Fee a ��S� C1 ereby �o ze r �resentclWes of fhie Coonty to enter � t O ab v t n d propeny for inspetlion p�rposes. � � � ^ - J IZ � SEE REVERSE FOR EICtLANATORY UNGUAGE � . Slgnatu Q Applicanl ar Agem Do�e - � z -' a ° � � �, ._�: o - ;-' - ••, : .v c� �c� o A � , � � r. n.a c�i a °o a v x n � t � � � t v o p � �m a � � p o- 9 •� ; �0 Q 7 � m :; m. � t� p = t .+p r F O n Q �. .-13 '.. •� N O j p :/� O p� . � n n P � 1 ' 1'q . �+ ^t o � � p `o � z� oA �. 3 ° i �, �, Cl S � p m :3 cT a p ° ,G ,O N R ° ° �1 0 ° a. ' � �n� S m.. S O � 1: � � o0 3' ,� 'a ° . 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