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HomeMy WebLinkAbout1522A 1523A (15) WORKERS'COMPENSATION DECIARA�ION � � �a�ab�affi�m that I hove a certificare of tonsent to self �� G APPLICATION FOR BUrLDtNG PERMIT insura,or a ceNi4icate o4 Workeri Compensotion{�uronce, o�a� ,�s�ed copy+n r of Sec.3800 lab.C.) �pUNTY OF LOS ANGELES BUILDING AND SAFETY �3..CK-9��-�04-.CpQ AETNA QcyNo. Compony BWL�ING Certified copy is hereby furnished. FpR APPLICANT TO Flll IN ADDRE55 � Certified copy ia filed with the co�nty buildinp inspec- BUItDING tiondepartme��. AD�RE55 24241 S E D iocnuTY NEAREST oo+e����84 appUcanr THR QN�RN r,unpp arv D ND BAR tia ckosssr. CERTIFIGATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. A55E55oR COMPENSATION INSURANCf SRE OF lOT NOW ON LOT NWV BOOK �AGE PARCEI (Thia sec(ion need nor be compleFed if the permit a for one USE ZONE MAP hundred dol lors(;t00)w less.) T2nR 3 3 0 2� s�ocK ior wo. nm. /�.�� h� SPEG0.i } I ceAl fhaf in Ihe performance of Ihe w«k for which ihis OWNER 1'[-[ Na — CON�ITIDNS h- permi�s iuued,1 shall nat empby ony perwn in any monner DISTRICT GROU7 CON ZON PROCESSED BY � so as to become subjact ro the workers'Compansolion Laws. �DRESS �.0 7 4 P1�12 K I EW D R, �Q �� �f � � Y Pole Applicapt � CITV C OV I N z�r O ARCHl7EC7 OR.. � '�.:7EL. STATISTICAL C1A551FIfATION APi. CONDO. u NOTI�E TO APPIICANT: If,.ahsr r'wking thla�Cartificate�of � �- ' .�p� 'f'� m EN iNfER:.�� D CtkSS NO. � bWELL..kJNrtS_ a � xemption, �you should becoma�zubjecr to the�Wakers' � , � � � � � � .:ompenwtion provisiont of ihe La6or Code;you must forth- �qppRpu.3 SeWER Mnv � with wmply with such provisions or this pumit xF1o11 be . � TE�� Z deemed revoked. CppiiRqRpR gK. pG, VAIIDATfON UCENSED CONTRACTORS DECL4RATION �LiC I hereby affirm fhat I am Rcenaed under provisiona of Chapter 9 A�DRE55 NO. VALtiATION � (canmencing with Saction 700D}of Divuion 3 of 1F�e�8wineas and UC. . Profeuicns Code,ard my license is iw futl torce ard sffecG ptt �V,55 a 64,,8 5 0 . ► 3 715 8 Q 3C7.FT. NO.OF ND.OF CHEIX LicBnb Numbar tic.GI�• � SIIE 15 0 Q STORIES 1 FAMILIES ONE E �,,,�„�,,,TH& ANDEN GRO[I��@ 1,�23�84 DESC(RIPRTION50iWORK C T NEW a � OF SINGLE. M LY H ME �� � I om exempt undor Sec. aiTER FINAL B.BP.C.fw thii reawn ��R � DATE � 1�(g USE OF � FINAL �1 5 2 2 A. DaN: E%ISTING BLDG. �EM�I Signplure APPIICANT TEI. � ��' #� � ��L� OWNER-BUILDER DEQARATIQN ��M NO. 1 herr.by affirm that 1 am��emp�hom Ihe Conmocior'a Liceme ADDkE55 10 74 P A R K V I E W DR. C � � �2��� 3 law for tha following roason�Sec�ion 7W1.5,Busineas and P,ofasaions Code): pRE • •L c��'J� ^ - BUIIDING � J 1, as owner of the praparry, or my employees with qpDRE55 �2,� 3—�S�l wayes as rbelr sole compensarion,will do Me work and ! '� ihe afructure is nof inlendad or offered for wle(Section ����TY �, 70M,8usinau ond Professions Code). MOVING TEL. �I � I,as owner of fhe �o e y coniraciing NTRAROR NO. p p rry,am exclusivel f 1 5 2 3 A with licensed conM1actorc to conahucf Ihe projecl(Sac- A�R� tion 7014,8usiness and Rofeuions Code). �� �� � �� REqU1RE� TOTAI 5E(HP.CK fROM E7(IST. CONSTRUCTION LENDING AGENCY �T gq�K YARD HWY pR�p��N WIOTH , I heieby offirm that there fa a consfrucfion lending ayency fa FRONT � •3 8 5�5 Q the performanca of th�work fw which this permit is iss�ad P.t. � S�� �Sec.3047.Civ.C.). � � SIDE t/ �S� . • •.�..�J�.�J O c=.� f P.l. J lander's Wme � �z,� 3'�$4 � Lander's Address V.C.Fee t :j- verm�t Fee .�7.�� ,�, 1 certify�Fwt t hav�r�cd this application and state thot the iuunnce Fee /O•�+� � nbove infamarion is conoc�.I ogree to comply with.all Counry in�ese�gwwo Fae s ordimncw and Slaw lavw ralating 10 boildiny conahuction, � Towl Fee .���7'3 d � nnd heroby oulhori: eprss�ntotivoa of 1hii.Counfy M enter u e ubovo-m � ned any for i�spection purposas. � � SFE REVERSE FO[EX►IANATORY IANGUAGE Siqnat ol ppl'Ka Aq�m Date ; �t � �. N n 01 _`„ �'O d ' G oi �. ' y O.a t+. w�f} `B S c��.r F v R�l�D� 1 . C � 'n� �' "��..X ,"�n ' O U �'�' .Vi ,K.. r . ' o� •� � c, c�;o « :�-� 3 0 0 � .,�•� � "� �n ° 3 y . �c� ,��:•�s �U „ r,h o i. M ��,. .� tt c d c" � y o p On " � �'w m'� �C'1„� e"� m Y �i.l� � �' y„�`n, a i � u y L•w.� _ ° � .e� c n� �'-�.�o..�` 0 3.�.��'r � �.�... � u ° � c� � a Z U a� � Y,:.tt c�°0 4�rc � � � Q wi °�'...�.. > a U �, y ae � . � m� � , � °' k•�Z! °' c ��r �r� � w p S~o�� �. 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