HomeMy WebLinkAbout1518A 1519A (15) - WORKERS'COMPENSATION DECLARATION - �
I hareby affirm thot I hove a certifieote of consent io self ��APPLICATION FOR BUILDi1VG PERMIT
insure,or o[ertificote of Workers'Compenwtion Ins�rance,
or a certified eopy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
o,�o K-956-1Q��A ��#�
Cerrified wpy is hereby furnished. FOR APPLICANT TO FILL IN nooRess
� Certified topy is filed with the county building inspec- BUILDING
non deponmem. a�oaess 24249 SEAGREEN DR. �ocaiirv DIAM ND BAR
NEP.REST
Dctel/23/84 ApplimnrTHF. ANI�F.N r.unrrp aTr ziP CR0555T.
CERTIFICATE OF EXEMPTION FROM WORKERS' � ���&�`� ��R
COMPENSATION INSURANCE 512E OF LOT NOW ON tOi . MAP BOOK PAGE PARGEL
(Thls secfion need nat be campleted if Ihe parmit ia for one iRACf &OCK LOT NO. USE ZONE NO� /�3�j�!J
hundred dolbn(5100j or leu.J . �
TEL SPECIAL y
1 certily that in the parformonce of the work fw which this OWNER NO. _ CONDITIONS qL
permif is issued,1 sFwll nof em(rloy ony per6on in any manner OISTRICT GROl1P NPE FIRE PRO�SSED BY Q
so ps to be[ome aubjetl to the Workers'Companaa�ion Laws. ADDRE55 CONST. ZONE V
' ' l Q �„� � � �
�� � A �.�a�� CITY Z�P STaTISTICAL CU1551FiCATtON APT. CONDO. �
pp ARCHIIEGT OR�. � '�.TEI,.
NOTIGE TO APPIICANT:.If. after moking this Certifitate�of EN tNEER � N6� � �� 019 D�'� V
� �emption, you should 6ecome-wbjacl�to�tiw Workart� � . . CLASS NO. DWELL,LNITS pW',
� bmpensat�on provia�ons of the.Lqbor Code,y0�moet fOHb- R�DRE55- � � A� SEWER MAF y
with comply with wch�pravisions ar this parmif shall ba � � � �
deemedrevok�d. ��Rq� �O'. —95tj1 � �c. pG• VALIDATION
CICENSED COMRACfORS DECIA.RATION � ��
I heroby affirm that 1 am licansed under provisions of Chopter 9 AD�RE55 NO. VAWATiON
�commencing witb Section 7000)of Division 3 of)he Businass and i��
_ Profasaions Code,ond my licenx is in full force and effect. CiTv CLA55 a ( � .
SQ.FT. NO.OF Np,OF CHECK
ucerwNumber371580 uc.cla�• R SIZE STORIES FAMIUES on�
DE52:RI711010UFWORK �W s
conhocrormgR �nFr�„�rAnrna„ � i�� noo
�I om Bxempt under Sec. �
A��R ❑ o E nf Sla� z151.8A
B.BP.C.for Ihis reason U�� REPAIR � � 2,�
fINAL •��•
OqfB: FJCISTING BLDG. �'�'a ❑ � `L��y.�
s9natu.e a�aucs,rar r�. �-9541 i •2 2 8 4 8
OWNER-BUILDER DECLARALIQN... �tiNT Np.
I hereby affirm 1Mt 1 am exempt from tiw Con�wcbr's Licenw ��.� • '2 2�.�l��
low for Ihe following reawn(Section 7031-5,Business and ADDRESS - � � � �� �
e�ofe��o�cod.�: E 0 2 1 3—8 4
BUIIDING
1, os ownar af tha praperty, w my employeea with pADRESS
! wages as their eole tompenaation,will do�he work ond � �
� the abocture is not Intended or offered for sale(Sectian ����iY . i
70M,Busineaa and Profeasiona C.ode). . MOVING TE�. - f 1 51,9 A
( � 1,os owner of the property,am exeluaivaly eoetracting NTRP.CfOR NO.
� with licenaed coniracto�a to conatruct the prajecf(Sec- qDDRE55 �� �� � � ,
� tion 70M,Busineu and Profesa�ons Code).
� �REQUIRED YAR� M4✓Y TOTAL SEiBA(7C FROM EXIST.. � I •3 9 4.5 0
CONSTRUCTION LENDING AGFNCY SET Bq[K vttpP.UN wioiH -
I hare6y affi�m ihot there is a conatruction lending apenq for F¢ONT ,�� �� � � � •�3 9 d.5 0�
the parfamance of the work for which this permit is issued P.�. . .
►Sec.3ov�,r�.c.). s�oe
P.,. S� /s� �213-84
Lander'a Name . -
S Lender'a Addrea+ P.C.Fee; ��� awm�r Fee .�f� �C7
� I carlify that 1 hove read ihis application ond sMte thaf the Issuance Fae /8-.SC!
� obove information is eorreet.I agrae to eomply with all Couny In�eetigotion Fea
ordirantes and$tate s relating ro building conshuction, Total Fee 395��d
Cj dnd hereby aulYwrize r ' eaentotives of this County lo eMer
� upo above-menti d roperty for inapection purpose[[[ayyy.��� ��, . � �
n ar �1�--� �( tFE YFVE�fE FOR EIVLANATOpV UNGUAGf
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