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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 ipnat of �licant w �nt . Dots � . �� ,�-� � .� � s °e �` - ,� � -. " " � ° • . - o' y % p V S .3 w « ry�M„_, . �- .'n.. Yt .�.'p U. �� . , �,,.Y.vs�C� ..,. O d � V �, y,.,.�,4�•� 6 ♦ L x ,,��„�•�� � D o�''�° �N„� � % e a V �i; .4 ;�'-_ `� i �,., � �c � M � � r:. O a�.{ n i� F C t%�C L.v: ci C' O "'U v,.S! z" " .+.: ' ? 0, y y, ;; ' 'n�C1 u�`in y;O1 w p.r. fe� m O b "� ..�`C i. �j .0�G .� - 1 � . . =V � Y��..y M �� T ,7>��4 .�Jf t3""�' � C' Y. 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