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HomeMy WebLinkAbout1512A 1513A (15) WORKERS'COMPENSATION DECLARATVON � �- � � - - APPLICATION FOR BUILD�NG PERfVIIT i heraby ofFirm that I have o eertifimte of tonaent ta selt �D � insute,or o certificote of Workera Compansation Inaurance, or o cenitied copy�hereof�Sec.3eoo,�ab.c.) COUNiY.OF LQS ANGELES :. BUILDING AND SAFE�Y �S�-oGZG-956-10��v A�vA _ euuoinic - Certified copy is hareby furnished. FOR APPLICANT TO FlLL W � qDDRE55� 2 ].�SEA��''•F�T��DR � Certifird copy is fil�d with Iho couMy buildi�g inspec- gU�IDING tio�depnrtm�nt. ADDRE55 lOG4UTY NEAREST Dafe]�[��$4 ApPlicant CITY ZIP CROSS ST. CERTIFICATE OF EXEMPrION FROM WORKERS' � N�'�B��' ��R . COMPENSATION INSURAMCE � � SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL USE ZONE MAP (This section need not 6e complated if the permit is for one Tppn 33020 BtOCK LOT rv0. 20 NO. ��3 �-�� hundred dollon($100)or less.) TE� SpECini Y I certi that in ihe� erformanca of ihe work}or which this OWNER CONDITIDNS Q fy P DISTRICT GRO�P TYpE FIRE PROCESSED BY O permit ia issued,1 shall rrol employ any penon in any manner Ap�� CONST 2�{� U so as to 6ecome subjatf fo the Wwkers'Companapfion Laws. �O �S � � cC J y arr ziP 724 s�nnsnc�i ctassiFicAnoN nvr. cor�oo. � Date ApPli[ant . . ARGHLtECT OR� � .. .�:TEL2 . .. . �� �NOTICE 70 APPLICANT: If. aNer-making th.Is�Centfiwre�of EN ir�ER TyQ.$ -$073�.� � Ct�LSS�tap, �m.p . DWELL..UN�7S�� � Kemption, you should become subjett-�fo the Waker§' - y �ompensation provisions af the Labm Code,you muat forth- pop� SFWER MAP z with comply with such provisions w ibia permil shall be . - TE�� � � � � deemed revoked. LpNTRACTOR O. � � �� �, VALIDATION LICENSED CONTRAC�QRS DECIARP+TION � � LIC. 1 hereby affirm tha�I am�icensed under prorisions of Chap�er 9 ADDRESS � DR. N0.37�8� YAIUAT101t (commencing wilh Settion 700D)of Division 3 of the Busineu dnd tIC � . Profeuions Code,and my license ia in fu41 force and eHect C�Tv tV+55 B E � � 5p.FT. NO.OF NO.OF � CHECK 37�7HO Lia Cla°• $ SIZE SFORIES FAMIUES �. �NE ��� � licenss Number � {�,Rd� � s Contraclor`��' ANhFT1 t,[2fY7P .DatBT�y�$� DESZdIFtIOFI"�WORK �I� �' SINC�,E FAMII�Y HQ[�S ''�� � �I pm exemp�under Sec qL7ER � FINAI 1 I S u I �1 5 i.2 A ❑ DATE ��{ B.BP.C.fw thb reason � rs�Pa�R • Dotc exi57ir�eioc. oE""°` � sr��(Y��I.tG,a°� #• . • •2 1 Si nafure . APPtIUNT TEI. + •'Z'���3 e aaiHr p,bIDIId (3ifJUP No. -9541 OWNEB•BUIIDER OECIARATION ► 1 hereby affirm�hnt 1 am ezeeep�fra»fhr Confroctor's ticetrse , ••2 2 3.1 3 v law for the following�eoson(Section 7031.5,Busineu and A�DRE55 v.afe.�;o„�c�da�: 0 2 1 3—8 4 ^ Il01NG � ' J I, m awner of tho property, or my smployaea with ADORE55 wapes as thair aole compenaation,will do the work and �� the structure is not inronded d offered for sale(Settion ����TM - 7061.Business and Professio��Code). MOViNG TEL. �1 5 1,3 A � 1,os owner oi fhe prOpe�ty,am axclusive�y fA�hOtting CONTRACTOR �� with�itenxd mntmctors fo conatruct the project�Sec- . �� �� ��j tion 7044,Business and Rofezaions Coda). ��� , REQUIRE� YARD HWY TOTAL SE�BACK PROM EXIST. - I •3&5 5 0 CONSTRUCfION LENDWG ACaENCY SET BAIX PROP.L� WIDTH ► � . i he�eby offirm that ihere Is a conatruclian lending agency for FRONT �,!f �/ •��3 8 5 5 0 c=i the performance of the work fw which this permR is issved P.L . � - 7sa�.3ov�.Civ.C.). SIDE 3 i �s� G 2 1 3—8 4 P.L. 3 lende/s Nome , � � � 8 � . . . . . . . P.C.Fee f .�3/ Permlt Fee Lende/s Address � I certify thot I hove read Ihis applicotion and state thm the Issuonce Fee a•.r� � e6ova informolion Is correct.I agroe to comply wirh all Counry ���.estipalion Fae ordinonces and Swre laws relotinp to building con�trunion, Tmol Fae J' ,�-��� tl and hereby avthorize preaentative�oi ihis Coonry to enlar � u e above-men ad proparly for incpoctlon purpwes. a � � � � � .� SEE REVfRSE FON EXPUNATORY lAN6UAGE . Sign e of Appliw r Ayant Dole . . .� .... �f }--- r-. N ,S ...M Aa . V N d ^w L'O Ol�.l �.Cl y � .,U U O Z G..., � . , . -. .. oif1 -C q:C � � i: 1 : ,� �n C:.,;ti'i.' +.\. O Oi �3 U w . .z ',���;�.'''o� o�n.o w"fl'�� '3 0 o c�i �,'" � �n `; ,., . - : : �o F � x �L'-� Y c'^'�o �i`w.a v-a�.r d °' � a w �. ; ° - a A �,e c��i " °' .ti`'�m'c°"� d o '�� o £ Y �"� e � ° �, � s�a°. 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