HomeMy WebLinkAbout1399A , _ ._ . ___ _ __._ _. _ _. __ _- —_
� WORKERS'COMPENSATION DECLARATION . - _. - . . . .
I.heseby offdm that 1 have a certificate of�o�5e�,,a=e�f �� APPLICATION� FOR BU,ILDING PERMIT ��
insore,or a certificate of Workers'Compensotion Insurance,
or o certified copy thereof�Sec.3800,Lob.C.1 COUNTY OF LOS ANGEIES BUILDING,AND SAFETY
�
Policy No� Company �� �
_. __._. . ._. ._.. .__�.. . ,
q.-Gertified copy ia hers6y fwnished. - FOR APPLICANT TO FfLL IN euuo¢�G , � � � �
ADDRESS
� Certified topy is filed wlth tFie caunry building inspec- BU�IDING n��-Z'i C t:.S C.._ - - - � ��
��tion department - A�ORE55 4 a� �- uC�t Y`QY,lri �V`�
Uat6 ` . . APPlicant CITv �.J, �lY�O� QY ZIP I� S LOCAIRY �
.� ��`�tERTIfICAiE Of ExEMPiION FROM WORKERS' �� ' ' ������-� `� "� '� - �
. .. . COMPENSATION INSURANCE . SIZE OF l0T. �-� . .�.. NOW ON LOT CROSS ST. ..� .y... � - � �
(7hb settion need not bd completed if Ihe permit is for one .. _........._..._ . . ... ........_ . . . .. ._.. ASSESSOR -:� .� . . ,.
hundred dollars(f1Q0)or,less.). , _ TRACT BIOCK l0T O. !,�Q �y�p,p gppK� �� PAGE PAR�L
OWNER L-R�l` TE.�I�'I QV.0 USE ZONE �N�1P . .
t certily thaf in the performance of the work for which this � O' � � ' �1 �`1�� - � �.
permit is issued,1 shall not employ any person in eny mnnner !� cs SeK�n� _ ' - o.
soas�fo6ecome5ubjecftofheWorkera' ompenaalionlows. ADDRESSZ-{Z�S- E - K�G 1+�- �� CON�ITIONS 0
� i1 �5. 10. , ��T� 4'�w.a�a R��- Z�o �i7 5 "
� oafe n�u�a�� m
NOTICE TO APPLICAAkT: If,'ohe/mpkiny�Ihis Certificole of ARCHITECT OR TE�� DISTRIR GROUP NPE FIRE PROCF55E�BY :�
Exemption, you should becoms su6ject to the Workers'
ENGINEER NO. CONST: � Z
Compensatiart pravisions af,ihe LaFjor Codc,you mual}orth- qDDRE55 Q d
with comply with�suCh pra.Yisions or this.parmil ahail be . . _ -... -____. .....,. ._.. ._....,..__..... ..._.'_"___._._._ I ` .y1
deemed revoked. . , �� 5rarisncra anss�F�canorr nar. coNoo. �
. . . . � .. . . CONTRACTOR ��tJ �f' NO.
�' .�._ _ _ _ _._ .. . _
UCENSED CONTRACTORS�ECLARATlON � ��QASS NO. � � � DWELL.-UNITS '
LIC.
I hxeby offirm that 1 om litensed under provisions of Clwpter 4 ADDRF55 NO.
(wmmenting with Setlion T000)of Division 3 of th�Busirresa and _ . „._ ��� SEWER AAAP � . . '. . '
.. _.. ..._._..._ .__ ..... .. . . . . , '
��� Professions Cade,ond my license-s in ful[force and effect. ai5' CtA55 BK � YALIDATWN
.. :.. � �. ,. ..... �.
. . .. -.. _ . ... Sq.FT. O.OF NO.OF CHKK -
. . . . . . .. .....
�-�'-� SIZE'� �STORIES�� � '� FAhLIIES� ONE� �
licanse Number �T�Lic:tlass..a ... . - . .
� � 'I��J- - � NEW -� VAIUATION .
CoNrador� � - pare � - DESCRIPfION OF WpRK s 3 c�a . . �.
�I am exempt under Set. - J�A 0.'Md -� Ol��� CAI�(�,�/� � � -
, � A[TER � � .
8.8P.C.for thia reawn. .- . . _. REPAIR.❑ f ... .. - � ,
Dafe: USE OF
. � EXISTING BLDG. �� O I
�Signofure �� -.. � 'CPPLPR NT Y, .._- /�NO. FINAIn 1,� �� �1 39.9A � :
OWNER-BUILDER DECIARATION . _.., . � ---.pA3�e- 'm�"..�-�t
!heraby�afEirm 7}wt�.am e:ampt from the Gannaclar's.licenae . ...
law for the following reasbn(Section 7031.5,Business and nDDRE55 � p�qp ,- � � � � �
PrOfesStbns COde): .. ...... .. . . . .... . ...... . ... PRE - ..._.._.._ . .. ...._. . .. .. , _. .._ . _....._.._. ..gr '�:"_ .... .._. �• • • • •�
aBUIIDIMG ..-� . ��`•. .�_.__. '. . . � �.�4'����
I, os owner of fhe properly, or my amp�oyees with PDDRFSS
� wages as their soTe compensation,wi1T do tFe w�(and.- .. .-- ---���.. �.�.".-.... .—...____ ___.__ .__ __. . _ _
the struuure is not intended or offered far wle(Section ����Tr � "'���`��``� �`� . �_ • s •C�;�,O�� I
- 7041,Business and Prafessions Code). ---� mOVING - TEi. �
CONTRACfOR NO.
� 1,as owner of the properry,am ezdosively contmcting 'Z ,,_�_, ��` ��,�.� ��.1 7—8 5
� with licensed contraclors to conatroct tha project(Sar qooRE55 � ��- �
fion 7044,8usiness and Professione Codej. - �
. ...`...' .._.-CONSfRUC710NlENDING�AGENCY"".. ..-�._ . SEiBACK YARD HWY .�T07APROP.LNE WIDTH. - . �. .
1 hereby affirm that there is a wnslruc�ion lending agency for FROM �
� the-performonce of�he wak for which�his�permi��ie�issued -._. .v.4.._.. ._...___--.- ----.....__..—_.----_.__ ...._-- ----- --------._.__.__ ____ . . :
(Sec.3097,Civ.C.�. SIDE �� �
m P.L
� ..__ _._____..._ .__...__"'_. _.._... _. ....._ _ �
Lender's Name __.__ . .________. .. .._.. . . . .. ._.. ..__..
g � j LDMA Ref.M . �� �
� .. .._._. . .. ..._. __. ...___....__. ._.__..___. P.CFeeS _. .._... - Permnfee � -- - --
lendar's Addreea ..._.__._ . ._ . ._" -....-_.. ..,
' , .
. 1 certify_thqt 1 have read.thiS.opPti[atioa4pd�tate.that 7he . . Fssoonce Fee�- .L�. tDMq aiG M - � . .
a abpve infwmmion is eorreet I agrae fo eomply with all Counry in.es��goeion Fee -
g ordinances_.pnd State laws relatiag to building.consn�e(ion, ,. . iop��....... . � � � �p,N,q pann.N �
u
and hereby authorize represenfativea of this County to enter �� �
� upon the obove-ment' ned operly fw inspeclion pur ses. �
o - - ------ --_._—� _ . Q !'. _. _ ___-- �---------------. ___. _
. . . __. _ . .. . _.. . .... _. .
a � �,— ' — 17 zi� SEE RFVFRfE FOR EX�UHATORY tANGUAGE
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