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HomeMy WebLinkAbout0737A 1586A 18872 I WORKERS'COMPENSAiION DECLARATION f hereby affirm that I have a cerli4icote at�o�5e�„o 5e�f � _ qpp�iCAT10N. FOR BUILDING PERMIT �=�"�`�� _inave, or o certificate of Workers'Compens�ion Insurance,or , " a certifi ed copy thereo4(Sec.3800,Lab.G) � ' � ' , t��� COUNTY pF LOS ANGELES BUILDING AND SAFETY Polr,y No. Company � �y �" rsc�. � Certified copy is hereby fumished. FOR APPLICANT TO FILL IN � Bnooecss d� �. `(\ Q�S C. � Certified copy is filed wi�h ihe counfy building inspeo- - BUIIDING �` � ti o�deparimenf. ADDRE55 � W L /�, j� IOULI7Y � NEARE57 ��� \r` C\,��� �. Daro ApplicaN Oiv �v � ZIP CRO555T. C. �\ CERTIFICATE OF EXEMPiION FROM WORKERS' NO.OF el�GS. .455ESYJR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT O MAP BOOK PAGE PARCEL ,. (Thii seetion need no�be completed if�he permit is for one / U E ZONE MAP ,Q a 3V TRACT BLOCK LOT NO. (� �� NO � hundred dolfors($100)or less.} . � > - tEL 1 V SVECIAI i,`� . I cerfify that in the performance of the work far which this OWNER (,V /2d�v ,cv ebNo. -9yE6 ��� CONDI710N5 permii is i55ued,I sholl not employ Ony person in ony monne� . 1 DIS RICT GROUP TYPE FIRE PROCESSED BY ' so ai to become su6ject to the Workers'Compensation tows. A�RE '� CONSi. Z�ONF � Dale Applicant CITY ZIP � . � r ARCHITECT OR -IEy.. / S7A715TICAL tlASSIfICATION APT.� C�NDO. V NOTICE TO ADPLICANT: If, ofter mokiag lhis Cerlifim�e of ENGWEER � NO. - `. �Na �-I w : Exemption, you should become su6ject �o the Workers' DWEIL UNITS_ y Compensotian provisipni Of Iha La6or Code,y0�must(orth• qDORE55 � �� SEWER MAP = wilh comply with suth provisions or this pe�mif sh011 be deemed tevoked. TE�� � BK.L PG. � � VALtDAT10N CONTRACTOR /Y ^ NO. LICENSED CONTRACTORS DECIARATION i��. 1 hereby affirm thot I om licensed under p�oviaions of Chapter 9 RDDRfSS rvo. _ yp«yp7�pq . ' ���I (commencing with Sectio Y7000)of Division 3 of the Busi�u and � ���. �C„�`�G �� I Rofessione Code,and m liaense is in foll force and eHeU. arv Cin55 5 . _,�'�3.� � /� � 5q.i7. NO.OF NO.Of CHECK license Number �4��f Lic.Class_J�;L.L— SiZE � STORIES FAMIllES �� - � � --- f�1 s -�,} he •(�i Conlroctor ��l�w��Dote '�4,���� DESCRIP710N OF WORK ADD y �,��j I�"fZl ' a;�.��/� ❑ Ky' � " v I am exempi fram the licenaing requiremenis as 1 om a lic e n s e d a r c h i t e c t o r a r e g�s t e r e d p r o f e s si o n a l e n g i ne er AUER �� fINAI/�� �3 e e j y.; �_. .. acting in my professional copacity (Sec�ion 7051, � DATE B�siness and Professions Code�. use vF n REaA�R � � ( 1 �EMOI FINAL r�C-F' Ex�STING BIDG. C �"�S ❑ 8 Lic.ar Rag.No. Dole A7MKP.NT TEL. � OWNER-BUItDER�ECLARATION PRiNT A%- �� NO. �' I hereby affirm thaf I om exempt from ihe Contrac�or'e License 7 Law for the followmg reasoo(Seciion 7031,5,Business ond p���Es . / fJ ��/, Professions Code): aRESehI �'� �•"b� BUIL�iNG � �� � � I, os owner of tbe poperfy, or my employees wilh A�DRE55 �� � � �'�� oges as their sole compensation,will do the work ond the strv[ture is not intended or offered for sole(Section LOCALITY �� • � �]']6!VI1 7044,Business and Professions Code). MOVING TEL. � •���'�b" CONTkACTOR NO. � ♦ � �I,os owner of the property,om exdusively contraUing , � � �� '7��� with licensed mn��octors to mnsiruct the project�Ser qDORE55 tion 7044,Business and P�ofessions CodaJ. p��(�fi'�� REQUIRED TOtAI SETBACK FROM E%IST - CONSTRUCTION LENDING AGENCY $Ei BACK yAR� HWY pROP.IINE WIDTH � - {hereby affirm tho+Ihere Is o consiruction lend�ng ogency for FROM , . � #� �� •��, the performance of the work 1or which this permit is issued P� � � I 1.1 6 b.5 0 (Sec 3097,Civ.C.). SIDE , , , [' ' '` • , • 1.1665d� j � Lenee:s Name /�d�"'''� ' o . _._.......... ... _ .. g I a.eFees �7� b ��d ve�muFee /� �D " ' 0218-82 lender's Addrass I / cerlify ihat I have read this application and state thot the � W I � I I�• 4'U Issuance Fee �..JLr obove infamotion is correct.I agree b wmply wilh all County . Invest�go:wn Fee � or � s �ate laws relotin to b�ildin construclion, �L� i !/�.'G�. d liereby ou�Vi ize e r nta 9es af rhis Counly to enter 7oiol Fee � upon Ih a6ove-m erfy for inspecLon purposes. � , � - • � �r�a�prr�� SEE RFYERSE FOR E7fPlANAiONY LANGUAGE � ' . � ^ Signomre af App6<anr m Ageni Dota - • •� ' � ��. �". ..�.. �....-+�"- �, . N • �\ y C'II m t * v v M� V� � � 0 6 � .°. � N ° 4 � � � � -o�"°'� 0 ��"� c "� c a «o �? �d �•« wG� �s .r�«,' � xma o m� dy �, °' m . 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