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HomeMy WebLinkAbout1586A (9) WORKERS'COMVENSATION DECLARATION � insureboraacertifcateofWorkersrtCompensationglnsura g" APPLICATIOIV FOR BUiLDING PERMiT or a certified copy rhereof(Sec.3800,La6.C.) COUNTY OF LOS ANGELES BU{LDING AND SAFETY P�olicyNo. Company BUItDING (� (� Cenified copy is hereby furniahed. FOR APPLICANT TO FILL IN qODRE55 d � � Certified copy ii filed wilh iha tounty building inspoc• BUIIDING .� tion department. A6DRE55 /� ✓J ►� LOC/+LITY NfAREST oore n����am an ^ m�r �/ z�v 6 crross sr. CERTIFICATE OF EXEMPTlON FROM WORKERS' �'�g��� ��'� . .. .COMPENSAStON INSURANCE � SIZE OF LOT NOW ON lOT hV�V 900K VAGE PARCEI (ihis section need not be completed if the permit is for one TRAR 0 gtp�K L07 NO. U�Z� OP � " hundred dollun(5100)or lass.) G I �f,, I certi fhot in the erformance of tha work for wh� rhis owNER �Y No. 061^�/� CONon�ONS � fy p DISTRIC7 GROUP iYPE FIRE PROCfSSED 6Y O permit la{uuBd,1 shall n01 Bmplay any onon in an nner qODRE55 � � ��' / CONST, ZONE V II �,a C n w/�as to become s�jecl to the Wor er' m o� ws � � �� {0 ' O ,/pple(_�'�`�o� AppliCnfq CIN mQ Y� ZIP STAT�STiCALC1ASSIFKA �. CON00. F ARCHITEROR L` , V r1^R . D CIASSNO.�DWELt.UNITS w NOTICE TO APPLICANT: if. aflar making this Cenifkare NG� E R y� W Exemption, you shouid become subjett to the Workers ,, -/ �' Compensation previaions of the Lo6or Code,you must fahh- ADDRESS .�[.�.C�t�^���' �0 t/���� SEWFR MAP �� with comply wilh such provisions or this permif iholl be �[] 7EL. VALIDATION � daemed revoked. CONTRACfOR 4�` NO. BK. PG, LICENSEU CONTRACTORS DECLARATION- uC. I heraby affirm tFwt 1 am licer�sed u�de�povifioro of CVapTer 9 ADDRESS No. YAlU0.TlON � ' (commencin9 with Seclion 7000)of Division 3 of the Business and IIC. = 9�A1 ' Professions Code,and my license is in full forca ond efFect. CITY CtASS / ti/ � SQ,R, NO.OF NO.OF CHECK . .... � ticenae Number L�C.CIasS SIZE STORIES FAMILIES ONE �,,,�,a,�a, oa�e DFSCRIPTION OF WORK ct'�! C 0 v? NEW = z 1 5 8 6 A ( � �I am exampt under Sec. ,e,�� � FINpI p #� �� � �� B.&P.0 for this rwaon �PaR � DATE a 7 O� � • •3 6 7 5 USE OF FINAL �f • � ��b,7 S= Oafe: EXISTINGBIDG. ��� � ���yC � Siynq}Vre - APPLIG4NT TEL- OWNER-BULLDER DECIARATION ��NT NO. O��Z 2-H 5 1 heraby affirm lhat 1 om exempt from the Controctor's Licanse pookf55 � Law for ehe fol{owi�g reoson(Section 703I.5,Business o�d Profee' s Code): P 6U�LD�NG 1, m ownar of the qoparry, o�my employeae wilh ADDRESS wages as�heir sole compenaafion,will do�he wo�k and `���T, the structuro is nat iNended er offared for sale(Section 7W4,Business and Rofessions Cade). A�/�NG TE�, � I,as owner uf�ha property,am eaclusivaly co�trecting C NTRACTOR �• with licansed coniracfors to mnaNuct the proiect(Ser qpDRE55 tion 7614,Business and Rofes�iane Code]. RE(�UtRED TOTAI SE7BACK FROM E%IST. CONSTRUCTIDN LENDING AGENCY SET eACK YAR� HWv PROP.LIN WIDTH � I heraby affirm ihat ihere is a canstructian lending agency tor ippryT Ihe pa�formance of�he work for which this permit is issued P.�. 7Sea 3097.Civ.C.). SIDE P.l. _ Lenderb Nome - - ]� P.C.fee{ - Permil Fge ��'V lender's Addreu O S� I cartify thot I hove read this applim�ion ond sloro ihat rhe iuuance Fee obove informatian is wrred.I aqraa to wmply wiih all County Invesiigolion Fae �/'� �� ordinances nnd Siate laws rela�ing�0 1lding tonsiroclion, To�al Pee (O and h by outhorize exntat'e thre County to enter upon t bova- m ne pro ty f inspactioo purpoees .. . ... . .... .. �J_.�i7��� SEF YEVFlSE FOR E%►LANAiO11Y LANGUA6E � ` , - � - �' � � SigrwNro of Appliwnr Or Aqent Dote � . O N y=.� C�i C.f p p��Y� L�� N V y C ,Y.�G W L U v� �`y G� S .. 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