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HomeMy WebLinkAbout1707A 1708A WORKERS'COMPENSATIDN DECIARATION �' ' � � I he�e6y offi�m.thpt 1 hove a certificate of consenl io self qpp�ICA�'��N FQR BUILDING PERMiT insura,or a certificote of Workeri Compensiion Insurance,or ' a cerrified copy ihereof(Sec.3800,lab.C.) COUNTY OF LOS ANGEIES 6UILDING AND SAFETY Policy No. Company ' � Certified copy is hereby`turnished. FOR APPLICANT TO FILL IN Bu��owc, (� /1 /�� � ADDRESS p sIO (� �C�_ Certified cOpy is filed wiih the county building inspec- BUILDING /� � / fion dapartmenf. ADORE55 `. LOCALITY �p iCLf.ff NEAREST Dote Applimnt CI7Y t f ZIP CROSS ST. CERTIFICATE Of EXEMPTION FROM WORKERS' wo.oF BiWs. a55essoR COMPENSATION INSURANCE 5¢E OF tOi� i7� � NOw ON�oi MAP BOOK paeE pqRCEL (This section need not be completad if the permit is for one USE ONE MAP TRACT BLOCK LOT NO, ' NO. Q } hundred doilars(5100)or less.) . ,/ — � TEt. SPECIAL a I certify that in ihe performonce of the work for which this OWNER h t No. 6 -lu 2 3 �6�OOp CON�I7iON5 Q ermif is issued,I sholl noi em lo an �iSTRICT GROUP TYPE FIRE PROCESSED BY p p y y person in any manner qDDRESS � CONSi. 20NE � sa as Io�ecopie subjecl to the Workers' mpensotion Laws. �a /O Da�e�/ �� � AppliWnl � CITY 21P STATIST�CALC�SSIFICATION � APT. CO� � NOTICE TO APPLICANTr If, after aking �his Cer �at of - ARCHITECT Ok . TFL W Exemption, you shoutd become wbject to the orkers' ENG�NEER NO. cLA55 NO. �0 oWELL.UNI75_ p, Compensotion provisions oi the Labor Code,you must forth- � � I AD�RE55 SEWERMAP Z' + wifb comply wifh such proviaions or this permit shall be TE� � deemed revoked. _ CONtenaai P � �,.1r�� No. y-?Z 2p BK �. VALIDATION � �.� LICENSE�CONTRACTORSDECLARATION ��� 36�JYJ "T hereby affirm ihat I am hcensed under provieions of Chapter 9 ADDRESS pL'��(/ .:�1 J fi' NO. YAtUAT10N �commencing with$ec�ion�000)of Drvision 3 of tbe Business and -}-. ��� Professions Code,aru!my license is in fu41 force and effec�. aiv L •yy.b✓�1 CtA55 G'.z b ��Q, f�'T� `'� i��.c�ass� SqEFT�p sTOR�s AMi�Es oNeK �1 7 Q 7 A LicenseNumbe� ���J � Controctor DESCRIPTION OF WORK /� �_ \J New " a #•.•••2 3 ^ • ^ OfC � 1 } AW � I �U�O �rJ � I om exempt fram the lice ing�equiremeMs os�om o },J � 2E'1 �d�� W P� • • licensed archifect or a registered professional angineer ALTER � FINAI �� �� ��Q�O� octing in my professional capacity (Section 7051, � DA7E � 3J REPAIR Business and Professions Code). USE OF p�IX � FINAL O�O�'8 2 EXISTING BLDG. BY y Li[.or Reg.No. Dafe APPIICANT TEI. - OWNER-BUILDER DECLARATION PRINT� ND. " 1 hereby affirm thar 1 am exempt from the Conrmctor's license . Law for the follOwing rea5on(Section 703�.5, Business end A��RE55 �,,7 Q$A Professions Code�: aRE eN - BUIIDING I, as owner of the property, or my employees wfth ADDRE55 �}�!�� �,� wages as their sole compensation,wi�l do�he work and the strutlure is naf intended or offered for sale(Settion IOCAUTY � ��2�5 Q 7044,Business ond Pro4essions CodeJ. MOVING TEL � � � . . - � I,as owner of ihe properfy,am exclusively controcfing CONTRAC7pR NO. � • •!2,,5 O�t with licensed mntractors to construct the project(Sec- qDDRESS lion 7044,Business and Professions Code). Q�Q Z••8 2 REQUIRED 70iA1 SETBAIX FROM EXIST. � CONSTRUCTION LENDING AGENCY �7 gq�K YARD HWV pROP.lWE WIDTH ' I hereby affirm that there is a construdion lending agency for FRONT the performance of the wo�k for which this pe�mit is issued p_� (Sec.3097,Civ.C.). SIOE � P.L. Lender's Name �/ � Lender's Address � P.C-Fee 5 ,�-f � Perm�i Fee ,/�� I certify ihot I have read this applico�ion and srote fha�ihe �sso ce Fee ��� iobove informofion is correct.I agree to comply with all County Invesr�goeon Pee �� ordinances and State laws relating to 6uilding mnstruc�ion, � � and hereby auihorize represenfatives of this County to enter Toiai fee ,-. � S u � opon fhe obo� -men�ion prOP �y for inspecti�on�urpas^es. . , � � /////J1 / �� SEE REYERSE FOR EXPtANATORY LANGUAGE � � + � � dd dS� �� o �o y�}�.Q..fl,� C� '�, w � .r m g p++ �c�j �L. . v ?�w�,t C Q �•�y�.L.'+ Oi R Ot � O u � ti.�� V m k � ,a�i p'�..''°�o T� �r ""' m u h« tl �,, u o o�''.t' � odb � . 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