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HomeMy WebLinkAbout1008A (5) WORNCRS'COMFENSATION DFCLARATION � � ' � ��,�h�o";,m rh�i I hr.v.o��,,;���a.��{�o�,��„o,��f , ..APPLI.CATION FOR BUILDING PERMIT � ��sure,or o cert�(�co��of LVerkers'Cnmpenso��on Ir.surance, ' ' or o ce�i�Ged cony�he�eoi�Sec.??00,lab.C.) _ : ' COUNTY,OF LOS ANGELES 6UILDING AND SAFETY Po❑IlcyNo. Compony .. i - � �. • • ..�. ., • - . CeniFirtd tcpy�s hereby�urnished. , FOR APPLICANT TO FILL IN,._• eu�iatie p�O � � . .... ti no�a[55 p Cer�lf�ed copy is(�Ied w�ih ihe couniy build�nq ins�ec- gU�l��vG ��on depo.imeni. n7CSES5 �. �.� Do�e Appllconr CifY '/n I��_ 2iP y�-/(�% ip�quTv �,f.uin. CERT�FICAiE OF EXEA!PTION FROM WO4KER5' ' � .sti -•�+�0.O�Bf�GS' � � � + NJ�PE51 CON'•PFNSATIOY INSURANCE 512E�C�LOT NOW CN LOi� �4055 ST. y�lL (This sec�ion nr.ed nof be.compleled if ihr.permii is for one n55F550e hu�dred dollan�5�001 or les:.) TRACT BIOCK l0T NO. ��+pP gppC OAGE PARCFL nio. -fe/2 usE zo!�e rraP � �- 1 ceri�ly rhat in ihr,perfo�mance at ihe wo�k for which ih�s OwnER L r�o. a' permi�is issucd,1 shall nol e!m�loy eny person in ony monner pDC4E55 SPECiAI � so as�o become subjr.ct to ihn Wo�keri Compensoi�on Lows. CO':`JITICN$ V � Da�� A�plicanl CITY ZI^ �� � NOTICE TO APPIICANT: If, nOcr moking Ihis Certlfica�e o1 AR�HITECT OR TEL. UiSIR:Cf GaOu? 1VVE FiAE �'ROCESS[D BY �- Exem lion, � fnG'NFE4 h0. � ^ COhST.� ZONE �.I� U p you should become sub�cct to �he Wo�kers' Compensation provisions of Ihr.labor Code,you must forlh• nD^�fSS K3 TS d with comply wilh such provisio�s o� this p�rr�it shnll be TFI. N dCemed revOked. �y/a�y� � � STA715TIG4L QASS�FICATION A?T. CO�DO. Z COVTRACIOR VW��.a�/V NO. LICENSED CONTRACTORS DECLARATION ���. C1A55 NO.��DNTLL.UhITS_ I hc�eby a�firm�hot I om licr.nsed u�der prov�sio�s af Chapler 9 aDDRESi Np (commencinq wiih Sechon 7000)o(Oivision 3 of fhe Buslness ond �i� ��R l��P Proless�ons Codc,and my Ii[P.�SP i5 ill IuII�O�CC O�d P.Iff![1. [ITY CLA55 �� � VALIDATION 50.FT. '`'^� NO.CF NO.OF CHECK Licr.nsc Num6e� lic,Closs SIZE W STORIES FnM�liES I �h'F VALUATION Con�rot�o� Da�e �FXR!PTi040F VJO4K � �Q NEW � '�. M s ��.r /. /. AC� �I am eaempt under Sec 1 f7� .� (J, a �: � !�i%'?i' A17E4 �p� B.BP.C.(or�h�s reason (,� � qEpq�2 � S •• + • • • � � Date: �� �F n �1 �� � E%ISiI+1G BLDG r'�� ,n��'T If DEM1"Ol ❑ � p ti V.._— Signoturc APiqI�,4Ni TEL. F{NAL p °„". . " O\VkER�6UlICER DECLARATION (PR!NT� n"���'����� DAT � � � c'��,b C�r. ii i; 1 — 1 hereby offirrtt�ho�1 om ezempt(rom ihr.ContmUoi s licen�e ACpaF55 .3 FINA�L law l0�Ihe!f011owing reason�Seclion 7091.5,Dus�ness nnd � Prciessicns fode)� �aE,c.i BY�� � eu:ic�:� I, as owner of Ihe properiy, or my employrses wflh ACDc[SS wa�es as their sole tompensa�ion,will do ihe work cnd � the s!rucfurr.i:nol�niended o�o(ferr,d fo�sole�Secrion ��CALITY 7044,Aus�ness and Profess�ons Ccde}. n�.Ov�NG TEi. � I,as owner of Ihe propr.rly,am rzclus�re�y coniracling CONTRACT07 NO with licensed controctors to construU�he prolecl(Seo- aDC4E5S tion 7044,Business and Professions Cadc). CONSTRUCTION LENDING AGENCY SEi BACO YARD HWY �U�ApRO�I�NE� • W�Di1/ I herr.by affirm that�here is a consiruciion lending ogenty�or �ke.�� ihe pe.(o�mancr.oi�he work for which this perm�i�e issued r t. �Sec.3097,Civ.C.J. S�OE P.L. lenAer's Name � LD'AA Ref.p Lender's Address P����Pe S Dermii Fee i � I cer��ly�ho�i have.read this opplimiion ond s�ate�ho�the issoonce fee � IDMA P/C N , ' above informol�on is correcf.I agree to comply w;�h oll County in�rsr�go��o�Fee l,.,/Tl `� ordinances and 5!a�e laws relnting fo bu��d�ng construcfion, Taiol F�e � �,!`� LD�M Perm.M ond hereby authorize represen�alives of ihis County�o enler upon Ih/r�obovr.-men�ionr.d property for inspection vrposes. A � 1 ��� ���� SFE RFVERfE fOR E%PLI1NAiONY IANGUAGE 4�� S�9nnW f Applicanl or A�Pnt p� — I, T r, _ �I N � I'---- -- - —� -.-7�--_�--1---_-���,,.I .> -,-; .�i-_-�;--•--- ---:---• �--•I�z�-. � � c ° ` ' �` � j .. � _ =_ I y � - . I t� �-- -!;c � o 'i �� - ^ -- I;`: _�� �, � � _ ' � � �'.. �-- -� �-- ' '; ;I �'., � _� � ; .. .; .. � _ _ � ., � j - ' :; .,, - ;. I. . i'_ i; j a:• H _":' _ - I` `,I L � I � ' r i �`� i y � ' � I� � , c+ i '" I I�, . 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