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HomeMy WebLinkAbout0854A (4) VlORKERS'CO"1.PENSATION DECIARATION 'I I he�eby affirm ihat I hove a ce.niilcoic oF�o�,e�,�o s��, APPLICATION FOR BUILDING PERMIT � insure,or a cerli(icofe oi Workers'Compe.nsolion Insurance, or a certificd copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company Certi(ied co s hercb furn�shr.d. euno!N� PY' Y FOR APPLICANT TO FILL IN n��q�Ss ri'�5L•1� �c,,���-•�w-a-�� � Certified copy is iiled wi�h�he county building inspec- BUnDiNG tion deparimr.nt. AD�RES ��' LOCALITY .-r7-s-,.�.�..�. ,��/ f�'EA4EST // �' Dale Applicant CIiV r� ZIP CROSS ST. e�-,�t• .�* CERTIFICATE Of EXEh1PT10N FROM WORKERS' �,/ NO.Cr BLDGS. n55E5<_Oe " CO!AFENSATION INSURANCE SIZE O�LOT (� NOW p4 LOT 1dAP 60CK PAGE PARCEL (This secfon need not be coriplered if ihe pe.rmit is for ono �7 f i7 u5E ZCn;E r,+aN hundred dollan(5100)or lese.) tencr � ?i«K _ ioT r.o. 1 l J ;E,'/ No. /D��3'r� � 1EL. SFECIAL I ce.ti(y ihar in ihr.perlormance of Ihx work for which ihis ���1NFR " NO. •��'��'� �ONDITIONS t}1 permi�is i55UPd,I Sh01�noi e Pr50R in On manner � U:SIkICT GkOUP fYf`E FIRE PROCESSFD DY o so as�o.bercome su je.cf fo e Workers Co � � n Laws. ADCPE55 � " CCNS�T. Z� � �J Da!e�A licant CITY _ +� ZIP ' /� �'� ' �G� �`j� Q PP !`-- � SiAf15iIC�lCl/l5S'�ICAIION APT. CCN70. I- NOiICE TO APPLICAN7: If, after mokin� Ihis Cerlificalr. af /+RCHITECTOR TEi. V Exr.mpfion, you should 6ecome subjrtf io Ihr, Vlorkeri �Ncl�:[FR NO. CLA55 NO.�DWfLI.UNITS �» r_ Compensation provis�ons af the la6or Cod�,you must fo�th- ppo2[55 SEWER�IA� '� wiih comply wirh soth provisions or �his permi�sholl be ttFL. t dcr.mrd revaked. [ONTRnCTC' .A T NO. Z)� I � eK� �. VAII�ATION � LICENSED CONTRACTORS DECLARATI04 ��� (� I hereby aifirm fhnt I am licensad und�r provisions of Chapter 9 PCDRES. 0(�_ NO 1 VAlUAT10N (commencing wiih Section 7000)of D�v�sion 3 of ihe Business ond �, �i� I},'.iFess�one Code,and my licensn is in tull force and eFfeU. �itv C1A55 S J✓�O fl ���Q�y���/ 2 $Q.FT. NO.CF Np.OF [N�CK ► Litensc Num/h�rr-t,^^,m.[a.1LLLL/liC.GIo55J.� S12E .r�L STCR�ES FAM•lIES Cf:f COn�fa[t0I\jW�"V 1'1��\7q I^ rY CESCR!PTIO40F Y.'C4K hEW ❑ S afe AD� � �1om exempl und?r Se[C. -' J ALTER � FINAL ti! B.BP.C./or th�s�eason.+J�����_ R«,A�Q � DATE �iJ� �'I USE OF Dale: ExiSnvG RIDG. — CEIfAL � FINAL^ SignolU ,� ACPLICAM1 � TEL. �f J °y • �����}+`+�' OWNER-BUR�ER DECIARATION �raivi� n0. r I he�eby aiiirm that I am ezempt irom�he Contrac�or's Licen�e r'� , low lo�thr,following reason(Sr.nion 7031.5,Ousiness and A����S, �,J� Professions Codr.): IN7E5(hf � 1, as owner of Ihe propeny, or my employee.s wiih Ao�osE"ss ��'Q�a 4 Pi wagce as rheir sole tompensaiion,will do tho wcrk and � ' . thr.strutt�re is not inlended cr offered io�Sale(Srclion ��CA�ITY „ . • . 704d,Business and Profrssions Coda�. h•OV:NG TEL. � I,os owner o(iha properly,om ezclusively cantrac�ing CONT2ACfOR h0. � • •4 9.2 5 with licensed tontractors la conslrucf Ihe projecl(Sec- qDDFE55 •(:�,G 5� iion 70�4,Bvsiness and ProFessions Code). • • RECU!R�D TOTAL SETOACK FRUM E%IS�. CCNSTRUCTION LEN�IhG AGENCY SEi BACK YARD FM151' CRO�.(INE W!DfH , � G 1.0�G—f3 4 I hereby affirm Ihat ihere is a consv�cfion lending agr.ncy for Fk�,y� the performante of Ihe work(or which Ihis permil is issued '-p.t. iSec.9097,Civ.C.). 5!CE P.l. Lender's Name p Lender's Addiess P.C.Fee E P�.m�r�ee .7 O� �7.5 � I teniiy tha�I hare read ih�s opplicafion and s�atr,tha��he Iss�nnce Fnn O. -S 0 obove informofion is correcl.I agrea ro comply wiih atl Couniy in.es��garon Fr.o ordinonces and 5!ole laws relotinq ro 6uilding construction, � .�j eby authoriza rapresentafives of lhis Counly fo enter Tolcl Fee �pon th ob n aned property for inspecti^n purp�e� . z/ u� SEE REVERSE FOR E%PIANATORY LANGUAGE �� S�gnarvre af Appliconl or A9en1 paie 2� .� a 0 .� .• �� � � � T ''C Q � _ � � G ��• � ' �n �� C� ::- C- C� {:- � � C ...� � ,C = O C :� � ry t'.�.' t: f•' 1y '�• C ' r, i�^ �. L t.' :. 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