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HomeMy WebLinkAbout1419A 8919A (8) VJORKERS'COMPENSATION DECLARAiION ^ I he�eby•offirm ,�a,� �o��a«,,,�,�a,�of mnsent to sel( APPLICATION��FOR BUILDING PERMIT LS ".fu"�e,,ar a��rfifica�n of Workers'Compensaiion Insuronce, • o�acerlified cepy Ihereof(Sec.3800,�ab.C.) COUNTY OF LOS ANGELES eUILDING AND SAFETY PolicyNo. Company B�IID�NG. ry O ����Q � Cer�ified topy is herr.by furnfshed. FOR APPLICANT TO FILL IN n..eR,SS -1 ❑ Cerjilied copy is(iled wilh Ihe county 6uilding inspe[- g�IIDiNG I/ li0n departmenf. ADDRE55 7 � � �C QU n� �(�J4 LOCAL�TV Date Applicant CiTv � 0/✓� /7/�/% Ziv y� ]�s CROSSSSi. J ���C CERTIFICATE OF EXEMPTION FROM WORKERS' NO.Oc CioGS. ASSESSCa COh1PEN5ATION INSURANCE S�ZE OF LOT n r. NOw OY tOT ti!nr AOOK PnGE PaRCEL (This sectian need not 6n compleled if ihe pr.rmi�is for one Q� u 20\'E MAP h�ndred dollars(SI00)or�rss.� TRACT �Z l P.!OCK LOT NO. � NO. I O� � -�7,iEt. S%'ECinL } 1 certify thot in the performonce of�he work for which ihis OwhER O �/Z - � f}-�u h0. ��.� CCN'JITICN$ o. permil i5 i55uBd,I Shpll npl employ any e.rson in ony nne.r , O:SiFICI GRCU? IYf'E FI7E FR(KESSEU BY 0 so as lo br.comn subject lo Iha Work C mp ns . Laws. nCCRE55 . . � . Q. L 1 O ^ CCNGT,r• ZC� ����� V �/' � - 1,� ��T� � ��)��7/� (,(•� I�)/1 � '� v " /l Da'e ApPlicor �Y=�=`=�—b�I�-! Z�P $TAi15TICnL CIl�S$'FIUIICN AP�. CONDO. O NOTICE TO APPLICANT: If, after making Ihis Ccrtificatc of ARCHITECT O TEL. V Eremption, you Should betomc su6ject fo the Workeri FNG!NFFa �A f� . 'Q � NO. CLA55 NO. d� DWELL.UNITS�I �!1 Compensalion provis�ons of Ihr.La6ar Code,you musl forlh• qDDRE55 � ' y?. Q SEWERh•.AP � w��h comply wiih svth provisions or ihis permit sholl br. 7_ deemed rnvo4ed. -�y�E�� � VAIIDATION '- CONTRACTO4 �s 1WI�IUNO. � �IC1 PK� �'• . LICENSE�CONTRACTORS DECLARATION /� ii�. I herrby nifirm thot I om licnnsrd undr.r provisions of Chap!er 9 ADDRE55 � l� l}7A-/] �Q;'O. �L VALUATION (commencing with$e:tien 7000)of Division 3 af the 6�siness and /� Prafessions Code,and my license is in full fa�cr.ond e.f(ect. CiiV 4.� v�C2 CLA55 5 Q�d SO.fT �/•, VO.CF �1 NO.OF CfiECK , ? � /� � ;v r� . Licensa Num6er lic.Clasa SIZE 7 STO4!ES /� FA!:.!LIFS OKE � � 1 5 �! •• • ►'z� � COnlraClol Date DESCRIDTiC,�F WO.% V (�./ . h��v+ ❑ �I am ezempt unde�Sr.c � � ACD � � .f���j` nliER ❑ DA EL 12'�.f` "/ � :� i . 8.8P.C.for th�s reoson �/� t-N� � '�' f'�- . a�rnie Doie: USE OF FINAL �� F%ISTiNG BIDG. ��"'�"• ❑ B ...:C`.� .,.. $ignOture APiYIUNT �,r� y OWNER-6UILDER DECLARATION IPR'NT � r`� � . � � � I hcreby affirm that I om eRempl from the Conlrac�or's Litensr. � low for the followin9 rr.aeon�Sect�on 7031.5,Business and ADDaFSS . ^ P� fesslons Code): oc�_tti; ���o�� �a�i.�r�. I, as awnrr of Ihe Arepnrfy, or my employees with ACC4E55 wopn.s ae�heir sole campensaiion,will do�he work and : � � � 1 the strvct�re is nol inlended or offered for sale(Sr.Uion �OCALiTv �r + • 7044,6�siness ond Professions Code). M.OwNG TFi. � I,as owner o(�he preperty,am e.clusively cantroUin� NiRAC10R NO. � •C� Q�(1 with licensed contrac�c�s ro consrruct the projeU�Sr.c- qeDe�55 �'��� i"�,Q^� �ion 7044,Business and Profess�ons Code�. �� ��- kEQU1fiED TOTAL SET9AIX FRU.•A F%iSI, CONSTRUCTION LENDING AGENCY SEl BACK YARD HWY ekOa.uNE wiorH• , 0 cz�8"Z,I I hereby aFfirm ihol ihere is a construttion lending ogency fo� .,,faUN� . . Ihe performonce oi tha work for which this permil is issur.d P.L. •� �Sec.3097.Civ.C.J. Sipc m P.l. � � Lr.nder's Name � lender's Address P.C.Fee S �� Permi�Fee `�•� ' � I cerliFy tho�I hove read this applicalion and stale Ihal the les� ce Fee 0 �`�� Obove inFormation ie correct.1 a9ree to comply with all County inves�igo��on feo a � ordinonces and Sla�r.laws relatin�to 6uildint�const�uction, p r Dr� � �7 and hereby o�rhorize represenro�ives of ihis Co�nty to entr.r TD�OI FP9 upo e above-menti0ne properly for inspe[tion p�rposes. 1 'l\M �5 � �� �✓L 6(� - -�7 �� i.s � . � ' . SEE REVERSE FOR E1(PLANATORY LANGUAGE � Signorure o!A�,icant or Agenl pni� 'E'�/ ! �+ r r m T (A � L� ^v � (,� -r� T � I . -i �4 � j � 7 O O L7 O 7 � n C �O � O O (1� fr 1` f. �; . . ' t O C K. C� i� i �- 1 V S � 3 � � �� ; T' O � �� � �," o '4 �' {: � __I�_ .. 4. � � � � � ! �� �'] .. c:. �� 1 � L . O '� O _. _ i . 1. � �, -t� .c L: ii 7 _ � c ; v: � � n �'' H �-� �' •. �_ `� ' , c': T; n (1 I h J a'c � -'} � , �` �.;J t C` :'? 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