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Home My WebLink About0639A WORKERS'COMPENSATION DECIARATION , _ C.i .. I'hereby offirm tha� I hove a certifimie of consent to self qpp`dCAT10�V FOR BUILDING PERMIT � �insure,or o certifimie of Workers'Compensation Insuror,ce, or o cer rf-ed c thereaf�Sec.3800,Lob.C.) � � - �- �-- � ,.. �rp�"�� • � � ,,.. , COUNTY OF LOS ANGEIES BUIIDING AND SAFETY VoIIcYNoylp.'3 30�3 ��ompany LS ri . . .. . . ..,.�... ...... _. . .... ..... �Q��. Cert�fied copy is hereby f�m+shed. FOR APPUCANT 70 FILL IN Bw�oiNc. +� �- ADDRESS .?�✓�.1��I � � Cerhf�ea copy is filed with the county building inspet- gUiLOING � � � fio,n depor}mem. ADDRE55 C � Date�Applicant �A+� r �-� -p C�Tv � i � Z�P LOCAIITY R7IFICATF OF EXEMPTION FROM WORKER$' N .Oc 6LDG5. NEAREST / COMPENSATION INSURANCE SIjE OF�pT . NOW ON LOT CRO55 ST. (This section need not be mmpleted if fhe permit is for one �� ' (� g�OCK �p7 NQ 1 �ESSOR hundred dollars(y100)or less.) MAF BOOK PAGE PARCE� TE�. USE ZONE �P �; I certiFy thal in the performante of Ihe work for which ihis OWnIER p NO. � � permit is issued,I shall not employ any parson in any manner r SPECIAL �� so os to become subject to Ihe Workers'Cpmpensaiion Laws. ADDRE55 � CONDI,TIONS a- Dafe Applicon� ��TY 'j . Z�P � ARCHI i ECT OR 7Et. NOTICE TO APPIICANT: If, after moking�this Certificate of piSiRiC7 GROUP TYpE FiRE PROCESSED ev � ENGINEER NO. Exemption, you should become sobject to the Workers' � CONST. ZONE Z— Compensation provisions of the Labor Code,you must forth- �fJ C.a ADDRE55. with comp�y with such provisions or this permit shall 6e �, TEL. � deemed revoked. CONTRAC70R NQ' STATIST:CAL QASSIFlCATION qpT, C pp, LICENSED CONTRACTORS DECIARATION ��. CW55 NO. �� DWELL UNITS � I hereby affirm thot I am litensad under provisions of Chopter 9 ADDRESS�) NO.�.Z �f (commencing with Sectian 7000)af Division 3 of the Business and � i�� [� SEWER MAP Prafessions Code,and my license is in full force ond effect. CITv � CLASS �'�� / VALIDATION 54.fT.n NO.OF NO.OF �HECK BK. FG, LicenseNumber ��9'�� Lic.Class_C-3g SIZE a,�, L�'�JSTORIES FAMILIES ONE ❑ VALUATION '� DESCRI7TION OF WORK NEW Convocror��2�y r�" Dare ❑ s U"',�;� , J 9 P� t'4' A�D �I am exempt under Sec. ��e_ 2, �� ❑ � ALTER B.&P.C.for 1hi5 reason s� REPAIR � s p u5E OF l� EXIS7ING BLDG. j � � �EMOL � �n. ,�/ �C63,rr. S�gnature �.+t'1� ��y 1. �� APPLICANT TEL. fINAL Ji/ OWNER-BUIIDER DECLAR,4TtON PRiN?� N�' DATE � f��? (} �`' � ° ` ` i I hereby atfirm that I om exempt from the Contractar's License Low for the following reoson(Section 7031.5, Business ond ADDkE55 FINAL � I � n O 6/v Professions Code): PRE N By � I, os owner of ihe o e�t or m em lo ees with AD^R SS � " �'� f� '�'�` P� p Y, Y P Y � wages as their sole compensation,will do the work ond , L'S`.C�,�3� the siruct�re is not intended or offered for sale(Section ��+��TY 7044,Business and Professions Code). MOV�NG TEL, � 1,as owner of the property,om exclusively contrac�ing CONTRAC70R NO. with licensed coMrocfors 10 consiroct the projecf(Seo- qDDBE55 tian 7044,8usiness and Professions CodeJ. CONSTRUCTION LENDING AGENCY SE BACK �ARD HWY T�TApROPICNEF WiDiH I hereby aftirm that there is a consiructian iending aqency for FRONi ��T1_� �he performance of the work for which ihis permit is issued p,;. -� k3'PJ ?�� (Sec.3097,Civ.C.). SIDE ''� v,t. Lender's Name �/�t ` IDMA Ref.$ m Lender's Address ~ ` v.0 Fee S Permi�Fee ,7 , 3 I cerrify that I have read this opplication and state that the issuonce Fee � ��raw aiC fl a6ove information is wrrect.1 agree to comply with oll County Invesrigaiion Fee ` � � ordinonces and State lows reloting to building mnstruction, imol Fee �J L�MA Perm.k � and hereby outhorize repres fafives of Ihis Coonty to enter $ upon the above-men�ione r perty for inspection purposes. � �'�'�_�� SEE RWERSE fOR E%PLANATORY LANGIIAGE Signoture vf Applicam or Agent Doie _. __----._,__ ___.�.._ _._.... _ _ ...___�_ .._.w_. _.____ ----_.�-- -.__..._.. .._._.__ , _._._ _._---,_._.__..__ ..._.___ � -��- -,--_ ._�.__ _.__ .�. �.. ..__.__.__.-__- .--.__ _ ...__�_. _.___._._ _---. �_.�._:._._�______�._._>..:� ��_w_.� --.�u.�. _. ;_._._. _ .___ _.__.____---�_. _ '_ ---- ---__._.._: . ; , . ... ___._...____A__.___�...__.___.___..v.___�_.. ____,,__::�.�.___-_.�.W._ _.:_F___.�_,��-�._��w��. �_ _____._ _. , . ..__ ___,__ ______ �.�._ � � �.....� _��.�w.___.___:._��.�-� _ .----.__. ,____ - -- --... ; , , __-_____.._ _... ---___. .- ---,- ____._._ ___..�__.�.._.___ _ __ __ _._- _,_..._._..____._._._ . ___.._.--- ___.�__.. _.._,._ �___�...�._.«____.__.._._.____��..�._��._�_��._ _ �_.�...__.._----- --... . . . � j a �,_�__ _.___ _ _ _ ,...: ; � ��:•-:-�;'...-� ; -----____ .._._,.____._._.___.---.__�.__� .____ w._._. _.w ��_.____-__._—__�_._.. _....._�__ ...__. ---__.____._ .. _. ____ -- – -... _____ ._...... __._.__._____..__ _...___._.__....__ ..__.�_..._. _�___._.,_wt_�_._. � ._. . __..--- -—.. .__ � _ _......__ ..: ___.__._._._ .---.._.___..__----_.__. _._.. i _.,.__._- _____._._.. ._.__._____ __�_..�____.�._._. ___�..�...__.�_..__. ...----- .___._�_ _.. . _.__ _ . _. - -- -,--- . .__ __.__.--__. _. , . i I , , , _,a�._.��.�_.._ _�._�,___�� __ __._.�.________.____..___.____._ _ __.__._.._�_ � � � �v __ _ 4 �_: . .� �._, � _._..............� ._...�..m.�_...._..,�,.._.�._..�,..__._._.m... ��a.� ::; . . . _.___.___._.._._.__,._.__....__,._..__ .:.�.,._ ..._�_, __._�_._____�_ _ ---_--- �_.A...__._..._._.�__._..,._... _,. .._. .._...._. � � � i i . .... _.�.__--' : ..,,___.._.....__..._._......�_V....�__„,. ...... __.._._._..._._...�._......�...�__ � _ . ,. ..._�_�._..__....__._. ._....__.. � ....... ._.�..�..---.��.___..,.i.�}.�....__ � --._,__._.. ._ ...__.,.....__. ,� --'—._._...__...,..__.�_.- ---.�.,`. . . _ ' .. . . _. . � � � , ..�<:s7�, ' � � _._,_..___.__ .._......___.___..�__....�....._.._..._ . ___.,...,, - �__.._ � . .:. . . . ........._...._ __ ..__ _.__..._ _._.__.._... ..._..._.._.. ..._._ , ..,�. ., _.,.__ . ,._ _.... ... . .,.,. . . , ..�_., ... 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