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HomeMy WebLinkAbout1248A VQORKERS'COMPENSATION DECIARATION L 14�ereby offum that I hove a certificate af mnseM to self ���m I�A���w, ��� ��f��'�� ��DAA'��i � � � � sure,or o certrf¢aie of Workers'Compensa�ion Insuronce, L h Ad ���V■ or�c tified copy thereof(Sec.3800,Lab.C.) rD'ff � T !' COUNTY OF LOS ANGELES BUILDING AND SAFETY Polic o�Al"V�"���ompany ��+/�1?G� �%��"""� � Cerhfied capy is hereby furnished. FOR APPLICANT TO FILL IN BW�DiNG ��. ��.;� . �Q f� �' p / ADDRESS i�Z.L.,,./c' f;I/Ceni£fed copy is filed with the county buildinc�inspeo- BU4�iNG m ��Q tion department, ADDRESS --2-3/s� STf?f�-/✓� �"X � � r � ,�/� �?.:�_�",�.� /�— Date '�Applicant�'��" �I CITY QA/ ZIP I7�1 LOCALITY „ NO.OF BLDGS. NEAREST 1!�r!� /�� ' CERTIFlCA E OF EXEMP�N OM WORKERS' SIZE OF LOT NOW ON LOT CRO55 ST. I t Uf �l ��a�¢u_-�___: COMPENSATION INSURANCE (This sedian need not be completed if the pe.rmii is for one �y ����'''ttt� � r ASSESSOR , . hundred dollars($100)or less.) TRACT /��� 6LOCK lOi Np. 1 MqP gOOK PAGE PARCEL TEL. owNEa EST No.t��a0~Sl us�yz�oNe nno.v ,.`�{'P_„y�y� I cenify that in the performonce of the work for which this /Y._.� NO. � permit is issued,I sholl noi employ any person in ony manner qpDRE55 �j sf/�iLN(7E G�Q��K DIL• a SPECIAL (�j so as to become wbject to fhe Workers'Compensolion Laws. p / l� CONDITIONS (;J CITY IId�A��� � ZIP J�7b� � Date Applicanf ARCHITECT OR TEL � NOTICE TO APPLICANT: If, after making fhis Certificafe of NGWEE b ��ME� NO. DISTRIQ GROUP TYPE FIRE GROCESSED eY � CONST. ZONE U Exemption, you should become subject to the Workers' .. !tA Compensation provisions of�he Labor Code,you must forih- qDDRES s�{,5 �6�y��✓ /V���/D�~ �v -tiYJ• • � � ith comply wiih such provisions or this permit shall 6e �y N� TE�. STATISTICAL CLASSIFlCATION } APi. NpO. � deemed revoked. � — CONTRACi NO. 3� LICENSED CONTRACTORS DECIARATION LIC QA55 NO. � DWELL UNITS I hereby affirm that I am licensed under provisions of Chopter 9 ADDRE5S�3 w• ST��' 'ST Np.u�7�3 (commencing wilh Section 7000)of Division 3 of the Business and ��� SEWER MAP , Professions Code,and my license is in full force and effect. CiTV f"��V CLASS C-^3 BK � VALIDATION ,J �7 q $Q.FT.dJyffi��NO.OF NO.OF CHECK license Number ✓���✓'� Lic.Class �'�� 9ZE �S STORIES FAMILIES ONE �������7� � y VALUATIDN Conlra tor p � � Date �ESCRIP710N OF WORK e^��V€ �� NFjDD � s �� �I am exempt under Sec �".7s Li�'(J . � N�Q ���f� fi �� �L•4 J ❑ , B.&P.C.for this reason � T �l� F '��� C �� REPAIR ❑I� S c f G�3��G. Date: USE OF ' DEMOL u rr� « c .. ��� E%ISTING BLDG. rf APPLICANT 7EL. �Jf33 ���f � '� � l��.�1:! Signafure PRINT) GU � ��G4GE No PINAI OWNER-BUILDER DECIAKATION DATE (/ 1 hereby afffrrti ihat I om exempl from the Contrattor's License Z� r F> m%'Q,j;�;� Law for the following reason(Seciion 7031.5, Business and ADDRE55 G/' S'r�E ,�� � � Fifd Professions Code): . PRE ENT gY ��.j��-,��:?, BUIIDING � I, n5(1WlIP.f nf fhP nlnnP.f�v (lI Tv P.TpIl1vP.P.S WiiFt AnnRFGS _ `� ages as the�r sole compensation,wil I do�the�work and ,,f the strucfure is not intended or offered for sale(Secfion IOCALITY 7044,BuSiness and Professio�s Code). MOVING TEL. � I,as owner of the properly,am exdusively contracting coNiRAC70R �NO. with licensed conrracrors ta mnstruct the projec�(Sec- qo�eeSS tion 7044,Bosiness ond Professions Code). ) ���7 ,w�a / REqUIRED TOTAL SETBACK F �f aJ V � CONSTRUCTION IENDING AGENCY SET BACK YARD HWY pROP.LINE WID71i @ I hereby affirm ihat there is a construction lending agency for FRON7 L} ,�',,[�'� the performonce of Ihe work fo�which this permit is issued P.L �'/—'�"`^""' (Sec 3097,Civ.C.). SIDE � P.L. Lender's Name ' � / �f ) L�MA Ref.# P.C.Fee S Permil Fee ur¢.Lr /� , Lender's Address ) I rerlify that I have read this application and state fhat the Issua�ce Fee 6��^'��� l�Mn P/C N above informotion is mrrect.I agree to comply with all County Investigonon Fae ordinances and State laws relatinq to buildinq construdion, Total Fee '�� IDMA Perm.M and hereby authorize representmives of this Coumy to enter upOn�he obove-mentioned property For inspection purposes. � �. ,���'� � 2 q �p SEE REVERSE FOR EXPUINATORY IANGUAGE ��gnoNre of Applican�or Agenf Dote _, _. --_- - -------- . _ .. �_._ ; F. , ,- _ . . _ . . . .... ...... .... . ...... . .--. - �-- . .. ..._...._ .... .._ ._ �_. . ....-- - , � . : . _ _ :� _ , , : � . . . - , , - . . : ; _ , ' , � . .. , . , _ , ,. + . , � , ,: � : - .._�_.. . ._... ( .. z s i i ( � �, . �= � . ' 't . . � . '� ; ' � , , ' '' ' t E , 3 �� � . . , .y.. .' , 3e. ._ _. + , . ., I f � , � f V �, ' ' ��J. � ' ; � ( ' 3 ?' 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