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HomeMy WebLinkAbout1199A (6) 1 WORKERS'COMPENSATION DECIARATION ��k � insureby�roafCp1iica�eolWorkers'1Companso�onlnsurancef \ APPLICATION FOR BUILDING PERMIT `� oi a certLif�ied coupy�hereoi(Sec.3800,Lo6.C.J COUNTY OF LOS ANGELES BUILDING AND SAFETY Polic�d,s'�7 Company '� � Cer�ified copy is hereby iurn�shed. '-Z�' FOR APPLICANT TO FILL IN ADDRESS �3s Q ,� L .r.l- Cerfified capy is filed wilh�he counry building inspeo BuaDiNG L (/ � U fion deporlment. ADDRESS � c7 !� • ` ooi����Applimn � an no J iocr,urv � CE IFICATE OF E%EMPTIO ROM WORKERS' NO.OF BtDGS. J �qp�55T. COMPENSATION INSURANCE . 512E OF lOT NOW ON LOi (This seclion need ne1 6e mmpleted if iha permit Is for one , ASSESSOR hundred dollars E1�0)or leis.) � TRACT 9lOCK LOT NO. MAP BOOK DAGE PARCEL � ' �E�' ��pp ��� USE ZONE �P I certify�ho��in the periormance of ihe work for which�his ��ER <t�QlLan. No. r.�p. } permi�is issued,I sholl not employ any person in ony manner {,/D SaEGaI iy�. so as lo become subjecf lo the Workers'COmpen5oti0n(.aws. NDDRE55�.35/ • CON�ITIONS 0 CITY �7 ZIP I��-S U Date ' � ApplicoM � ARCHITECT OR TEI. , oIARtCT GROVP TYPf FIRE DROCESSED BY O NOTICE TO APPLiCANT: If, afln moking this Certificoie oi ENGWEFR �� NO. - CON�ST.}----- ZONE I-- Ezemp�ion, you should become subject to tha Workers' R ���� + `-��`` U Compensa�ion provisions of the labor Code,you mus�forth- qDORESS �V "'- � � ` p�, winc �ompty with such provisions ar this permit shall be n TEL p STATISTIGAL ClA55ifICATION Avi. COrvDO. cq deemed rovaked. CONTRACT W.NO. 7� 7Z Z LICENSEO CONTRACTORS DECLARATION �,�. 3$ yg 0.AS5 NO.��µ'FlL UNtTS I he�eby aHirm�hor I am Ifcrosed under provisions oi Chapter 9 AOORE55 / /Lt+�n�0. ��R�p (commencing wiih$eUion 7000)oi Division 3 of the Business and �n� LiC. C r2 VALIDA?ION Proleeeions Code,ond my IicenSe ie in(ull forte and effeU. CITV O l.�•. CUSS � BK pG ?,¢ f� Q SO.FT9 NO.OF NO.OF CHECK Licensa Number-J u�r�/ L(c.C�ass�� � SIZE il3 SiOR1E5 FAMItiES ONE VALUATION��00 p� ZZ, pE$CRIOTION OF WORK N� � Comrotlor 'Date �, ADD � S , . �I am empl onder Sec. '3� qtiER � B.BP.C.for�his reaeon ��' REPAW s USE OF � � Dats: EXISTING BLDG. DEMOI Si noture � AvaiCANT ' TE�• FINAL 9 OWNER-BVILDER DfCtARATION PR��'�T N NO. �� pATE IZ��, I hereby afiirm that I am ezemp�(rom the Contrac�or's License qp0aES5 -�3 w N/� /) CT ONT. FINAL Lew(or the following reason(Sedian 7031.5,Business and Profesaione CodeJ: - - N . �y ❑ BUrtDING . �1 1 (�,(�A I, ae owner of the property, or my empioyees wilh ApDRE55 woges as thelr sole compensarlon,will do the work and , �� � �he strocfure ie no�In�ended or aflered fa�sale(Seclion ��`��T� � • • •� 70<d,B�sinefs ond Professions Code�. � � � MOVING � TE�- � I,as owner af Iha properly,om e.clusively controcting CONTRACTOR NO. � . •�j(j�]j wirh licensed comracto.s io consrruct the project(Sec- qooaESS-- " �ion 70A4,Bos�ness and Professions Code). ' " '�L �"�' RE�l1�RED 101A1 SEi3ACK F i CONSTRUCTION IENDiNG AGENCY SET BA�K �ARD Hvn PROP.lWE wiorri O E 2 6—a b 1 hereby offirm that Ihere rs o constrociion lending agency far FRONf I the periormance oF Iha work ior which this permit is issued D.L. � � - (Sec.3D97,Civ.C.). SioE I P.l. lender's Noma (�N lDM4 Ref.M m P.G Fee S Permil Fee dr� - ' � �e�de,•s ndd.ess � I certify That I hore reod Ihis opplicofion and slole that Ihe � Issuonca Fee la .S o LDMP.PIC M above informatfon is corracf.I ag�ea ta comply with all County �mesr�gaaon Fee I w� S ordinancee and S�are lawt reloling io building coailrottion, Tmoi Fea Y� .L� IDMA Perm.�1 ond hereby au�horize representa�ives of this Counry to enter' � upo�the obove-men�ianed property for inspettian purposes. M1 ���G���yN Z �� SFF RFVFRSE FOR E%�IANATO�Y IAHGUAGE S�gnorore ef Applimn�or AgeM � Do�e � � , � � T� � �, n 2 � � '_` " '^ o 'v+c c c n;^ � rn � L� ;' � , �o` o ? 7 0 0 - �j O O � N n F _ f' 7 0 - � � O � C � T 3 5 � �O _ p _ . C � � r. ' - � i � � '� � a o - = r = ° � n = . o =� ,,, ,� � < . a F o � � e __ _ ,o ,; � � n � �? �c o f � ° � � � ° �' n° - �- � `� D a v 3 -, o c v � � ','., c� g � � o - I v � � ° � ° = o o. o c � � o '% - c � o v �- ' o a � vo� -c a - � n o c I 7 = = - - m - . 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