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HomeMy WebLinkAbout0837A 2274A WORKERS'COMPENSATION DECLARATION I hereby affirm ihat I hove a certifitafe of consent fo self APPLICATION FOR BUILDING PERMI� � insure,or o certificofe af Workers'Compensation Insurance, or a rertified c thereo4(Sec.3800,Lab.C.) . Policy No. �����Company �`j���K. f-z.s�r� COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING� �����- R �� ADDRESS � � . �Certified copy is filed with ihe county building inspec- BUILDING �q/�' . �..,_. tion departmenf. A�DRE55�JgGY��~ vS� � Date T✓`r����Applicant���/'� �_� [.-"t"��'�C�iq CII��� �w1i�� ZIP �.9 l k�" ' IOCALITY -�� i CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. NEAREST -C` . COMPENSATION INSURANCE S¢E OF LOT NOw ON�07 CRO55 ST. F.;,' -.....5 i�-.1�+,�a��..�._� � .1��,��"�.�,a;�.. (This section need not be completed if the parmit is for one ASSESSOR hundred doilors($100)or less.) TRACT BLOCK LOT N0. MAP 800K PAGE PARCEL `. OWNfiB. 1,�'��L- �lf.�✓r •�- NO� ��, _� USE ZDNE P ,���.� C. I certify that in the performance of the work for which this NO. �,,; permit is issuad,I sholi not employ any person in any manner SPECIAI p„ s0 os fo became su6ject to ihe Workers'Compansation Laws. ADORE55 �. CONDITIONS � Dafa ApplitaM CITY ZIP r� NOTICE TO APPUCANT: If, after making�this Certifitote of ARCHITECf OR TE� ` DISTRICT GROUP TYPE FIRE PROCESSED BY O ENGINEER i ���.. I'1'� /✓ND. BT��l L CONST. 20NE �" Examption, you shauld become subject to the Workers' a s� � -_.�,���.�-�;-� ,,,,r� r, fa Compensation provisions of the Labor Code,you must forth- qDDRE55 �� 9+� �^ �`�� fG� 1.l.,'s 1\� 'u �_-- �g� `�.` � with wmply wifh such provisions or ihis parmit shall be i TEL.�7�i� STATISTICAL CtAS51fICATION � APT. CONDO. WJ deemed revoked. CONTRACT {p�/ �+.s.c/�y NO.J�' '� l!�+ {'� ; � LICENSED CONTRACTORS DECLARA710N ��� � CLA55 NO.�L—DWELL UN�TS I hereby affirm that I am litensed under provisions of Chopter 9 ADDRESS �-�'� � '�. ��fGh's-� NO�� . � (rommencing with Section 7000)of Division 3 of ihe Business and � ��� y� SEWER MAP Professions Code,and my license is in full force and eHect. CITY �'1"N"s�'�� /�.°� C�A55 r"=� BK � VALIDATION 1� �" SQ.FT. �dyyyS�NO.OF NO.OF / CHECK License Number������� Lic Class� 51Z -�'�STORI S FAMIUES 1 ONE } VALU TIO r�,w a�F I ers-/ress E^�'-rr-S¢s �ESCRIPTION OF Wok - �» -, New � --�.Y-- -:•'C S�`,7'� Contraefcie� Date -_'�".. , ADD •'-� ... " ❑I am exempt under Sec. — ��'"�r ' :� �n � '�� I r� ALTER � //_ �':°r a � �•�" ` 8.&P.C.for this reason f� �i;7t'�i�':`� �J���.�'�✓'�'✓�'-�- REPAIR s �'�F� ��� O �5 � f ���2gb5 USE OF r1 Date: DEMOL EXISTING BLDG. u e;_ Signature APPLICANT +;� ry� . TEL. s� s PIN ,.p 3 ��r�.(:��v OWNER-BUILDER DECLARATION PRINT).-4.�L'T!V il r`�s�G'G��S NO. �a����if�' pA�'���7 ��.� � _�� I hereby affirm ihat I am exempt from the Contractor's Licensz � :a�v fo�the follcr�ing reason(Seclion 7031.5, Bosiness and ADDRE55 ����.`1%1 d��'99e%8l/�71sBY� �'�. FINAL � Professipns Cade): PRESEN gY "� ni, as owner of ihe property, or my employees with ADDRE55 — wages as their sole compensation,will do the work and ;,�,- the structure is no�intended or offered for sale(Section LOCALITV _ ' ._�_C�l,�l I�l 7044,Business and Professions Code). MOVING TEL. , � � I,ps owner of ihe proparty,am exdusive�y canfracting CONTRAG70R NO. �{° �' ° �� � I with licensed coniracfors ro construct the project(Sec- qDDRE55 i o�/1�,L r tion 7044,Business and Professions Code). - RE�UIRED TOTAL SETBACK F CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE WIDTH "' o�4. ;.(i(J� I hereby offirm Ihat there is a construction lending agency for FRONT Ihe per4ormance of the work for which ihis permit is issued P.L � C i�7,_�8 (Sec.3097,Civ.C�. SIDE P.L. Lender's Name r C� / �n � IDMA Raf.A Lender's Address P.c Fee% ��',). � Permu Fee �V�� ' I certify that I have read�his applicalion and sfate that ihe Issuan<e Fee �t`-,Q LDMA P/C X . above information is correct.I agree to comply with all County lo�esfigafion Fee / ordinonces and State laws relatin to building construction, To�al Fee /i�� LOMq Perm.R and eby authorize resenf es of this Counly to anter �pon the abave-me io ed pr erty f inspection purposes. /7 ��.���/�� � �*"�'r ' ��"r�"��1 SEE REV RE SE F R EXPLANATORY LANGUAGE .._.. Signoture ,Appliy nt or Agent Date �,. r—` ---•----..__..---'...._..._._...,__... .. -'- ._. .._ ...... _ _ .. . . ,_._.._...... .__._ �. ._ ...__ .._._......... ...' -'-- ....-' -_'.. . . ' - '.___ � � -.,.r,i.. ' ,.. � '.. ' £--- . . .. _ _ . ._._....a.. ; . . � . _ ,. ; � .. : i _ - 3� - _ 1 �Y� i ( " � a q � . 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