Loading...
HomeMy WebLinkAbout1074A - WORKERS'COMPENSATION DECLARATION . �� I hereby offirm tha�I have a terfifitate of�o�,e��,o self , , - �� .APPLICATION FOR BUILDING PERMIT insure,or a certi(icote of Workers'Compenstion Insurance,or a certified copy�hereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY PolicyNo. Compony � CerriRed copy is hereby fumished. FOR APPLICANT TO FILL IN nooeess o?//� �iu�� � Certified copy is iiled with ihe county building inspeo BUiL01NG !p n / � /J � lion deparlment. ADDRE55 �I/ /�N Le��7� LOCALITV �«..w�+e�� ,p s(�(/ � / NEnREST � �� Dale Applicanl � CITY � Hph�/ Qr ZIP fROS55T. CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR � COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MA7 BOOK 7AGE 7ARCEL (This section need no�be mmple�ed if the pe�mit is far ane //n n u5e zONe hwP . hundred do�lors(5100)or�e55.) TRACT �(/(+d/ BIOCK lOT NO. /Q �/ Np. } TEL SVEGn.L d OWNE ., rhPr NO. ��d CON�ITION$ I cerfify that in the performance o!iha work for whi<h ihis 0 permil is isz�ed,I sholl nol employ any person in any manner DISiRiCT GROUP TYPE FIRE PROCESSED BY V AD�RESS � � //�S H!� CONST. ZONE so as�o become subjec�to Ihe Workers'Compensation laws. �/ • � � 1/ � CITY � /11D/�L/ /� ZIP /a '�3 � � , Do�e AppliCont STAi1511CA1 CLASS�fICA110N APT. CONDp. V NOTICE-TO APPLICANT: If, oifer moking fh icaf of /RCHITECT02 � 1EL � W Exemption, you should betome suble[i fo fhe Workers' � ENGiNEER NO.- CLASSNO.�� DWELL.UNITS_ f1, . Compensoiion pro��sions of the Lobor Code,you mu5/forih- ADDRESS SEWER MAV w Z with comply with such provisions or �his permit shall be TE� deemed revoked. � CONTenCTOR(/fF •No. BK. PG, VALIOATION LICENSED CONTRACTORS DECLARATION �J i��, � I herehy ofFirm thot I am licensed under provisions oi Choprer 9 A��RESS /�� �'¢ NO. � VALUATION Pmmmencin wilh Section 7000 of Division 3 oi the Business and /�/� rofessions Code,and my license is in full force ond ef(ect CiTv/�.C+• 9/73v c1A55 C—�q S �U'¢'� / $Q.FT. NO.OF NO.OF CHECK li[ense Number ��Oa �ic.Class L � SIZE ' $TORIES FAMI�IES ONE Contracto�V�r�T����'f Dofe Z�� DESCRIPTIONOFWORK / �P NEW ❑ s . � I am exempt from the licensing requirements os I am o G 7�as � ADD � � licensed archi�ecl or a registered professianal engineer _ , ALTER � FINAL acting in my prafessional capacity (Sectian 7051, REPAIR � �ATE Business and Professions Code). USe OF DEnnO� FINAL � E%ISTING BLDG. ❑ g Lic.or Reg.No. Date nPPIiCANT iEt. Y OWNER-BUIIDER�ECLARATION (PRINT) NO. w�� � _ nn_ I hereby offirm Ihol I am e�empt from the Contraclor's license _ /�=�+'�� C�� �� ��],�j A law for the following reasan(Sec�ion 7031.5,Business and ADDRESS . ProfessionsCade�: -��'�n,; ��„�, ,�/vt�z-C�Gi.. ���`• • • • � OeUiLDING V � 1, as owne.r oI the propeny, or my employees wilh ADDRESS � • �3 1,5 0 woges as�heir sole compenso�ion,will do Ihe wo�k ond L N 7(�• GJ�Z��f1L fhe structvre is not inlended or offered for sole(Setlion LOCnuiv 70d4,Business and Professions Code). MOViNG TEI. �p/�/�z �h,��V��� • • •3 1,5 0 c=i � I,os owne�Of the properly,om ezclusively Contracling fON7RACTOR NO. ( �/- ' with licensed coNrodors to[o�strucl the projecl(Seo- qDDRF55 YLU'1�� � C 7.{— �2 2� �a'� lion 7044,Businesz and Proiessions Code). J��� � � REOUiRED TOLAL SETBAIX FROfd ExIST. at �: i, CONSTRUCTION LENDING AGENCV SEi BACK �AR� HV"Y PROP.uNE wiDiH �p �� '�+" � ��e..�. ' ' I hereby af(irm�hoi ihere�s a construction lending agency for FRONi ' �he performance of the wo�k for which Ihis permit is issued P L. � — /� � (Sec.3097,Civ.C.). SiDE � 'K/,� it_�/y� P.L. V Lender's Name _ ��� M/�j��j� .-. /v G m ' Lender's Address . P.C.Fee 5 Permii Fee `, W I certify ihal I have reod this appiimrlon and sraie�har the �ss�o�ce Fee 6'�v �v�v �(/l��T� ` . Qobove in(ormotion is corred.I ogree ta comply with all Counry i„�esngonon Fee y7 g ordinances and Stote iows relating to building mnslruclion, � Torol Fee ��(/ ' and hereby outhorize representolives ai this Counly to enter mopon fhe bove-menfioned properfy�or inspeclion purposes. � . a �����/Ji� _1,(�/- SEE REVERSE FOR EXPLANATORY LANGUAGE ctr� � Signmo I A a�olyR9en� . � 2t G (/ . � � a o G� -"• c o N T� � a p � ^ Q � O 9('.1 � m o �' � 'S C� p � ^-- �� �a � t� � m T+ r R� -n o �' m� _' ' F . �� O a o �' ^ o s = � � r p � � d-. ;- `� a � n� � ^ o ,,,-n f�S o 0 3 6' a, o.o �9 0 � o v m � � ° 0 0 � n i+ i ,o o v � � 3 n � � � S � � m C�: g �c 7 'ci N c, o o m o � a, � � ` �p -c � p� � � Q o � va ? � •e o � =� x �"c N ^ N. �� b • yQ �.^.. r � P�� co o a c V) a o- w � � y p O� O � :!) �� � � . N , ' N �j ( O r O � �i � O fJ ^ � � Q O 0.� � p � � � O � P � � 0 C• � 9 � 7 � � � � d � M � ` U � JD � � , . 0 4 i' --� . q� v 1D o A v ^ v � � o N ' O �j p. ` O"Q. K: 7 s c 0 . � . � �o ._ � . • • O A . .. VN , z ' � O , . � m N j � i ', ,7 p ^O�.� C���� m S �t q p C�.A„ �0 � ... a O ' ' Q„V L""y "�`� A� C! � ❑C...T.Oo �V O C`"S p h ��„ � � �,,,��! - p..� � o p � � ...� ,� `a C..o o N:.�,'� � r''� � nb �y O w �e � F c x '� ty� c ��=.� �„� ^ Q Q a � Q,C •y �� ❑'O cQ,' e -'�.�� ° o. � � a n k +.wC..C^r A 3� � �t, ,� ' '^4 =:7 p N ^ � N N f_ � ``t�."= �p �"' cC, N�p G d ~S� � ^ p n f 4 � "G !"� . o o n F " m bs-� o ., «�e��; x s ic S ^�' �N H``=. ? o ° 3 .,"ti , '� � ti � !"N -Q H,0 S �"' T'.. '^ �A";; ^' £ r 6 w,n C q{�n � ^ .+N � � �.^ � N N O C O R7 Q+� O q qpS O O �� O 4 o i�p rn'A'6 R' F. D i" O p '��^ � `^�� a.� N � N=.��.'' � �'Q�-'.� o o b y o'6 N z..� o N —r X r A � n P 0-� p � C A;� ~ S� ,��'. � ^ -�i �� X(`��b'O � p 3 d V x � � S .G. : p � N O A^ M W L.A � F •+ A � o p �r^,-, ^0.�p �'Lw,,,� p� fi c 7 3 � «�t � s � � p'� o O� '� � _ � ,,y� ? ��o �t, R� � �Q,� `N Q,�...� ^.� �� £ � G . c � � p � Q � � �t p O C1 O-7 p �. � � �.ti C " p' � 3 (^ '^ o �o c 4� Q o �G„�� A' o� 10.'. p o-� �~�o'�b�0 1� ���� t" I m N H� O�n � �� � � o; ��7,� � �„ � O M•O� �� r p �� O n �'" P v' � K »7 A � h0 M`w n f0 �L O� ~ c��+.U n » c�`. A p 3 tt � 3 9 } `•c.a o d"~ e a'c7 a-�3 � cy, F.. i� r'�';p�n� -c• T .�+ � � �� P.N 3 fi C„»���LS-��� aK o 4"•C'A � � in 4 � � O(1� � � �p � :;�C CJ � �•.1 �. lp y ,n O m .O N R. 'i" il. K 1 • � . 0.n 1 � ,x, �'� G. o ~ ti a .3•v Z p x Q•„�'r��^a o a x n ? e, .Q,o o '�s� � p o ^��e o n m o « ��k p � �.Q ,�, ``._ �o v� O -zi �;�n ca � ,:.:�-c 16'E.-ain�•� inow��"'� �� o � u� � � � � A Q Q O � � �F'M � � o r^ �M o A �' �-y o� �•z'^; yo i 'O 3 ��i'l �l9 f+ O C Cp Q'n �'n v� �L �`� L"'.Y � � «N C`L+ N -„ K � o o .`�:a w n "��cQ .^. � m - o �;,,...M aa � . ctia ,'= o ° � Fo �o ��"m:�3 '�' �'o .�a. F 's �'^�.c h^ � 0 _- �