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HomeMy WebLinkAbout1822A (10) WORKERS'COMPENSATION DECLARATION � I hereby offirm �hot I hove o certificale o�mnsen�to self APPLICATION FOR BUILDING PERMIT � insore,or a tertificote of Worke�s'Compensolion Insurance, or a ceriified copy ihereoF�Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY PalicyNo, Company Bl11lDING � Certifled copy is hereby furrrished. FOR APPLICANT TO FILL IN_ aoo&E55 �d /I? F � � I f:l�fertilied copy is filed with ihe county bvilding inspeC � gUIIDING � �« �ion depa��men�. � ADDRE55 ',10 � .� L/NE Gd L uT /78 I G �anv►+� �2�PSo.��Y . , ,. , . �,- ..` � Dole ���`J 9 Applirom CiTV /fL I � 1i7 IOCAutY ,n O�?Q CERTIFICATE OF EXEMPTION FRO ORKERS' ' �• . �'�", � "NO�_OF BLDGS.:��.-� •�[. � NEARESi 1 / COMPENSATION INSURANCE ' SiZE OF lOi� NOw ON�OT CROSS 5T. /l '/�+JQ P< o/)� ' (ihis secGon need no�be cample�ed i}the permi�is ior one • • " n �j , � - ::� ASSESSOR hundred dollars(5100)or less. 1RAC1 .�.0 O BLOCK ' �OT NO. O� MAP BOOK PAGE PARCEI � iEL . USE ZONE M4P I cerlity ihm in ihe performonce af Ihe work fo�which ihis • OWNER�: r NO'-.-": .� NO. ' ��� 4- permif is issued,I thall no1 employ any person in ony manner SPECIAI �i �,� •�. U so os to become subjet��o�he Wo�4eri Compeneotcon Lows. � /DORESS /� • Z `• CONDRi0N5 V aTv , p�L� zir � Date Applicaol qRCHITECT OR T�Z � NOTICE TO APVLICANi: If, ofter moking Ihis Certificala of ENGINEFR NQ ,j��j DISfRICT GROUP ttFE FIRE PROCESSED BY Eeemption, yoo ehould become sobject �o the Workers' � �-� ro�I ' ZONE w Compensarion provisions of the Labor Code,yo�must ta�lh- qDDRESS a with comply with such provisions o� this pe�mit sholl 6e TEI. // STATISTICAI CLA55 IC TION APT. CONDO. Z deemed revoked. CONTanCTOa /qr. NOST���f� LICENSED CONTRACTORS DECIARATION ���, QA55 NO. DWEIL UNITS I here6y olfirm thoi I om licensed under provisions of Chopier 9 ADDRESS �l sr iCE NO� � � 5�y,�R M4v (mmmencing with Seciion 7000)of Division 3 oi Ihe Bu:iness ond ,1 UC. Prokssions Code,ond my license is in(ull force ond effect. � CiTY /��//� ��'� C1A55�''7� BK. eG. VALIDATION � �C. �� 50.FT. NO.Oi NO.OF CMECK liC@n50 Numf�er ����� lk.C�ass�� �"� SIZE STORIES fAMiUES ONE ,�v��r G- �" VALUATION :;� � ;%I', SLiM/h/T/"/�•7"'^ 4/—/G�FJ � DESCRIPTION OF WO4K c.p � E� �fi— A D O = /� 5 �D �' e Contracbr pote - � � o � *, • � �I am exemp�under�ec. . � ,l L aliER ❑ , � , .,�`?7 B.BP.C.for this reoson `y v�x 'n RfPAiR ❑ f e �. DOtC: -�y USE OF DEMOI ❑ e � a.��r,�::.:.. V E%ISTiNG 9lDG. � i1r....e Signoture 1` Av�PRI T)S4M/TG/T /11�7'f�N�Y TEI. FINAL � '�1 :l'^.�� OWNER-BUILDERDECLARATION NO.SYD�eS( OATE `O- — 1 hereby aHirrrt ihat I om e.empt Irom�he Comractor's License � aDDRESS n _ � Ys FINAL Low for the following reoson(Seciion 7031.5,Businets and Professione Code): �� f�Cu�r — sY � BUiIDiNG I, as owner of ihe property, or my employees with � ADDRE55 wages as�heir sole compenaotian,will do�he work and ����t� , the shucture is not iMended or olferrd for sole�Sec�ion 7044,Business and Professions Code). MOviNG . TEt. � I,os owner of the property,am ezclusively contratting CONTRnCTOR � �� wiih lice�eed controdors ro conslrucl the projecf(Sec- . qDDRE55 tion 70Ee,Business and Professions Code). � CONSTRUCTION IENDING AGENCY SETOBACK YARb HWY T�TApRpP.LCNE � WIDTN I hereby ofiirm tha�ihere is o to�srruciion lending ogency for fROr+i - . . Ihe performanta of Ihe work for whith lhis permif is isfved P.L. . " � � (Sec.3097.Civ.C.). S��E C.l. lender's Name � � LDMA Ref.N m P.C.Fee S Fermit Fee , ' lender's Address / � I cerliiy ihat I have read�his applico�ion and s�ote rhol the �seuonce Fee /�'J iDhl4 P/C N _ o6ove infarmafion is correcl.I ogree to mmply with all CovnN Inveu�go�ron Fee ordinancei ond Slafa laws reloting 10 b�ilding conslructio�, Torol Fea �� LDMA Pe�m.M ond hereby outhorize representativee of ihis Coumy ro enier ' upon iha ebave-menlioned properly for inspecfion purposes. � SFE lEYERSE FOR E%►LANAtONY U1NGU�GE ~ S�gnorvre of Applicont or Agent Do�e --�- v �— ' Z � � n�I � .., „ -� v ., - �n - �. �. -., _ � - � c �: o � , � � � � o�� ��� , __.r--Y—i� _���,: �� o ' , ; �: � , r--�—_ ;.. 1 O C T J .. Cr � C.C � _ CJ J .� � N � C t. I . �_ � m � � �� m �" � � O I D � C _ � r. :: u � n � , —•�' O � m 1 � F- � ' - D - � U C f I I� T °"� � o F N o a: ' ' � ° -:' � n� o `_-' zo � D `:, � ' I� a v 3 _ o � � � ' 'o `;� u� :° T � o _ i r ; � ° ry o = a e I o` o T_ � o - � 3. , o • , I �� �O . 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