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HomeMy WebLinkAbout1822A WORKERS'COMPENSATION DECLARATION � I hereby offirm �hot I hove o�e�„���o�e o�mnsen�to self APPLICATION FOR BUILDING PERMIT � insore,or a tertificote of Worken'Compensolion Insurance, or o cerfified copy�hereoF�Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY PalicyNo. Compony BUiIDiNG � Certified copy is hereby furrrished. FOR APPLICAN7 TO FILL IN_ aooeE55 �d � F � � I f:l�ferlified copy is fiied wilh the counly bviid�ng inspee- � gUnDiNG � �« �ion depa��me�L �7 ADDRE55 ',10 � .F L/NE Gd L uT /78 � c �M/n( `�'(/�SO/d/�Y .,' _,�. �. � . .r .._ � � Dole ���`J9 Applicom Ciiv /f� �` 1iv . •.` IOCAutY .n p�?Q CERTIFICATE OF EXEM.PTION FRO� ORKERS' ' �• . �'�", � "NO�_OF BLDGS.:-�. �� •�I. � NEARES� 1 / COMPENSATION INSURANCE . SiZE OF lOi� NOw ON�OT CROSS ST. /l "/�+JQ P< o/)� ' (ihis secGon need not be camplc�ed i}the permi�is ior one • • " , � - ::� ASSESSOR hundred dollars(5100)or less. TRA�� ��� � a�«K � LOT NO. 0 MAV BOOK PAGE PARCEL � iEt. . USE ZONE M4P I cerlify ihm in ihe pertormonce af Ihe work fo�which ihis . �OWNER�, . NO.-.••, „ NO. ' �� 4- permif is issued,I thall no1 employ any person in ony manner SPECIAI �i �,� •�. U so os to bemme subjetl�o ihe Wor4eri Compeneot�on Lows. � /DORESS /� • Z �• CONDrti0N5 V aTv , O�L� zir � Date Applicaat qRCHITECT OR T�Z � NOTICE TO AP7LICANT: I(, ofter moking Ihis Certificala of ENGINEFR N� ,j4/�j DISIRICT GROUP ttFE FIRE PROCESSE�BY Eaemption, yoo ehould become sobject �o the Workers' � � � ro�/ ' ZOhIE w Compensarion provisions of the Labor Code,yo�must ta�lh- qDDRESS a with comply with such p�ovisions o� this pe�mit sholl 6e TEI. STATISTICAL ClASS fC TION APT. CCN90. Z deemed revoked. CONTRACTOR /�r. Nps�O'���� — LICENSED CONTRACTORS DECIARATION ���, QA55 NO. DWEIL UNITS I here6y olfirm thoi I om licensed under provisions o(Chopier 9 ADDRESS �l sr iCE NO. ? � 5�y,�R l�e.v (mmmencing with Sec�ion 7000)of Division 3 oi Ihe Bu:iness ond ,1 UC. Profess7ons Code,and my license is in iull force ond effect. � C�TY /��//� ��'� CL455�'�� BK. �. VALIDATION t�//�-p� � -�� p' 50.FT. NO.OP NO.Of CMECK license Nvmber �•7(v�P�O l{c,Closs�L_ ` SIZE S70RiES fAMI{IES �Nf � �" VAWATION :;� ' %I', sLi�/T�7�i�'2�' �—/G`F� `r� DESCRIPTION OF WO4K c.O � E� Kl— N� = r 5 �D ,' e Contmcior Dme � ' ADD � / � o o ., . 1 �I am exemp�under�ec. . � ,l L aliER � � � , :.«'7 7 B.BP.C.for this re.oson `y v�x 'n RfPAiR ❑ f e ;. DOtC: -�y USE Of DEMOI ❑ e � a.-'r`�::_'.. V E%ISTiNG BIDG. � ifr....e Signo�ure 1` Av�FR,i�S4m��T m�f�N�Y TEI. FINAL � '�� :l'�.R OWNER-BUILDERDECLARATION NO.SYD�eS( OAiE `O- — I hereby aHirrrt ihm I om e.empt Lom�he Comractor's License � pDDRESS n _ � Y.2 FINAL Low for the following reoson($eciion 7031.5,Businets and Professiona Code): �� l�u* — sY � ❑ EU4DiNG I, as owner of ihe property, or my employees with � ADDRE55 waqes as�heir sole compenaotian,will do�he work and ���t� , tha shucture is not iMended or olfered for sole�Sec�ion 7044,Business and Professions Code). MOVING . TEt. � I,os owner of the property,am ezclusively contracting CONTaaCTOR � �� wiih liceneed controdors ro conslrud rhe project(Sec- . qD0aE55 tion 70Ea,Business and Pro(essions Code). � CONSTRUCTION IENDING AGENCY SET�BACK YARb HWY T�TApRpP.LCNE � WIDTN I hereby oHirm thaf�here is o to�srruciion lending ogency fo� fROr+i - . . Ihe performanta of Ihe work for whith lhis permif is isfved P.L. . " � �"(Sec.3097.Civ.C.). S��E F.l. Lendei s Name � � LDMA Ref.N m P.C.Fee S Fermit Fee , , lender's Address / � I cer�iiy ihat I have read�his applim�ion and s�ote rhol the �seuonce►ee /�'J iDht4 P/C M _ a6eve infarmation is corred.I agree to comply with all Covnty Imev�yroiron fee ordinances ond Slafa laws reloling 10 b�ilding tonslructio�, Torol Fea �� LDMA Pe�m.M ond hereby outhorize representativee of�his Coumy ro en�er upon rha ebave-mentioned properly for in5pecfion purposes. � SFE�EVERSE fOR EX►tANAtONY LANGUAGE ~ S�g�o�vro of Applicont or Age�� Da�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 . G'1 • 7 � n �.O r� ] y i . 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