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HomeMy WebLinkAbout0866A 0867A (4) WORKERS'COMPENSATION DECLARATION - ^ � 1 here6y aifirm Ihol I have o cerlificole of�o�,e�,,o self qpp��CAT10N FOR BUI LDING PERMIT � ' insure,or p ce�tificate oi Workers'Compenso2�on Insurnnce, - u o�a cerrified copy rhereoi(Sec.380D,tab.C.) ' GOUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company Ce�ii(ied co is hereb furnished. BUR�iNG ���,a ❑ py Y FOR APPLICANT TO FILL IN ADDRESS L � Certiiied copy is filed with the county building inspec- BuiloiNG �� tion depanment. ADORESS � � � �� Dote qPPlicanl CITV �1L� IV LOCAL�TY CERTIFI COMPENSATION�NSURAN EORKERS' SiZE OF lOT 1 SO K�f �/?jjj'��w pN�ipTs� O C OSSSST. (This seclion need nof be tompleled i(the permil is for one ASSESSOR hundred dpllars($100)or less.� TRAR (� BLOCK LOT NO.� MAP BOOK PAGE VARCEL OWNER 1EL' USE ONE �P I certify fhal in Ihe performance o�iha work for which his � ��'f NO.i , .- � , �, QS� j ' permi�is issued,I sholl not employ any person in ony ma er 1� SVEGni so as to betome sub"ect to the Worke�i m nsation l s. • ADDRE55 0. � J f !� O i a D_ � � 2oirrt� conroinoNs ,/ utr i 9I'7G> c� Da�e�.L�APPticont � pTIC{TO PPIICANT: If, ofter moking�lhis Certifitole o ARCHITECT OR El.� p(f DiSTRICT GROUP 7YPE FIRE PROCESSED BY Q FNGINEER � J1J� NO. � emption, yo� should become sub�ecl to fha Wo�kers' CO T. ZONE F— Compensmian provisions of ihe Labor Code,you must forfh- _��, � � 1� ����✓ C w with comply ith s�ch provisions o� �his permi�shail be AO�RFSS deemed revORed. ,� tE�• STATISTICA�QASS�FICATION APT. CON�O. U CONTRAROR Np. z LICENSED CONTRACTORS DECIARATION ���. QASS NO. �'O DWELL.UNITS I hereby aHirm that I am licenxd under provisions of Chop�er 9 AD�RE55 NO. (tommencing with Sectian 7000)of Division 3 of tha Business and ��� SEWER MAP � Proiessions Code,ond my license is in fuli forte and eNect. CIiY M55 VAIIDATION � 50.FT NO.OF NO.OF I CHEIX BK' �'' , Litense Number LIa Closs SIZE STORIFS FAMILIES ONE � ' � VALUATION � DES�RIPTIONOF WORK � N� = c � Contrac�or Dale V , A�D ❑I am exempl under Sec. �� L O . B.BP.C.for�h�s reoson G�w u�,� atieR � -t O f'� G2l�17�••�Y'e=i2�•�i� REPAIR � _ Dote: EXIST�ING BIDG. S-h�',D DEMOI ❑ �O S b.b F� Slgnafure AP�vR MT ��!,/ q El N FINAL �• • • •'�J OWNER-6UILDER DECLARATION �p� t� rr DATE I hereby affirm thot I om exempt from the Conhacror's Lfcense qDORESS (f V7�j �(`��(Cy• '�� �' � • •��G J Low for the follow�ng reeson�Secr�on 7031.5,Busfness and FINAL Pr fessions Coda): pqc N 6y � � BUILDING ;'�; I, as owner of 1he properfy, ar my employees with ADDRE55 • � `� ^ ' wages os Iheir sole campensation,will do rhe work ond � , ��� G—a 8 the s�ructure is not intended ar offered far sale(Section ����Tr 7044,Buslnees ond Professions Code�. MOViNG TEt. � I,as owner of the properly,am e.clusively contracting CONTRACTOR NO. � wiih licensed confroctors ro consr�ucl ihe project(Sec- pDORE55 ' tion 70<d,Business and Professions Coda�. CONSTRUCTION LENDING AGENCY SET�BACK YAR� HVJY r�Tp'p OTP,UNEF WiDTH �O&6 7 A I hereby affirm thaf ihera is a conshuc�ion lending agency for FRONi �� � � , � � ihe performance af ihe work for whith this pe�mi�is issued P.t.- (Sac.3097,Civ.C.). SiOE I • •S�,J O P.L. � lender's Name �j �[ LOMA Ref.N • • •,rj J;;(J u � Lender's Address P.C.Fee S �d� Permii Fee j S� ' a&� 2-8� ��,, I certify thol 1 have read this application and slata that tha Iss�ance Fee 1 0'�� LDMA P/C N ° obova Informa�ion is correN ogree io comply with all Covnry inves�igm��on Fee f�> p' ordinonces and State low r lofinq fo b�ilding conelruclion, iorol Fee ��1 ✓ LDMA Perm.N ond her y aulhortza repr s nlotivas o(Ihis Counly to enfer � upon th bov menllone roperty for inspettion pvrposyes.� m ` � SEE REVERSf fOR F%PUNATORY IANCVAGE Signowre of Applimn�or ent pote' �Z o \`o 1 . � - .n Z �= , \ G� G� � c �- ` - "c � Q J t� ,O t1` ,g O G N C b q ' 4 r' C�9 C O 9 G � �O ' \l0 r G O o i. ✓ �O `G v .p ... 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