HomeMy WebLinkAbout1372A (221) � 1 WORY�:RS'COMPENSATION DECLARAT;ON ' I hereby oilirm Iha1 I have a cerrificate oF consem to self qpp�ICATION FOR BUILDING PERMIT �� insure,o�a certllico�e of Workeri Compensaiion Insuronce, vr a certified mpy�he�eof(Sec.7800,lab.C.) COUNTY Of LOS ANGELES BUILDING AND SAFETY PolicyNo. Compony � Cerrified copy is heieby furnished. FOR APPLICANT TO FILL IN sunoiN� 9�.7/O � G A�DRESS •C. � Certified capy is filed with tha counry building tnspeo- gUiLDiNG �� � � �� lion deporiment. AD�RE55 �/in�r/(� �/�,1 Da1e Applicant CITY �/c2Mt»d [J�r ZIP �p�,q��Ty CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF LOT��O��07,C3/�NOW ON�LOTS O NFqREST ' COMPENSATION INSURANCE c7 CROSS ST. Lt �This�etfion need not 6e complated if fhe permil Is for one TRACf c77 7 D BLOCK t0T NO. ���� AUESSOR U hundred dollars(y100)or le7s.) 3 MAP BOOK PAGE PAR�EL � /. y TEL. OWNER C'�lz ��.v�-� NO.H/Y X�61 U` USF�ZONE N✓aF � I cenify�ho�tn�he performance of tha work(or which th's ��� ��.NO. /��—�5`/ permit is iss�ed,I shall not employ any person in any mann r qDDRE55 . Qp p�0, SPECIAL . �' ' so os lo become s�bject to tha Workers'C mpensotion lo � CONDITIONS Q 1� ' CIN �.. . _ . � ZIP ' U - xDare �� APPlicant � . NOTICE T�T: If, offer making�lhis Certificete oi ARCHITECTOR � / TEL. ' DiSTRICT GROUP NPE fIRE PROCESSEDBY O ' ENGINEER G �GY'liq^� NO. '— ��/ E�emplion, you shauld became su6�ec1 fo tha Workers' // � CONST. ZONE I— � Campensotion provisions of�he Labor Coda,you musl foAh- qDDaE55 9 ��. L✓i�X$��i..itL ��val. /l'�/02 (,� • e �/'r' . � wi�h comply with s�ch provisions or this permit sholl be . deemed revoked. ,Q �� T��• STATISTICAI QASSIn ATIpN APT. CtlNDp, � CON7NACTOR��'�+� �I'�• ' Z . LICENSED CONiRACTORS DEQARATION � �� Qn55 NO. � DWELL.UNITS I hereby a(firm that I am licensed under provislons of Chapter 9 ADDRESS p�p. ' . (commencing with Settion 7000)ot Division 3 oF the Business and . . ��� SEWER 1rtAP - Professions Code,ond my license is in full force and efiecl. CITY CLA55 BK. �. VAlIDA710N 5�.F7. / NO.OF q � NO.OF � CMECK license Number Lit.Clas� SIZE !G 7 V STORIES .L FAMILIES ONE ' � VALUATION ��_ "., ��.�f1 DESCRIPTtON OF WORK ControUor Dale � • NEW � f 2.y�3�6. ' /' _/ AD� � � �1 e • • a a � . �I am aKempt under Sea �v��� jL'� qUER � s � e � �+����i i B.BP.C.for fh�s�eoson REPAIR � Date: use oF . . � C�j,U n� , E7(ISTING BLDG. DEMOL Si nafurp APRICANT TEI. FINAL ' I 9 oaiNt No. 0 9.0%—o II OWNER-BUIIDER�ECIARATION DATE � I hareb offirm�hat I om a:empt from tha Contracror's License ' Law I r ihe fol�owtng�eason(Seclion 7031.5,Business and nDORE55 FINAI � Prof ssions CodA): 9y , BUILDING � . I, as owner of the property, or my employees with qoDRESS � , wages as their sole tompensation,will da iha ork ond , - . �the struc�ura is nol iniended or offered Iar sale(Section ����TY • 704G,Business and Professions Code�. MOVwG TEL. / I,os owner of!ha property,am eztlusively con�raciing CONiRaROR NO. with licensed centrecten to conslru;l the pro�eU(Seo- pDDRE55 � tion 704d,9�siness and ProFessions Code). i ' REOUiRED iOTAL SE�BACk CONSTRUCTION IENDING AGENCY Sei BnCK YARD HW1' PROP.LINF WiDiH 1 hereby affirm fha�there is a construUion lending ogenty ior FRONT iha performonce o/�he work for which�his permit is issued p.�, .� ($et.3097,Civ.C.). 9DE � ' P.L. lander's Nome_ �����. /��� 1"}� I�MA Ref.N m Lender's Address P.C.fee f Ge.mil Fee Jv , � I cerlify Ihat I hova read ihis ap Icolton ond slate ihot ihe Iss�ance Fea �'�`�' LDhW P/C N ' obove informolion is correct.I ogre to tomply with all County Inves�igatian Fea 7 � 'q ordinonces and$lofe lows relolin to building conslrucHon, To+al Fea / /r�Q ' and hereby �horize represemo�i as of this County�o enter IDMA Perm.M � �ponp fhe ab e-me .' n d prope� for inspection pvrpose�. v`-'� SEE REVERSf FOR E7(PUNATORY UNGUAGE S�gna�ore of Applicam o.Agenr pore - _ z '' o °• . . 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