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HomeMy WebLinkAbout1692A (223) WORKERS'COMPENSATION DECLARATION • � � I he�e6y,�ffirm Ihal 1 have o cerlificote of�o�se�,�o,e�f � APPLICATIDN FOR BUILDING PERMIT i�sure,or a ter�ificate oi Workers'Compensatian Insuronce, � or o certif�r,d copy rhereof�Sec.3800,to6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑o1lcyNo. - Company BUitDING .'{� �p Ceriiiied copy is hereby furnished. FOR APPLICANT TO fILL IN ADDRE55 �8�`� �-...C�._.�j eU/n-• � Cerlified copy is filed wilh fhe munty building inspec- ' BU4DwG .�' lion deparlment. AD�RE55 �,• Doie Applicanl CITY 21P S �p('j���TY CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF iOT NOw ON�tOis C OSSSST. '�'�� 't1'o COMPENSATION INSURANCE (This seclion nead not ba Complefed if the permif is for one TRALT BLOCK LOT NO. ASSESSOR hundred dollors(E100)or less.) 1�MP 900K PAGE PARCEL TE -�2 U ONE hV+P I cer�ify�hat in the periormance oi the work for which�his �'�'NER Z �'(�G,7 � � '��g�j3 permit is iswed,I shall nol employ any persan in any manner ADDRESS L ��D� SPfC1AL a so os�o betome subjet��o the Workeri Com enSation Laws. CONDITIONS Q '1 v w1 + � -� U XDate� -/S � 'APPticanf f lii•�9C r! CITY `.tX W) K ZIP � NOTICE TO APPLICANT: If, aFler moking Ihis Certificafe of ARCHITEC70R ` TEI. r, DISTRICT GROUP TYPE fiRE PROCESSEDBv p Exemplion, yov should became subject to Ihe Worker5' ENGINEER �� l,l �j CONST. ZONE U Compensotion provisions oF the Labor Code,you must forth• qo0aE5S !v YC-,3 � W wi�h comply wiih such provis�ons or �his permit shall bc TE(, $TATISTIGIL QASSIFICATION APT. ONDO. 0. deemed re�oked. r Z CONTRACfOR NO. f,,� LICENSED CONTRACTORS DECLARATION „ •„y� ���. M55 NO. `� DWEIt.UN�TS I hereby offirm that�am licensed under pravisions of Chapter 9 A�DRESS � Np, —' (commencing wiih Section 70U0)af Division�of iha B�siness and p ��� SEV✓ER MAP Professfons Code,ond my Ifcense is in fotl forca ond effeU. Crtv ,�M tf�' �� JCi� Cta.55 — BK. pG. VALIDATION SO.FT. NO.Of NO.OF CHECK License Num6er Llc.Closs SIZE STORIES FAMILiES ONE � ❑ VAIUATION � DESCRIPTIONOF WORK h� �-J Conlroclor Date ADD � _ /� , �I om nxempt under Sec. . �� 1'� O � . �y1 ALTER B.BP.C.for�his�eason � `J �r REPAIR ❑ s �1 6 9.2 A Date: use oF EXISTING BIDG. P r 0. � p/ DEMOL �j• . • • . � si9�ew« APPIPRINiT rt� • i � d � ��l FINAL � I + •3 Q 5 0 OWNER-BUILDER DECUIRATION OATE �ZZ! I hereby affi�m�hol I om e�empt 6om Ihe Conlraclor'e litense �� fi' ^�^ �7 � • •J i)J Q c=i Law for the following reoson(Section 7031.5,8usinees and A��aE55 � �' '�J- FINAL l�1 t ; Protess�ons Code): N ' N' �/�j '1 0 9.1 5�8 7 euiioiNc � � I, as owne�of the properry, or my employees with ADORE55 woges ae�heir sole compensation,will do ihe work and I the elroctore is not inlended or offered far sole(Settion LOCAUTv 7014,Busine�s ond Professlons Code). _ MOVING TEt, ' � I,OS owner af 1ha properly,am ezclusively confroefing � NTRAC70R NO. with Ifcensed contrac�ors 10 construct tha prolect(Sae- � ACDRESS "" tion 70<d,Bvsinees and Profeseions Code). �, . • • CONSTRl1CTION IENDING AGENGY �Qgq�� YARD HWV T�TApROD.�CNE WIDTFi I hereby afFirm thef there is a consv�ction lending agancy for �RpNt tha per/ormanca of 1ha work for which this permil Is iss�ed P.l. (Sec.3097,Civ.C.). SIDE P.l. lender's Nama - � � LDMA ReL M � ;." m tender's Addresi O.C.Fee t Permil Fee ,�� ' � I certify that I have read this opplicotton ond stote Ihat Iha . Issuance Fee ���� mMA P/C N I 9 obove iniormafion is correct I agrea to comply with all County Investiqarion Fee r i o ordinan[es and State Iaws reloling lo building[onslrutlion, To�al Fee ����1 � IDNW Perm.N and heraby authorize represenlalives a(Ihis Co�nty to enter � � vpon Ihe ove-mentioned property f inspection purpases. I •� �i"IQ•�� SEERFVERSEFORF1f�tAHATORYIANGVAGE IIIgnorore ol Applicom or Agen� pote ,�.\, � � a �• ,-��� ,/�•.� _,..�-- �;' �:�\ � � r � ' /'�..G` .�,\+' \ f� "^t _ \`\ � \O . `., -�� '' `' _ i ' �^ 'y� ` . � 'c' \� � . 'V � � _ �: \ � r . � �C',G• . ,� _ r' \` '� • Z �.! '��\� .. J:. ,,� C' \ ' \1.. � \ �-�� �+ � '.., � � �"`\ v ,F �• � '\ �, " � . O �� � � a ? \9 ,�? ' � � ° � � r � ~� ,o _ � ,\' / ` � ^ ' �i' � , - "� 9 -o .�.. (l1 G % 3% '� JD �` ; 0 � tt �\ .-^+!\� . 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