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Home My WebLink About1254A WORKERS'COMPENSATION DECIARqTION �� I hereby affi�m ihat I have a cerlificoie of�o�s��,�0 5e�� qpp�ICATION FOR BUILDING PERMIT � insure,or a certificaie of Workeri Campenstion Insurance,or . a ce�tified copy thereof(Sec.3800,lab.C.) � COUNTY OF LOS ANGELES BUILDING AND SAFETY� � I PolityNo.�n0�0 o¢CompanyC_S�A�C v[4'� � Cerrfied mpy is hereby tumi:hed. FOR APPLICANT TO FILL IN ADORE55 -.�.^ '� ��1-� � Cer�ified copy is filed with the munty boilding inspeo gUILDING ' Y;�� . tion deporlment, ADDRESS LOCALITY V Dare Applicont � CiTv 1; ZIP CROSSSST. ��V .11=�'�� CERTIFICATE OF E%EMPTION FROM WORKERS' NO.OF e��GS. ASSESSOR COMPENSATION INSURANCE SIZE Of lOT NOW ON l0T MAP BOOK ' PAGE PARCEL (This seuion need not be compieted if ihe permil is for one uSE ZONE �P � . TRACT BLOCK LOT NO. NO. L�S� hundred doliars(5100)or less.) }� `, TEI. /.�� SVECU+L 1 certiFy ihor in ihe performance of the work for which ihis OWNER c\t � NO. �•� CONDI110N5 ' Q DISTRICT GROl1P TYPE FIRE PROCESSED BY V permi�is issued,I sholl not empioy any person in ony monner ADDRESS ' CONST. ZONE � so as to 6ecome subjec�ro the Workers'Compensaiian Laws. !p ,n �uL`�' O v DOtC Applicant C'lY ZIP STA715TICAlCIASSIFICAIIpN APT. CONDO. .V NOTICE TO APMICANT: If, aher making Ihis Cerlificate o1 ARCHIiECT OR � � TEL. � �lr iy Ezemption, you should became subject lo the �Vorker5' FNGINEER NO. CLA55 NO. ��"` DWELI.UNITS_ y Compensation provisions of the Labor Code,yoo must forrh- � qDDRESS SEwER^nnv ? winc �omply wilh such pravisions or this permit�shall be . � TF� deemed revoked. � � CONTRACTOR � Q\�LZ. � NO. � � BK� �. VAIIDATION LICENSED CONTRACiORS DECLARATION , i��. I hereby aHirm Ihal I am licensed onder pro�islons of Choprer 9 a�ozE55 G�� NO.3 7� � VALUATION (commencing wi+h Sec�ion 7000)of Divis�on 3 of the Busineszand \ �� //_ J, Professfons Code,and my license is in(ull forte and eHeU. CiTY G Q �C'' Cta55 �'1 5 �''�/ � /_ (�� 50.FT. NO.OF Np.Of CHECK LicenSeNum60r��`�'� Lic.�lo5S�1_� SIZE STORIES FAMILIES ONE NEW � b Conira[lo��H��_Dale ��-^S+Z DESCRIPTION OF WORK . � I am ezempl from 1he licensing requiremeMs as I am a — � �2 . ADD � � � . licensed archi�ect or a registered professional engineer _ . ALiER ❑ DATEL rC /� �.� � , ocling in my profezslonal capatity (Section 7051, REPAIR � Business and Professions Code). IISE OF 'I . E%ISTING BLDG: �� f S I�A�' DE.MOL ❑ F�NA� By _•�t� LiC.o�Reg.N0. DaIE , APP�ICANT TEL. � OWNER�BUILDER DECLARAT�ON (PRINTI � NO. - J I hereby a4firm thai I am e.emp�Irom the Comroctor's titense . - law for the fallowing reason�Section 7031.5, Business ond ADDae55 - Professions Code): -E;En� a6UIlDING I,as owner af 1he property, or my employees wilh ADORE55 wages os iheir sole mmpensa�ion,will do the work and ' �� z�(1 A �he strocture is not iniended or offered for sale(Sec�ion �«AIITV 704E,8usiness and Praiessions CadeJ. MOVING TFI. #� � � � �, � 1,as owner af the properry,am eaclusively contraciing CONTRACTOR - NO. , with licensed confractors�o construct Ihe project�Sec- ADDRE55 �,• •4 3 5 0 lion 7044,Business and Pralessians Code). � _ REQUIRFD TOTAL SE78AIX FROM EXIST. , _ CONSTRUCTION LENDING AGENCY SEi 8.4IX YARD HWY pROP.LINE wi�iH ' � - '' ' '4�5 O c�� I hereby aifirm Ihot ihere is a mnstroclion lending ogency fo� FHpNI ihe performance oI�he work for which�his permit is issued P t. �� 2"$2 �Sec.3097,Civ.C.�. Si�E P.L. Lender'z Nome / " ' � � lender's Address P.0 Fee S Permi�Fee `. �'� � W I certify thot 1 have read this opplicotion and slate thol the Issuon<e Fee •�� obove information is mnecl.1 ogree to cOmply with all County In.esegoi�on Fee / $ ordinances and S�ate lows ieloting to building tomtiuttion, To�oi Fea `r�•-�O , and hereby authorize represen lives ot this Couniy to enter � upo/n fr`'e', ve-me��i ned pr erty(o�inspedion purposes. ¢` •r �/ �/ /f�—�� SEE REVFRSE fOR EXPIANATORY LANGUAGE - SlqnoNre o�Appllcon�j gen� , Do�e � / � � � o � �-� � � " � a � cn -n o � o �+ fl � v a nv � a. o n. p � p 3 n � v O j O S � . r, m ,� V' O �� O �^ � m 0 � � � . ^ M_n n1 4 � ,p fl :�iT � 69� D � 7 j Cl� n � O � b P � � �C S � �'Wy O �U Q 7 � � 4� 7 � R a O N ' 7 -� - � t ID � Q` � CJ O O ? Q O � � O I �� v D � .� •7 �I � � � +- � � ? M 7 z •� �n V :%. { � p +...� 'C Q°c (D O ;c: O .K...7 ' r � v3 -• Q y1 • � M � 1' ? °� ° I O � " � � � , .� a� � a `' O b ° • � I'� T \ (,� � M• � ,} C. 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