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HomeMy WebLinkAbout0938A (5) , _. ..... .. .. .. . ..... _. ... . � . . . . _. _ WORKERS'COMPENSATION DECIARATION "' � . � �� ��e�eey afiirm tha�I have a tertiiicafe of�o�=e�„o=e�f APPLICATION FOR BUILDING PERMIT� � insure,or a certifica�e of Workers'Compensa�ion Insu�ance, or a cerriied copylhereof(Sec.3800,lob.C.)' COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy�No. � Compony � O �Certified co s hereb furni5hed. . - BUILDING�o�33 � E � � - Pv' v FOR APPLICANT TO FILL IN nooa¢55 � � Cerlified cop'y is filed with the co�nry building inspec- '� BUIIDiNG . , fipn deporfinent. . ADDRESS � Date�• Applicom ' CITY D7 LOCALITY � CERTIFICATE OF EXEMPTION FROM WORKERS' � - NO.OF BlIX',5. NEAREST. . - . .. . . . . . � ' � COMFENSATION INSURANCE' � S4E OF LOT nIOW ON i0T CROSS 5T. �This section need nof be completed if the permil is for one ASSESSOR �- hundred dollars(5�00)or less.) .. TRACT BIOCK lOT NO. Mqp gOOK PAGE PARCEL . TE�' U ZONE 1N+P I certify that in ihe performance�of Ihe work for which Ihis OWNER � ' NO. �� � � � r permit is issued,I shell nof employ any peison in any manner ,� SPECIAL a so as�o become s�6jec110 ihe Woikers'Compensafion laws. �� ADDRE55 � � - � � �CD CONDITIONS 'y . CITY . 21P . . .. . p� Dote ' � Applicanl � qRCHITECT OR TEL. � NOTICE TO APPLICANT: If, after making this Certifi[ate of ENGiNEER NO. DISTRICT GROUP TVPE FIRE PRO ESSED BY F Ekemption,�`you should become s�bjecl to fhe Workers' " � CONST. ZON V Compensarion provisions of the lobor Code,yo�must forlh- ' -3. y ADDRE55 wiih comply with soch provisions or this pe�mit sholl 6e � '� ' TEL $TATISTICAL CUi551FlCATION APT. CON00. 2 deemedrevoked. ' ' � �� " CONiRnCTOR NO. UCENSED CONiRACTORS DECLARATION - �i�, � CtA55 NO.� DWEII.UniiTS _ I hereby offirm ihal I am licensed under provisians af Chop�er 9 ADDRE55 NO. (commencing wilh Section 7000)of Division 3 of the Bosiness ond . _ ._ . ���, ��R�P ' ' P�ofessions Code,and my litense is in full force ond etfect. CITV C1A55 BK. � VALIDATION �, . SQ.F NO.OF NO.OF CHECK Li[ense Number lic.Class � � � SRE S70RIE5 fAMIlIES ONE .. . . , , • ' ' N� SALUATIO_N, �O C/3 t�'A • � COntra[lor � Dote � � DESCRIPTION OF WOR ADD ❑ Z) . . �I om exempl under Sea . - � , - +�• • •�•�; -- ALTER ' • •Q��� B.BP.C.for this reason .. . REPAiR � f � . .. Dale: � � EX ST�iNG BtDG (. �I, `i . � DEMOt ❑ . • • �+..==�=� - APPLICANT F '1,r EL ..Signotdre �� . .. . . ... ._ PR�Ni -�� o. 5' FINAL . �,J�2���� OWNER-BUILDER DECLARATION DATE � � 1 hereby affirm�hot 1 am evempt irom tha CoNractor's licensa !,', .r. � , . law for the following reason(Se2tion 7031.5,Business ond AODRE55 FINAL� Profes ions�ode): � ' -� ��� - - � vkeseNi BY C BUILDING w �I, az awner of the properly, or my emplayees wilh ADDRESS U'� ' �woges as their�sole compensation,wi�l do ihe wo.k ond , - � -/rr' � � the svuc�ure is no1 iMended or oflered for sote(SeUion ��titt � � � �� � 70<4,Bvsiness and Pro�essions Code). � ' MOviNG �- --'- -- �TEt.-- /� ��� -- - � � � � �� - � � I,as owner of ihe property,am extlVsively toNracling CONiRACfOR NO. ',y�.�'/ } +1 , �wiih Ilcensed con!roctors�o consrrucr�he project(Sec- - -� -�-� � � �� ��-- - �Y - —V ----- - . tion 7044,Business and Professions Code). ADDRESS �� _^/7;� �. __._ .._ REOUIREU. IUTALSEiBACKFRUM XI i. �' _ .�7IV_. .. .� .. . ... _. .. . ���CONSTRUCTION IENDING AGENCY-'"----- - "'- �i gp�K YAR� HwY PROP.IINE N/IDTH �� ��� I hereby affirm that lhere is a construction lending agency for FRONt ' � �' ' � -Ihe performanm of the wark far which thie permil is issued -- P.L -- -- - - --- -�� - -- -- - �,� - � -� �� � , -_ ,�� • �Sec.3097,Civ.C.). SiDE `� - _. . . ._ .__... . _. . _ P.L. . . .. � lender'sName - � --� � -- - -� --- - . . .. . � y� LDhM Re4,# ' � Lender's Address � -� - P.C.Fee S Permit fee- ' -- � ;� � .. '" J certify that I have read Ihis opplicalion and slate lhat Ihe Iseuonca Fea - LOMA P/C M - - - -- _ . . a abova information is correct.I agree b mmply wi�h all Counly �r in�esngm�on Fee ' $ ordinanCes ond.Slole lows relating fo building canslruclion, y� - -� Torol Fee� � � � �LDMA Perm.N -- � - � �- ' u and hereby authorize represenlafives of this County to enler +'' � $ upo tha a ve-meniioned property for inspec�ion p�rposes. � . -- YJ� -( E J � �e�� - ' - _. o ���f���,r .�i�x=f��*'�f, ��A�•�f�-�F SEE REYERSE FOR E%PLANATORY LANGUAGE � �� nl A ent.. '- -S�gnaNre of Appl g Da�e . . . . -- . . . . .. . _... _ _ .i lr z � - o a T �' ',Q N �� � � � O � r ��p f0 ¢, O' 0. � T .n p � O N n t'��, O' a � - � n�� �., c0 t0 � O fD 9 C� � T r' 7r O n 9 :". �O O N v'� � � ^r � O � i+ r C 7 O � � 6p� y � P �'�^ j �v j 3 a � � -n (�2 o c, 3 0- °° .v w a� o o , � .. .o 7'� p0 S T � � �. 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