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HomeMy WebLinkAbout1319A (30) � WORKERS'COMPENSATION DECLARATION �R � "'" � � 1 I hereb affirm thot I hove o cer�ifimte of consenl to self �'1, insore,or o ce�tificare o4 Workers'Compensation Insurance, �PPLI ATION FOIt �UILDI NG PERMIT or o cenified mpy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY . Policy No. Campony � Certified copy is hereby fumished. FOR APPLICANT TO FILI IN bWLDMG �J a !/ • ADDRESS �'yt�� f��R.K.�.p•s,.�,._.r � Cenified capy is filed with the county 6oilding inspec- gUiloiNG �� ��on department. qooRe55 f �. �^. � Date Applicant CITY . � M r ZIP ( J tOCALITV CERTIFICA7E OF EXEMPTION FROM WORKERS' NO.OF B�DGS. NEAREST / COMPENSATION INSURANCE SIZE OF�01 NOW ON tCT I CRO55 ST.(7}' � d(. (This section need not be mmpleted if the permit is for one TRAC? r �. �ESSOR ��o ' � hundred dollars($I00)or less.) �.,.) BLOCK LOT NO. Mqp gOOK PAGE ��, PARCEL� t TEL. ef / Urfi5s, ��j ( a�/� OWNER i� L� I'� NO. i� 1"'(% /1�J �P I3I—,d Y-. I certify that in the performance of the work for which this ND. permit is issued,I shall nof employ any person in any manner /� � {� SPECIAL ADDRE55 Iry-� S: �'I .LJ r�' � 47 t� CONDITIONS ' so as to���gggb///ecome subject ro the Workers'Compensation La�w/s..-. U'C � 7..Date�Applicant ��Q�••"""�� CITY j � ZIP � `�J � � NOTICE TO APPLICANT� If, after makin this Cenificale of ARCNiiECT OR i' TE�� �ISTRICT GROUP NPE FIRE PROCESSED BY Ezam fion, 9 ENGINEER N� NO- o p you shoold become s�bject to the Workers' CONST. ZONE � Compensofion provisions of the Labor Code,you must forlh- qDDRE55 ��In�_ �� �.� W with comply with such provisions or Ihis permit shall be � deemed revoked. TE�� STATISTICAL CLASSIFI TION APT. CONDO. t/y CONTRACTOR NO. � �. LICENSED CONTRACTORS DECLARATION ��� CLASS NO..�DWELL.UNITS , I hereby affirm that i am licensed under provisions of Chopfer 9 ADDRE55 NO. SEWER MAP (commencing wiih Sec�ion 7000)of Division 3 of the Business and . ��c. Profess�ons Code,and my license is in full force and effect. Ciiv CLn55 VALIDATION SQ.FT. NO.OF NO.OF CHECK BK. pG, — License Number Lic.Class SIZE 0 STORIES FAMILIES � ONE � VAtUAT10N � DESCRIPTION OF WORK NEW ; � �, � Confraclor Date O �'' ADD , �I am exempt�nder Sec. 1�.+ ALTER � B.&P.C.for this reason �L �U W'1 � �� �'V REPAIR ❑ S �� � L'SE OF ��' �'��� Date: EXISTING BLDG. � ' ��Q c , DEMOI ❑ �6 � y tl � ,� $ignature APPLICANT- / 1 7EL // FINAL ^ PRINT� � CJ L t � N NO. �1p1'^ �v c OWNER-BUILDER�ECLARATION DATE �� ��� I � Ea�J J I hereby affirm that I am ezempl from the Conlractor's License f L , �z - �y Low for the following reoson(Section 7031.5,Business and ADDRESS� rj: 6 1�.. �� !� FIN A�r `� ° ` '- �^ (���.+ Professions Code): ay� n G n O..n� �� BUIL�ING ` • I, os owner of iha property, or my employees wifh ADDRE55 wages as their sole compensation,will do the work and � �he siructure is not inlended ar offered for sale(Section LOCALITV ' ,�C=G''�J�'�Z�__- 704A,B�siness and Prafessions Code). MOVING TEL. ��� ��� � I,as owner o4 fhe properfy,am exclusively Con}rpt}ing CONTRACTOR NO. with licensed camracrors to construct the project(Seo- � � � � ��1 ADDRESS tion 70d4,6usiness and Professions Code). � ;�_ 1 REQUIRED TOTAL SETB � CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pRpp.LINE WID7FI I hereby affi�m that there is a constructian lending agency for FRONT the performance of the work for wh�ch this permit is issued p,�. (Sec.3097,Civ.C.). 51DE - P.L. Lender's Name �G 2 .-• LDMA Ref.# m Lender's Address P.G Fee$ Pe.m�r Fee ' ; ,�U ,S 7� I certlfy thar I have read this applicmion and sfate rhat the issoance Fee LOMA v/C N a6ove informotion is correcf.I agree to comply with all Couniy Invast�gar�o�Fee r� ordlnances and Smte laws relating�o building construUion, To�al Fee ��"/ LDMA Perm.N and hereby authorize represematives of this Coumy to enter � upon th�e/a�bove�-mentioned property for inspection purposes. 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