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HomeMy WebLinkAbout1553A WORKERS'COMPENSATION DEC�ARATION � � � � -•1 hereby affirm that I have a certificate of consent to Se�f qpp��CATION FO�t BUILDING PERMIT � insure,or a carlificate of Warkers Compenwtion Insumnce, w a certified topy thereof(Sea 3800,lab.C.) COUNTY OP!OS ANGELES - ---- - BUiIDING AND SAPETY Policy No. � Compan�r ❑ Certified co is hereb furnished. FOR APPLICANT TO FILL IN BUR°�NG '9 PY Y AODRE55 �3�O `�L I��O �. � (/ ❑ Cehified copy is filed wRh the couny b�ilding inspec- q�pouEs�s I3�0 E.VRLL 1i�sT�pRiYE ���, tion department. Date npp��can� aTv DIRMONI7 � zir �av.0 NO.OF 8tOG5. NEAREST CERTIFICAlE pF EXEMPTION FROM WORKERS' SIZE OF lOT NOW ON l0T — ��q 5 COMPENSATION INSURANCE ��� (This section need nm 6e completed it the permit is for one '� TRqCT '3J�s'�� g�p�K - LOT NO. � - /�qp gppK--------- -- -- pqGE PARCEL h�ndred dollan(SIOOy or lesc,) owr�R�Y,�+41..C'�W� ,� np�Ll�(a13�103(� usE Zon� Mnv I cartify that in Fhe performance of ihe work for which this r�o. ��-33 permit is iss�ed,1 sha�l not employ any gerson in ctny manner AUORe55 Q>�'$w• s�"i.'�7� � ���A� - a so as to become sobject to rho N/orken'Compensation taws. �No�T�� �P3 3 0 ciN tos�tC��t�s c� ZiP�►7 v Dpte Applicant ARCHITECT R 7E� � � NOTICE TO APPLICJSNT: If, o6er moking lhis Corti{icaTe of ENGINEER � {,(N ��� DISTRICT GROUP NPE E PROCESSED BY � Exempfion,-yo� should become su6ject to tFre Worken' c� / �j �ONST. Z � Compensofion provisions of ihe La6or Code,you must fwth- ADDRE55 ��Y+�W'1 5'�'.w.P�Sf�O��g�� ����f� (J� �I N V W winc �omply wi�h such pro�isions or rhis permit shall be rEL STATISTICAL CIASSIFICATION r coNop, '� deemed revoked. COMRnCtOR��R�(W1 Cpnip, Z � LICENSED CONTRACTORS DKLARAiION uC. CwSS NO. �'S DWELL.UNITS I hereby offirm thpf 1 am{icensed under provisions of Cfwpter 9 ADDRESS NO. ��� SEWER MAP (commencing with Setlion 7000)of D'evisicn 3 of the Business C�n, �� and Professions Code,ond my license is in fult forca ond eHect. gK, pG YAL{DATION SQ.Ff�,` NO Of !I NO.OF CHEIX ticense Num6er Li0.Class SIZE !i� � STORIES � FAMILIES ONE OEXRIP�ION OF WORK�C�PS�S NEW � VALUA7ION Conhactor pote � s. �'Q��p � � ❑I am exempt under Sec. �,►-w„�,s'�4 A� ALtER ❑ B.&P.C.4or ihis reoson f u�� REPAIR❑ Date: E7(ISTING BLDG. DEM01❑ ����� FINAL S+gnmure (PRINT� OM LI(�IpS �Nopil$ OWNER-BUIIDER DECIARATION DATE ;. 1 �5' i hereby affirm that I am ezempt from the Confraciors Licensa � . " ,..� Law for rhe followl�p�eason(SeUian 7Q31.5, Business and AODRESS F� . � - Professions Code): PRESEM By `' �'�-'�.�F�J ❑ I, as owner of the ro er BUILDING _ p p ry, or my employees with qpDRE55 - •' ' � - — wages as tbeir sole compenaafion,will do the work and LOCALIN � � '�C��-�,""•^ Ihe Sfrodure is not iniended or offered far sale(Section " - • ❑ 7044.Businwc and Drofoaw�e Code.) . sAOv�tdG TEL. I,os owner ol ihe property,am exciusively conhocfing �NTRACTOR NO. wilh licet�sed[ontraciots fo construd the projeci(Seo- AD�RE55 tion 7044,8usiness and Professions Code.) ,REQW RED IOTAI SETBqCK FROM�� FJ(IST.- •� /) �7 .� CONSTRUCTION IEN�ING AGENCY �j gq� YARD HWY pROP.LINE ��� n�� � I hera6y affirm ihat there is a construtlion lending agency for FeOhli Wy�,�jk a.�,�i the performance of the work for whlch this permit is issued P.L. -� r (Sea 3097,Civ.C.). SIDE � P.L. Lender's Name � m t� . . LDMA Ref. P.C.Fee S I/� .�o Permit Fee � Lenders Address , o I cartify that I have�ead fhis opplication and state ihat the M� 60� � iss�ance Fee LDMA PiC M $ above information is correct.1 ag�ee to comply with all County imeatigorion Fae R wdinonces and Staie laws relating to building construction, Toial Fee IDMA Verm.A � and hereby authorize repiesentatives af fhis County to enter g �pon the obove-mentianed property for inspecfion purposes. � SEE REYfRSE fOR EXfLANA70RY LANGUAGE � $ignature of Applicanf or Agent Dole � y � �N � GbC Q��N O . .m o H �a i3 "� � ` c.o ° y°' ° o'a v. �m w E.' o � '�' = m � �" o� �a N'� oi c� � m�'r � v as � :.r.t G���a,c�,c� n >e�iu �.�c w � fS� 3 ,N v, n?,�:. wr �a�' �v�.r=o� ;m ��q 0 3� p W q C Cw�S�ub,��,� �,� OE v� ,'Z dw i)NU ���j,�.1 O v:�o,om°=°'U�yu,io�� �°yd��.�Xw�om� mo�omN \ Z rc— �6' m.ss.mwor`�" s+.'SSTcrmvi'�i Evc �,c,F N .r c", 3 o m m•Y 3t II c m m�q.'r.,�o m.�,� u�; �6 v +n— o c� • � � m C vwam ��� �Eo, � cc.�yo�oE. a�,= s�ua.°�»-.-�;`ci md.�m�3ao m O "'�ci�v$���.r',o m av��"'D��n�v,�o m,`�o� �o Q o��� tf+ W . p m o m af 0> G� c U} W nt �''� m�o N' O g V� C N C v+ 6 p' p�NU > co o;m m.,.. °l =o �ia v.�n-p �.�'� ms�i � G N �oy�'oar�,>E�,E°�«c'�`�,G�ti"'ov ��em•� a'"�cw oQcau � Z �r G T E a0 (� O��� O b L'G✓� m� G 61�Q C II � U N� � "� M4 r�p��Ty�m �...3�°a��.�C����3a�Eo� `��c�� �i m .. ;wm Q �VMT��V'�;F�aa�c��Qc,o �9 s`.=�N U� m , w°'�� 'o'=°e,�cc«'.c� � E�pO.`°�o��@ � ,dv,m coc' °' � pm';Qy Ecm Ed���U�m��' c.'vot 3 .emoQ� � �.� oV..2m�U� a�ccm m O ¢,r���;m nw u v:���op'V �J°'oNc�fl-�— �mOao6p�Qaamo �° ya.y A � mt p m �j�"' c °c�a` on�' Q '^ a°SEC�a�o" �n ��Ea' •' rn��oi.�r Q `Ae0 O � .'-�y �r' '"d��.01c.�Q'+�-07'o y�.� ,ni m.m"yu'r-1�,J-a m` � � tflA »?«?pv,v�-0 xCCWr mmQ� �>oQyVWv a�'.. 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