HomeMy WebLinkAbout1554A 0031A 0032A (440) - WORKERS'COMPENSATION�ECtARATION . �
. -i'hereby affirm thot 1 have a certificate of consent to s APPLICATION FOR BUILDING PER IT �
insure,w o certificate of Workers'Co at' n In n
,�QVr�p e��[1 rfied pcqpy ihereo,f�,yLSet /� COUNTY OF LO;ANGELES BUILD{NG AND SAFETY
Pali�No. o �� Com y -4(. n'
❑ Cert�tied copy is hereby f ished. ''�3 FOR APPLICANT TO FILL IN B,qp���ss 7J,SQ `�'- U U��, �,�•
❑ Certifiedcop � f� i c- �u'7j�� C, v VtS-[� S'J�LI\{E
tion depart ./�•
oa�e '�' � an DfMhDND 6�4't nv iocnu
NO.OF BLOGS. NFqREST
CERTIFICAiE OF IXEMPTIQN�FR�4VORKfRS'� � SIZE OF LOT Now oni iAt �p�5
COMPENSATION INS1fRANCE' .' � ��
(This aection nead nof be completed if Ihe permit is for one i�c��39(079 BtOCK LOT NO. � � Mqp gppg pq� PqRCEL
hundred dollars(5100)or lass.) «�- /+`��� TE� 'y1 1�
OWNER�7YN.KO(.(,r w!N NOZ�!{�✓'I�.�(! USE ZONE � 1-��
�^ i
I ceAify that in fhe performanca of the work for which I�i._, .. � u (� r�, /.� -7� �` /• SPECIAL � D p.�
permil is iuued.I shall nof employ any peraon in any mann¢ �"� ' ADpRESS`C�E4�''W� 7''�'�v'«`� {`"� '' �.r�......'�pjyBlfiONS�"�('"��8+7 iZ'� d
so as to betome subject to tha Workers'Compensation Lnw's. � s_ .
._;;� ciiv�'��51`�L'1�I.z5s.CA:"z�v'9Lnt �_ . • . O
DGte Applitant r ARCHITECT O hL c�L'•�i -/ p15TRICf GROUP TVPE FI P �CESSED �
NQTICE TO APPLICANT: If, after making this CartificWe of ENGINEER 5 (`1-�13D$� NOFw J99. O
Exemption, you should become subjpct �o the Wwkers' �,�oN s. ,�' CANST' ~
Compensafion provisiona of the Labor Code,you must forrh- ADDRESS P1'�vENA 9to3a f�,Q7�-�. �J {I
wifh corYipty with suth provisions w lhis permit shall 6e y�,,� TE�� STA715TIG41 CZASSIFICA ION APT NDO, N
deemed revoked. CONTRACTOR(�L�L �����NO. AS Z
LICENSED CONTRACTORS DEQARATION ��C. QA55 NO. ���DWELL.UNITS
I hereby oH'um thor I am licensed un�ier provisions of Chapter 4 ADDRESS NO.
� (commencing with Section 7000)of Divis�on 3 of the 9usiness - , , _ 11G.. , SEWER MAa
and Professions Code,and my licanse is in full force ond affect. ��TM -� �7' � -��u? `�� � pG YAIIDASION .
license Number
T�9���� Lic.Class� �E��2 � 5 ORI�EFS� ` F MIL�IES ` ONEx
X6LL �'fQG1GTl�� cS.�/Qf� DESCRlPTIONOFWORK CE F.�1.O�a. NEw � VALUATION �
Contmcfor - � ❑ s �
$i1tf.Dif3 ��o
❑I am exempt under Sec � _ � sr c r:
ALTER Q .•. -
B.B�P.C.{of flli5 fea5on �� REPAIR❑ s �BQ�� „ • _
' a o
��e" EXISTING BtOG. DEMOI❑
Signafore APPIICANT � � . � . •,
,v�ir,,,TnM L�r�lp �Na8t6 .C�Ao Fwiu , �l-Q�
OWNER-BUILDER DECIARATION pA� Q� -/D ` ' � ' - �
I he�eby affirm that I am exempt from the Coniroctor's License _ �
Caw for the foliowing reason(Secfion 7037.5, Business and p'�RE� FINAL � =��- ' '� �
Professions Code): � PRFSENT .-8y-
❑ I, as owner of the ro ert or m em lo ees with ������ f'1
P P Y, Y P Y MDRE55 �U�..� � I'-,
wages aa their wle eompenaolion,wi�l do the work a�d ---� � �
the strutlure is not intended or offered for sale(Setlion ����TY � �,.s�,.,• .��
7044,Busineu and Pro4eccions Code.) MQYING . 7FL. , •. . . --, ' �• �. .� •
❑ 1,os owner o{the property,om exclusively tontracting �NTRACTOR NO.
���� Cl� I %
with licenxd convactors to consrrucr the project(Sac- aooRe55 -
tion 7044,Business ond Profesaiona Code.} + i,� �c.,j ,� _
RCflU1RED . TOTAL SEtBqCK FROM � EXIST.
CONSTRUCTION LENDING AGENCY SET BACK Y'4RD HWY� P V I I �
I hereby affirm thm there is a construction lending agenq for FRONT ���C����'
the performance of the work fot which this permH is issued � P.L. �-
(Sec.3047,Civ.C). SIDE �G G 3 2 A
P.1.
Lenders Name o C �*'�' • ` � (
� G.G Fee S �•6� Permit fee � ,�7�S� ��Ref.M ��7�f;�G
lenaers Address /
� 1 certify that 1 hava reod ihis application and sta'te ihat ihe N �P 0-W Issuance Fee �3• � LDMA PiC N ► s 2 j��_`;c-
above information is correct I agree to comply wiih all County Inve i9ation Fe C�Q "-
8 ordinon es and 51ate laws�elo�ing to building construpion, (� Toral fee ��/[J• � LDMA Perm.N
� 4o i o.G���s
� and h eby authorize rapr sentatives of this County to enter + , �
up e o e-mentio qp�rape for inspsction purposes. �-�r
n i( SEE REYERSE FOR EXPLANATORY tANGWGF �`U
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