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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 SignaNre of AppLconl or nr po1a r_ n o�,'" s , � � _�dm �aUai'��, '° ' y.p���«� Qj c;Q a �,__°o a c� . �.T-" L C�L.-._II� �v�-- Oi U Q- '. c �Co���:..3ag ,mc�a �t' a,�a�' uc+�o�¢+ °6 G �. • M�C'/,=Cl=i»�d��� ��c��� ¢O 6� �LY�• .���L �✓�O�Y���C � ; tiS `i �O�t O Qy Wt �WOaiT'$iQ'TY a6.�"� o>G.�.. 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