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HomeMy WebLinkAbout1069A 1070A (9) WORKERS'COMPENSATION DECLARATION 'I 1 here6y affirm thot I have o�e«;f��a,e ot cansent fa self APPLlCATION FC?R BUILDING PERMIT �s insure,or a certificote of Workers'Compenstion Insurance,o a cer�ifie co rhe f� � saao,�ab.c.� COUNTY OP LOS ANGELES BUIIDfNG AND SAFETY Po���i��������y BWIOWG --� �:+ � Cer�ified copy is hereby turni:hed. ' fOR APPLICANT TO FiLL IN ADDRE55 �'1 LP Certified copy is filed with�he munty 6uilding inspeo BUiIDING `� � tion depoAme�t ADDRE55 � LOCAIITY � NEAREST Dai��� Applicom . �r CITY 2iF CROS55T. �J.. V�� NO.OF BLDGS. ASSESSOR � CERTtfICATE Of EXEMPTI N FROM WORKERS' SIZe OF i0i NOw ON lOT MAP BOOK PnGe PARCe� COMPENSATION INSURANCE USE ZONE MAP 7 e� �p (Fhis section need not be mmple�ed if the permit is for one TpA�T g �Vi NO. ' No. �Q U / � !vp 3� Y huadred dollars(S��)ar less.� � � TEL. SPECIAL p, i cerlif rhaf in the erforma�ce af�he rk for which rhis OwNER ! O 't' i�� CONDITIONS � Y P / DISTRICI GROUP TYPE FIRE PR ED BY V permit is issued,I shall not employ o erson in ony manner ^ CONS7 ZONE so as to become subject to the ' ers'Compensa�ton taws. AO�zE55 ! � !�P �'L7 `O ,{�---� � 1„ (� O � n b `1�L� �s,�� \�� Date q i�onl arr STATISTI[AL CLASSIFICP,TION AFT. CONOO. ARCHRECT OR ,r.!+ .TE�� Q�'K W NOTICf TO APPLICA . If, ofrer mokinq ihis Cenificote of ENGwEER �� �+ . �UA55 NO. DWELL.UNITS_ fL Ezempfion, you uld betome subj�cl to fhe Workers' p �� VI Compemation visions of Ihe Labo*Code,yau mu5f forth- qDORE55 7 �� � ' t� ��'NER'�P z with compl ith such provisions or this permit ehall 6e _ T deemed r oked. COtvtRACTOR Na. BK, PG, VALIOATION LICENSED C4NTRACTORS�ECIARATION � tK. �� .. I her �y aFfirm fhat I am Gcensed under provisions o4£hap�e�9 AODRE55 7 � �' YAIUATION (mmmenting wi�h Section 7000)ot Division 3 of the 8usiness ond / . " ., Professions Code,and my license is in full iorce and effect. CITY / CLA55 s3,o0 o pL�Q 6 9 A �Q SQ.Fi O.OF NO.OF CHEIX � Cice�se LiG C{a53 �J SIZE STOR�E$ FAMIUES � ONE � s #•�••23 �ESCRIMION OF WORK NEW CoNraci ' Dare � � ADp � ! •�2 3 2� ❑ ' �+ �+' I om exempt from ihe licensing requiremenfs as I om a AL7ER � FINAL 'Z�'�Q= licensed archi�ect or a.egisteied professional engineer DATE�'� /"S�— ��� " acting in my professionol capaciry (Sec�ion 7051, yC� ��� Q REPAIB ❑ � Bosiness and Professions Code). USE OF ��� � FIN �2� 8�S'� EXiST'�NG BLDG. � � Lic.oi Req.No. Dole AGPLICANT • 1 TEI. Br ��O Z O A � OWNER-BUIIDER OECLARATION (vRM71 / �(, NO. i I hereby affi�m�ha�I am exempt irom the Coniractor's license l � /��� - ���� ��� I Law for Ihe foll owi�g reasan(Section 7031.5, Business and p��RE55 �- J I��- r%r.s' � n'- t �l�/t / //�7 � //� Professions Code): PHE N7 �(��/�_ ��z-j„ �/I C Q.a... �.[►w g'l r���3 7,5 0 BUILDING ( � Yt�x � 1, os owner of the prpperty, or my employees wiih A�DRE55 YI • � �3 7.5 a� woges as their eole rompensation,will do the work and �aA�liv p��Q ���'� 1n� /� the strocture is not inrended or offered for sale(Sec�ion A^"' lri�`-t��2� 8�a� 7044,Business ond Professions Code). MOVING TEL V � I,os owner of the prope�ly,om eadu5ively controcting CONTRACTOR ND. wiih licensed contractors to conslruct f e project(Seo- qpDRE55 tion 7044,Business and Proiessi oda). REQUINED �TOTAL SEi6ACK FROM EXISi. CONSTRUCT�ON ING AGENCY SET BACK YARD HWV pROP.L�NE WIDTH I hereby aFfirm thol ihere is consrruction lending agency for FRONT �he performance-of the ork for which�his permit is issued P L � (Set.3097,Civ.C.�. SIDE P.l. Lender's Na /�, $ P.C.Fee$ ��, O Permn Fee `7 Lend s Address W ertify thot t have read ihis application and state that rhe issuo ce Fee l aabove in4orma�ion is correct.I a e to comply with all Counry in�esugarion Fee n � � $ ord�no ` �e Iaws r ng fo building tons�ruuion, Total Fee�_ � o ereby authori e pre atives of this Coumy to enter m Pa roperly fo inspectiAon purposes. � /y_/�'/ - 5EE REVERSE FOR E%PIANATONY IANGUAGE � � ignatu e pPl�coni nl "� . 0 �^ N �r m S'��m G S d N L b O�4 m w � 'y-O' m ! m e.Q-O��A 1 c Q � � R�t w� �O m �� �w +L- � a� �o.o.�m«,� c�sg «� � �'am��.' � aa o�� ri " 'o �` k £ d w�. .�`1,.n o'n � J a o � � N« tl � d ��°., O u i-''V O �y 3 ��Y� �3 tn"y�e"L�4 '^ • ��.� � O Q C,�.`^i X a :�•,1`' 0 mv �;��d ° x�� � a� aL m N �"���°;�:'� > m`' ,~0.�..� ao d t � o•Y E -a � � 03 ; � �' � i ° °i' �� n�:,^'`o mo " �, 3 n ° '��o� � � � � � ���n.� � �y'b m �� �^'� `o k 4.p� �•: m� x �-E"�a ��a' p / � E ° �� e"o � " ° , -oU �?��K�t � m'x O m W P a mch 'tt E=� o a� L 4.� m �G ,- �y � x °o,� � 3 m �b ° m x'� E �,'t+ �^� � p • a � ��•�... ��.y•� ,.'�s o m o m � a. �,o ,• o c �.0.3 m - (� a R,..., �`1 m� x � [ ,g � T� m"a o c� � � o U e, Z W E �4o' °:am"�° "g,Ct4oE-� �,� c' pd � i. ug ez+ �n fa � � .;w�i M � m � e;s m � m c y v °w �� d °_S ,°, °1 � a ' d 3 y �` � � w�.e o a� u� `o� ��a mv aov o • �� a� O , W E� V � � � � o c: a.,a.v� o-�-8i�'° 3 �m� m o �r�V�O,y 1 "' t�i , A � �d .,� t a ., C�,3 « s. m�Q �-`u`,�o,� � 3 m` u� � ,.ao X � .� C�m�` r �„�ns £�.e � � �•� ow s ° � nd'�,� � N o ��-¢ � o o cf y � a« •� � �� x �.$.k� �' �m p � t'y � ! d O K C w� o p 0. c � my � Z . �'i. 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