HomeMy WebLinkAbout1197A 1300A (6) WORKERS'COMPENSATION DECLARATION ��
I hereby affirm fho,� ha�e a certificate of�on5enf�a self qpp`�CATIO(�1-���FOR BUILDING PERMIT
insure,or a certificate of Workers'Compenstion Insurance,or
n certi8ad copy theJreof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P❑olfcyN . I r Company R_ Di)IVN & Cqo BUILDING
Ce�r�fied copy is hereby f�rnishad. ,�� FOR APPLICANT TO FILL IN q�oaess �—�����. C3� _Rn_��n'-
� Certified mpy is filed with the unty uildi�g inspeo- J BUItDING ,,�^1�
iion departmen�. � � � .,� AD�RE55 2 44 N�a �� Tra in Lane LOCALITY �`.��"�('V�SS.�� F--:�.�z/'
oore ��4�52 Appliwnia � r � Di3m011d B8x' ZiP 9z7 5 ceossSST c � �
CERTIFlCATE OF ExEMPTlO F OM W RKERS' NO OF BLDGS. n ASSESSOR
COMPENSATI NS RANCE SIZE OF LOT 1 acre NOW ON LOT �v MAP P.00K PAGE PARCEL
�This section need nol 6e compF d if ihe permit is for one �/p o USE ZONF MAP
hundred dollars(5100)or less.) 7RACi Q r U BLOCK LOT NO. 1�U '(�� NO. �C� ' Z ��� r
TEL. p C SPECIAL �„
I wrtify that in Ihe performance of fhc work for which ihis UWNFR NO. p4 U6 ���g� CON�ITIONS �1
k permif is issued,I shall not employ any person in any monner 1b33 DERRINGER IN• DIS11tICT GROUP TYPE fIRE NROCESSED 6Y �
ADDRESS CONSi. ZONE
�' so os�o become subject to the Workers'Compensation Lawa � � G�
� cnv DIAD`i01�D BAft 7iP 9i765 1 ��—' �'=� r �
Date_ Applicani $TATISTICAI CLASSIFICATION APT. CON�O. {�
ARCHIIECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certifimie of �+ �+ ntt1�c+T 11 f e��!
Ezemplion, you shoUld become SUbject to ihe Workers' ENGINEER y;�� �oL'R.711iL NO. `Y 2^ 1 �LAS$NO. � UWELL.UNIiS_ �
Compensation provisions of the Lobor Code,you must forih� �DDRFSS SEWER MF�P �
with cemply wifh such provisions or ihis permit shall 6e TE��5C3$_2666
deemed revoked. CONTRACT[)R L.F. PiG w��s NO BK, PG, VALIDATION
LICENSED CONTRACTURS DECIARATION
i r�P«;hY�r���m maf i�m n«�s�d��d�.„�0��5�o�,s��r cf�<,�f��v noorzess 6 DERRIN GER No VALUATION
ap ��om«,e„���,�w�rh s��uo„�000�or����s�o„s ai�r,P a�����Ass a�d DjANeOND $AR uc /��/�,
g ,-'Professions Code,and my Lcense is in full force and effecL CITY CLA55 � �� \.7�.J\, �� � q�A
� y—�
��� „��4 S(7.F7. tJp.UF NO.OF CHECK
�u�F�s�N�mbe� u�.ci��� t3 � si�E sTORies rnMwes oNe #�. . . .2 3
eom�a�ro�7 ft�Zd�ls�tRr Q oao I •_�C�.—g'� oescHiaiioN or wozK 3 r��5 r & 6� "Ew ❑ � I • •4 2 4 0
� I um exempt from the licensing requiremenis as I am a RET�NING WAL3�S AUD �
licensed orchitect or a registered professionol engincer AUFR � FINAL �, d e e L�.[�4�
admg in my professional mpacity (Seclion 7051, REPAiR DATE =�����`-/ V
Business and Professions CodE). USE OF ❑ 0�,���'�2
� F�NAL
txisiiN�eiu�. — oennoi sr i"1;1. .c�...,s
LicorReg.No. ,_Dnte "PP;PRN",i LOU PZERP��ARINI No. 98-2b6
� OWNER-BUILDER�ECLARATION
I hereby affirm rhat I om exempl irom the Conlruclor's License
Low for the following reason(Section 7031.5, Business and /+DORESS DIAA';OIvD ]3AR
Professions Code): PRESENi
� I, as owner of ihe property, or my employees witfi' AUDRE55. '
wages os their sole compensatwn,will do ihe work and '
Ihe strutture is not intended or offered for sale(Section LUCAUTY .
7044,Business und Professions Code). MUVING ?EL.
� I,ps owner of fhe property,am exclusively conlrocting �nNTRACTOR NO.
with licensed coi��raciors to censlrucl ihe project(Ser qpURhSS
tion 7044,Business and Professions CodeJ. :1 3 p�Q Fl
RE�UIRED IOIAL SETBACK FROM EXIST
� CONSTRUCTION LENDING AGENCY SFi BACK YAND HWv pHOP LINE W�DTH #�
I hereby affirm thot there is a consfruc�ion lending ngency for pkON1 s • e s�
� the performance of rhe work for which+his pormit�s issued r L
(Sec.3097,Gv.C.). sio� � ' °6��5�
vi
Lender's Narne � ° •6 1.5 p c=j
(� �� � 01.19�82
P C.fx$ � �•��� \"j Permlt Fcc .7 Q
Lender's Address______
w I terlify ihat I have rend ihis npplimhnn and state that ihe � i5suunc�c Fee ��
- above infannation�.mrrect.I ayree to mmply wtlh all County in�esegaiion Fee
0 ordin ces and ai�laws relating to budding mnsiruction, Tmnl Fee �I ti�
� and e6y au onz�represenintives of this Counly to enter
Q upo ihe abov mef�tloned F>roperty for inspectlon purpose.s.
a 'L ^� Qt•��.—__ t ^1`� `a Z SEE FEVERSE FOR EXPLANATORY LANGUAGE
��� Signa�ure ot Applicani or Ayenl'— Date ��+
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