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HomeMy WebLinkAbout1130A 1292A (5) WORKERS'COMPENSATION DECLARATION I lnsurebor�afcertlfcatteofWorkesr'Compensafoninsuronelf APPLICATIQN FOFt BUILDING PERMIT � �a certifie mpy there f llSec.38 la��.�,,. �'� �.`� �y��&� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No:"'l l O I ompany � � � ��� , ,_ � Ce�ti4ied mpy is hereby furnished. � FOR APPLICANT TO FILL IN ADIDRE55 ��,.`_S��r �� C:1\+` � Cenified copy is filed with�he c unfy bu'din �nspec- BUILDING f'L C'" '�, (• �A�� `� tion deparfinent. 1 ADDRE55 � �� �' b� � r t7 , � Da+te�r�Appliconi+ CITV ZIP �Cc%� LOCALITY ~c G�*�"a C�F\ \�;" ,i�J i��^CERTIFICATE OF EXEMPTION R M WO CERS' ' NO.Oi BLDGS � NEAREST 1 � 1� "'1 COMPENSATIO U NCE SizE OF tOT a L. /�V NOw ON iOT CROss 5T. , ��Js�.._ ��._ j(T is se�[tion need not be mmple e if the permit iS for one TRACT fi� �� BLOCK LOT NO. t.L� MqP BOOK PAGE PARCEL hundred doilars($100)or less.) �"� M A n,� • TEL�.-!'� iy USE ZONE OP ^ � � . I certify that in the perfarmonce of the work for which this OWNER I��+a.L.�r � NO.�"i `d d3 } permlt is issued,I shall not employ ony person in any manner f SPECIAL p, so as to 6ecome subjecr to the Workers'COmpensation Laws. ADDRESS ��^ � �a Y��LS CONDITIONS U � Da�e Applicant CiTv Li,'Cki�N l.� ziP �'�1 �j� �. ARCHITECT OR , TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: I4, after making this Certificate of �,jA'�(;�lL;�.S� NO. CONSLzU}-�—�� ZONE n M� Exemption, you shou�d become s�6jecf to the Workers' ENGINEER � Compengption provisions of the Labor Code,you musf forth- qDDRESS S�''u �.� „ ` -'-'"�-� 1 °��*=7-�'� ��, � with comply wi�h such provisions or this permit shall be i: TEL STATISTiCAL CL4SSIFICATION APT. CON�O. CA � deemed revoked. �ONT2nCtoR �(.Ai���`�'Li No. e� �, LICENSED CONTRACTORS DECLARATION ���, CLA55 NO. �WELL UNITS !'� I hereby affirm that I am licensed under provisions of Chapie�9 aDDRe55 tv0. (mmmencing wi�h Section 7000)of Division 3 of the Business and ��� SEWER MAP Professions Code,and my license is in full force and effect. CITV CLA55 BK � VALIDATION $q.FT. NO.OF NO.OF CHECK ,r�icense Number 1.�'3 7 2� Lic.Class� SIZE STORIES FAMILIES ONE �� y� 3� �� Ve1lUATION � DESCRIPTION OF WORK � ���y,(� NEW ,� ConVaUor Date App ❑ S �d �C3� �I om exempt under Sea ���l-c1%��' �Ey"�"' ❑ / '�� � .�i il(�, ` A!TER e a \ B.BP.C.for this re son q REPAIR � S ��° °�-� ` �°��'�'�""'�'� EXIST�ING BLDG. C� �EMOL � ,� �(� 1 (` APPIICANT • ;El. � Signature PRINi �.0 ��.(�1/�:LwvNO. �Q �Gv FINAL/ m a a F(i � O NE -BUILD R DECIARATION DATE�-'f _ � � 9�' I hereby a that I m exempt from the Contractar's License L- / Law for the fo g reason(Section 7031.5, Bosinase and /aDDRE55 -��-'�';' FINA "� � �&.C;:-F;� Professions Code)� � vRE EN BY ggg ❑ BUILDING — � I, os owner of the praperly, or my employees with ADDRESS ' �,�1_L�!f1 � wages as their sole compensation,will do�he work and G" `� ihe slrucfure is not intended or offered for sale(Section IOCALITY � � 7044,8usiness and 7rofessions Codei. MOVING TE�. � I,as nwner af the properly,am exclusively canfracting CONTRACTOR NO. � with licensed conhactors to cons}ruct the projeU(Seo pDDRE55 tion 7044,6usiness and Professions Code). REQUIRED TOTAL SETBACK FR CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE W�DTH I hereby affirm ihat there is a construction lending agency for FRONT ihe performonce of ihe work for which this permit is issued P,L. (Sec.3097,C��.C.). SIDE y 1` �"�q P.L. � I C C G It g! Lender's Name LDMA Ref.# i m P.C.Fee$ �� Vermii Fee ' �� `' ° �� '� � f � Lender's Address , � '� +'%4.(�,' � o I cenify 1ha1 I have reod this opplicalion and state thot the Issuvnce Fee LDMA P/C N m V above� otion is correcr.I agree to comply with all Counly Imestigation Fea ordma ces and State laws relaling to boilding constr�ction, Total Fee �DMA Perm.# °�������5�� /J and h e aut rize re�Jjesentatives of this CouMy to enter ��upon abov mentioneH property for inspection purposes. �8�J� -`a 8 �m $ '?j�r�� SEE REVERSE FOR EXPLANATORY LANGUAGE € Si notu of Applimnt or Agent Date � _... __ _. ... .,_ , ..._ .. .._ _ _ ... - - . , , . � � • . � f � � � � _ ; ' _ : _.� � 4 ' � � ' - �; ; i � ' , � _ � 1W . � . a 1 ' � , .. ' j � � + • i � m ; <I --- , , i 1 J i � ; :� ' . � ' — � , ,, i _ � '" � 4i • ; � � i i �� �' i , � f , , ' , i � ) ^ { j' � � ' " i ( ;� ! i ,�( � i . I i I i j i : k a . J . � € � I � t � �� i i ' � f i � ii 7 , � k � .. 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