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HomeMy WebLinkAbout1335A (145) WORKERS'COMPENSATION DECLARATION , � � he�eby aff��m ,�o, � ho�e a�e„�f��afe of consent to 5e�f APPLICATIQN FOR BUILDING PERMII� insure,or p certificaYe of Workers'Compenstion Insurance,or a cert fied wpy Ihereof(Sec.3800,Lab.C.) 1�T � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No��'rJt^!7�%-� Company�C's'�1� 6UILDING N , � Certified mpy is hereby f�rnished. FOR APPLICANT TO FILL IN ADDRE55 z 1�� �,�'r'K.tv'7 ��}(�lr� f-��a� rj1 Certified copy is filed with ihe caunty building inspec- gUILDING V ' ���� tion department. ADDRF.SS � �� \ LOCALITY �� 'j�}'if�.'L , � NEAREST Dafe�-Z.'1"i-�� Applicqnt,� ��' GTY ` CROSSSL CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR � COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP 600K PAGE PARCEL (This seciion need not 6e completed if the permit is for one USE ZON[ MAP hundred dollars($too)or less.) Tencr alor.K �or No. No. � 7"' �{ iEL. SPECIAL @, I certify that in the performance of the work for which this OWNER 7-�'✓�/L�„ !� NO. � �>� CONDITIONS �^� permil is issued,I sholl not employ any person in ony monner � ^� DISTRICT GROUP TYPE fIRE PROCESSED BY (a so as to become subject to the Workers'Compensation Inws. A�DRESS . � . � J� CUNST LONE � ❑/�7 \O �.�� � ��c�, � Dat�- Applicqnf��'�=� CITY � �� Z�P y7q115TICALClA551FICATION APT. CONDO. (,�,) NOTICE TO APPLICANT: If, after makiny thls C^rfificate of ARUIITECTOR TFi. � Exemption, you should become subjecl to Ihe Warkers' F.NGINEER NO. C�ASS NO. DWELL.UNITS_ � Compensation provisions of the Labor Code,you must forth- qDDRE55 • SEWER MAP � with �omp�y ith such provisions or �his permif shall 6e '" deemed revoked. � TE�""r+ / gK. pG, VALIDATION CONTRACiOR NO� (, �k� l ICENSEU CONTRACTORS DECLARATION p � �i�� I hereby affirm thal I om Ilcensed under provisrons of Chpptcr 9 _ ADDRESS � IC NO. � yqLUATION (commencing wiih Section IOW)of Division 3 of the Business and ��� • r�r��V Professions Code,and my license is in full force ond affect. CITY � CLASS�' � �� �=��-� �j,[�. � SQ.FT. NO.OF NO.OF C41ECK LiCense Numbel �-��/-/�%�� lic.C�ass r."7f�> 517.f S10RIE5 FAMILIES UNk Contraclor 9� J.1� Uate � lI,J"�O� oESCRIPiION oF wORK NF``N ❑ ' � I am exempt from ihe Ilcensing requirements as 1 am a �� .��C� ADD � licensed architect or a registerad professional engineer AtrER � FINAL , •� .� acting In my professional capacity (Socfion 7051, � REPAIIt � DATE � _ � Business and Professlons Code). USE OF � � EXiSTING BLDG. DEMOL ❑ FINAL :, � Lic.or Reg.No. Date APPLICANT TEI BY ,� V i,l..;`�; OWNER-BUILDER DECLARATION (PRinli) - NO., ��° , , � � � i I here6y affirm that I am exempt from the CoMracror's License �/ p� Law for ihe following reason(Section 7031.5, Business and ADDRE55 pY y I Protessions Code): peESFNT ❑ BUIiDMG I, as owner of the proper�y, or my employees with ADDRE55 ages as their sole compensarion,will dn the work and � ihe struc�ure is nor intended or effered for sole(5eciion �OCnuTv 7044,BuSiness and Professions Code). MOVING TF.L. .7 � I,as owner of Ihe property,am exdusively roniracting CONTRACTOR NO `�'� ,�3,5 A with licensed contractors to cons'Irucl ihe project(Sec- qDDRESS �o s e • � '� tion 70a4,Business and Professions Code). RE(�UIRED TOTAL SETBACK FROM EXIST CONSTRUCTION IENDING AGENCY Sfi BACK 1'ARD HWY pRnP.IINE WIDiH I • •2 5,5 0 I hereby affirm ihat there is a consiruction lending agency for FRONT �he performance of ihe work for which ihis permit is iSsued ��L s . « 0 25,50� (Sec 3097,Civ.C.1- SIDE P i. Lender's Name (� ��'2`r`'_8 2 P.C.fne b Pennir Fce .V)� Lendor's Address __ �y I certify Iha�I hove read this application ond state thot ihe Issua cP Fee D,+�� Qabove Informafion is correct.I qgree to comply with all County Invesegnrc��oo ordinqnces and State lows relotiny to huildinq mnslruuion, �" � and Viereby oufhorize representotives of�his County ta enter TO�O�F`�" �`�� aupon ifjq o- ve-mentio d property for inspenion purposes. a �If; � 1��ti-�,�� SEE REVERSE FOB EXPLANATORV LANGUAGE S�yn Appl'ican�or Agent �atc bs 0` _ ��....�,�-'>..r-;-"'"! tl,o .,,..._�----` .._.�--�����--"^ m , p � �; ''o O S- c� { ' �.,,,." .� ''" �(1^� � n.. � O 0. 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