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HomeMy WebLinkAbout1637A 5332A WORKERS'COMPENSATION DECLARATION `� I her,eby affirm fhat I have a certificate of consenf�ogelf APPLICATIQN FOR BUILDING PERMIT � insure,or o certificate of Workers'Campensation In urance, or a certifie copy ihereof(Sec.3800,L .C.) o,)...t�Kv\� �;�,� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N � ' ���Compan BUILDING !`\ y,,� � . � Certified mpy is he�eby furnished! FOR APPLICANT TO FILL IN ADORE55 �r7� W ~�.J� � Cartified copy is filed with ihe county building inspec- eUILDING y� �, (�1� tion d por ent. ADDRESS �) � �OCALITY ��Ck1 �_ NEAREST ote � Appllcan � ' UiY - zIP CRO55 Si. C IFICAiE OF EXEMPTION FRO WORKERS' ;� � NO.OF BLDGS. nS5E550R COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be compleied if ihe permit is for one � �i--- uSe zoNe n�P r�� �v TRACT BLOCK LOT NO. "� NO. 1 � hundred dollars($100)or less.) �I �.� iEl. SPECIAL I certify that in the performance of the work for which ihis OWNER , j � NO.i'f" � ' P� C9� CONDITIONS � DIS ICT GROUP TYPE FIRE PROCESSE�BY � permit is issued,I shoil not employ any person in any manner • ^� i � CONST 2 � Z'' , so as to became subjecf to Ihe Workers'Compensation Laws. ADDRESS ' . - � �o �., I CITY ' � ZIP �" �� � r .�i Date Applicant $TATISTICAL CLASSIFlCATION APi. ONDO. � ARCHITECT OR � TEL. � � NOTICE TO APPLICANT: If, ofrer making this Certificate of ENGINEER ,� -� NO.�"����^� ;s�^�7 CLq55 NO. ��� DWELL.UNITS�' � Exemption, you should 6ecome subject to �he Workers' �a Com ensafion rovisions of ihe Labor Code, ou must forih- �- t i �f'��'� SEWER MAP P P Y ADDRESS � �=j � , with comply with such provisions or ihis permit shall ba TE� f deemed revoked. CONrenCTOR i �" ` } NO.�uf� - BK.1�PG, � VALIDATION LICENSED CONTRACTORS DECLARATION LIC. i I hereby affirm that I om licensed under provisions of Chapler 9 ADDRE55 7 NO. VqIUATION (commencing with Sedion 7000)of Division 3 of ihe Business and r, , ���. � Professions Code,and my license is in full force and effect. Ciiv (__.' ' aA55 $ ► � � � SQ.FT./%"�t}�"' NO.OF f^� NO.OF 7 CHECK License Number Lic.Class SIZE � � STORIES �= FAMILIES 7 ONE i , '"' ' L7���='7 r NEW S .-�� I �;J. �R Coniractor Date �E S C R I P TI O N O F W O R K I C:!_ /.' .Y %!C.. AD� � #e o • a C S � I om exempt under Sec. . � � FiNAL s���,•.�R ALTFR EB.&P.C.for ihis reason � � �W '' '� ��- REPAIR � bAYE ;��' A � m C��(-;Z 'c,` j Date: USE F -� DEMOL ❑ BINAL n �C C�.��z 5 �. EXISTING BLDG. �<� Y + Si noture APPUCAN7 -� TEL._., g OWNER-BUILDER DECLARATION PRINT �� NO.�J' r��j�/� 'J�L � I'"C>4 1 here6y affirm ihat I am ezempt from the Contractor's License �4... � , Law for the following reason(Section 7031.5, Business and + ADDRE55 ..7 I Professions Code): PRESENT 7 BUILDING ���_'„� I, as owner of the propeity, or my employees wifh ' ADDRESS � wages as their sole rompensation,will do the work and fhe sfructure iz not intended or offered for sale(Sectian �OG4�ITv 7044,Business and Professions Code). MOVING TEL ��'�J,�'ti, � I,as owner of the property,am exclusively contracting CONTRACTOR NO. wilh licensed mntracfors to construcf the project(Seo- n �* Q a a � � � tion 704A,8usiness and Professions Code). � nooke55 REQUIRED TOTAL SETBACK FROM EXIST. ! CONSTRUCTION LENDING AGENCY SET BACK YARD HWV PROP.LINE wiDTH � I�! U J G'C � I hereby affirm that there is a convruction lending agency for pRONi , � ��. the parformante of the work for which this permil is issued P.L ° ��,f -1 3O l�o � (Sec.3097,Civ.C.). . -SIDE � � � � j m r.�. 0 E�.c 1 '�8 4 � lender's Name ��I I $ Lender's Address P.C.Fee$ �� Permi�Fee ` ��5 I � I certify Ihat I have read this applicolion ond stale ihat the Isso ce Fee lv�` m ahove information is correct.I agree fo comply with all Counfy Inves�igotion Fee �n �Ig ordinances and State laws relating to building construction, Total Fee � o . � and hereby_ ulhorize rapresentatives of this CouNy lo enter � upon t e ove-mentioned property for inspection purpos s. g\ �- � SEE REVERSE FOR EXPLANATORY LANGUAGE � ���-}-� a�af QP.�t genr are �s 1�� s �`I_.�_.. .� . ,--^--T- �y�,, 7 T�(?2 G O n ' '� � T �r � � 'a � :1: � -O i �n ° — 1 t��J ��� e �� o o� o o �. �. 6, � 1. �s o fp n C S � S� S� .� fl I C � n .._..�_�_�. 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