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HomeMy WebLinkAbout1395A (217) WORK€RS'COMPENSATION DECLARATION �� : ' � I hereby affirm that I have a certifiwte of�o�5e�r,a��f qpp��CATtON FQ� BUILDING PERMIT ��, �� insure,or a cer�ificole of Workers'Compensation Insuronce, or a certified topy thereof�Sec.'3800,la .C.) COUNTY OF LOS ANGElES BUILDING AND SAFETY � P❑olicy No. CompcnV r• "'" � � , Certified copy is hereby-furnished.- FOR APPLICANT TO FILL IN �����' q f� Certified co is filed with the tount tuildin me eo ADDRESS J� w/ �o� V� i py y g� p BUIIDING � Q � tion deparfinent: ADDRE55 W 1 r`� � � `�� I Dare��ApPlicam . - c�tt W�L�1 zIP LOCqI�m Yy �- , I �RTIFICATE OF EXEMPfION ROM WOKKERS' � � NO.OF BtDGS. NFAREST p �7 � COMPENSATION I RANCE SIZE OF tOT NOW ON l0T CROSS ST. y_ O N �L�/ � (This section nead not 6e complated if�tha permit is for o�e ��R ���� hundred dollars(UW)or less.) TRACT� � BLOCK LOT NO. � MqP BOOK PqGE� PARCEL TEL. �/ OWNER I�G ��i NO. � E �,p, /��-�ea� I rertify that in Ihe performance oF the work for which this � � " ) permit Is iuued,I shali not amptoy any pe son in any monner A�� ��9� ���A� - d w os ta bacome sub�eci to fhe Wor ers' mpe tio Laws. p CONDITIONS u .� � /"� . - . . .:.� GITY �11r V Y N ZIP �� � Dote APp��COM ARCHITECT OR 1EL. O DISTRICL GR UP NPE fIRE SSED BY NOTICE i0 APPUCANT: If, after aking ihis CerNfitare of E�,�NEEB P10. ✓J µ57. ZON (~j Exemptan, you should becom subject to the Workers P P . Y ADDRESS �` L L- d Com ensatian rovisions of the 6or Code, au must forih- with comply with such provisions or this pormit shall be ------ -- .._ . -._ - -,l.. ......._.. ....�L. . deemed revoked. � .. - � � CONTRACTOR �` � g �� STAASTiGAL CiPS�5;1�[iG/)aTION APT. CANDQ�-��� LICENSED CONiRACiORS DEQARATIOIV -- 4 p - itc.�j p- �5 nw. "'" �wEu UnUTS- - I hereby affirm that i am licensed under pravisions af CFwpter 9 A�RESS�J d$ G +� NO.iJ� �� D (commencirg wilh Section 70(10)of�ivision 3 of fhe 8usiness a� . �/ . .. ..11C.- _ �R�P . ' � Profassiona Code,and my litense is in full force a�jn�d effeGL CITY 1'<<W�d� CtA55 C�� ��/���� y/UApqn(xd . .� ���!O O -..� . �. .. �fr'�� 5(i.Fi. NO.OF NO.OF CHECK license Num4er Lic.Class' S2E StORIES FAMILIES ONE . � }�!y'h J(� VALUATION � CoMrocfor�B�V_'�jf Dute �� DESCRIPTION OF'WORK �O � ; ��A 0.�� � � `e r' W � u � I om exempt under Sec. � ALTER 8.8P.C.for rhis reason REPAIR [� S USE OF - - Date: EXISTIIJG&DG. �� ❑ APPLICANT� � 7EL. "Sigirotwe FINAI OWNER.BUILDER DECLARATION PRINT .. NO. ..��,_ _�r�.�, : � ,'n t,�,. 1 here6y a4firm thot 1 am axempt foom 1he Cenuacwr"aLicense .- - low for ihe followirtg reason(Section 7037.5,Bosinau and ADDRE55 - ---- � FINAtuj-'"�_�-=- � n.: •s • • 'ProfesslonsCode): .. . . ... .. . _ PR . .-_ ._ -_. . .._ __.__. --gY .--i.fL� - . . .. - ❑.. BUIL�ING ' � < ��� „ .. 1, as owner of fhe property, or my employees with ADDRESS �wages as tFei7�sole compensation,will do tha work and � �; ; , �„ the slructure is not intended or affered for wle(Section ����T� � , � - 7M4,Bvsiness ond Vrofessions Code). MOVING- � 7EL. � � I,aa owner o f�he propeMy,pm ezc tusive ly con l r ac�ing CONTRACfOR NO. � il U. I � -C�-F � . with�titensed tonrcotlors ro conshvct the praject(Sec- � qDOR�55 .. tion 7044,Busineu and Professions Coda). , � --- - - CONSTRUCTION LENOING AGENCY ��gq�K YARD HWY T�T pRpp�ME WIDTH 1 hereby offirm thpl there is o construction lending agency for FROM � the perfwmonce of the work for which this permit is issued � - P.�.-� - -- � � � (Sec.3097.Ci�.C.). SIDE .. _ P.L. . _. . . _ . $m Lender's Name ��� . � IDAM Ref.N - Lender's Address P���Fce S Permit Fee � � I certif_lhat I have read this a licauon and_swte that ihe _ / 1� ' y pp luuance Fee J� LDMA P/C M � nbove informatian is cwrect I agree b comply urith all County i�„esecqa��on fee , � � ordinances and Smre laws relating io 6uilding construcrion, Toro�� ���b LDMA Verm.# ' '" and hereby authorize representatives of thia County to enter � up ih bov ' a roperly��Inspeclion purposes. � `/�� SFE REVEiSE FOR EI[PUNATORY UNGUAGE �grioturo oi Appl�can�a Agent Date - - p' � ' '-; � � y t .. u�� �� � ,' • J � � � N � �dt S'yc,� �"'i d ..�'i O� U . jf L�� F O � a� ? o�� ��� �_ G ,. �r °' x ? �-"o 0 0" " � � d s� ��' � a;�,:;a .� o o M.�c.,��« ,�r` .�t�� m a.V a �_X, � �w„ •u ~Y„r�'v OO a � '.l �... �^ y �y ,n y °i o p� . 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