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HomeMy WebLinkAbout1636A (224) � WORKERS'GOMPENSATION DECLARATION I� �� � he�eay aff��m �ha� � ha�e a�e�f�f��afe a,mnsenl to se�f APF�LI�ATION FOR BUILDING PERMIT � insure,or a cenificate of Workers'Compenstion Insurance,or � a certified copy rhereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Campany BUILDING ��•��,, ,/�.,�, � Certrfied copy is hereby fur�ished. FOR APPLICANT TO FILL IN ADDRE55 ,��Y7"=C.J t�.�.Z.> �l� � � � Cenified mpy is filed with the coomy b�ilding insper BUILUING ;�' I / /" �+r" ��+y„ /y/ � tion deparimenf. ADDRE55 - r. �J ,�,; (_�(_j�/ LOCALIiY -,l6�I�:���/�'7�,� .o � �y� ) NEAREST ��, J �y�1 Dafe Applicant CITY _ ZIP /�1��?� CRO555T. fl .� -�f-!'j/'i�`.t'����.F�-� �-r+'�"�-� � CERTIfICATE OF EXEMPTION FROM WORKFRS giZE OF LOi (YJ� �.f�.Y.3 NOW ON IOTS ! MAP BOOK PAGF PARCEL COMPENSATION INSURANCE This setlion need not be com leted it the e mit is fo�one �-7•-r USE ZONE MAP �, �i ( � P � ,�" '� 3 3 hundred dollqrs($100)or Icss.) . TRAQ ., '�) BIOCK l07 NO. �„ / NO. } ' / J TEt. ��/J �j SF'FCIAL �, I OWNtR /5 � �� NO-p-,.i'/ ( ��� CONDITIONS � ,� I certi4y ihut in the performance of ihe work for which this uiS�RICi GROuv ivPt tiR6 PROCE55Eo Bv y„j � permit is issued,I shall nof employ any p rson in�.p ny manner � .'.7>f'1� L/ ) [ J •LL �•�� _ ,.� �� ADDRE55 �{'Y'(3�.1 C L"'J '` CONST. Z E so as to become sub�ect to tha Workers'Compef[a'sation Laws. � p arr zia z"` /�� ,���!� �.�!�.. i�a<.<.�.,c.r O p Date, f � °�Flppliran `, '��'��� � � STATISTICAL CLASSIFICAiION APT. CON00 � ARCHITEC(OR TEL. � NOTICE TO APPLICANT�. If, nftcr making t is Certificate of ) � p Exemption, you should become su6jecf to ihe Worke�s ENGINCER ��- CLnSS NO. �f DWELL.UNIfS_ » tlCompensnlion provisions ot ihe Labor Code,yo�m�si forth- qppRF55 SFWER MAP � A with comply wi�h such provisions or +his permir shall be ) � deemed revoked. CONiRaC70 ,"�P;{J,� 1 NO y_���„3� 6K. I'G. VALIDATION � LICENSED CONTRACTORS�ECLARATION ,�;�.. y .r �y I heroby affirm thnt I am Ilcensed under provisions of Chaptcr 9 AODRt55 . � `.�� ����/ ` " NO_�.�/ .i�"'! VALUATION (rornrnencuiy wdh Seclion 7000)of Drvision 3 of fhe 6usine.ss and r / ��� � � Professions Code,and my license is in full force and effect. UTY �i 7'� .D CtnSS ,.� S �� 5(].FT. NO,Oh NO.Of CHECK � License Numbey+'� � Lic.Class� ' S17E STORIES FAMILIES ONE � � .'� �' 7.•.sy V �^�j�� f DCSCRIPTION OF WORK NEW � Canfractof=� � �.�- s. Date ,f . ADD j � I am oxempi from the licensing requiremenis as I om a � � � Ilcensed architect or a reyistered professional engineer � Ai�ER � FINAL � acting in my professionol capacity (Section 7051, � REPAIB � DATE �/ d � �7� � Business and Professiore Code). u5E OF EXISTING BLDG. i DEMOI � FINAL � Lic.or Req.No.-----oate AVP�vaw��_ � ,7 .��CL� NoC� „..� ev � 1�3Y2 c.� / �1 6'J.b�1 ; �+� OWNER-BUILDER DECLARATION ���'ry I here6y affirm that I qm exempt from rhe Contre ctor's License ,/ �° • • • • � � Law for ihe followinq reason(Section 7031.5, Business and � ADDRFSS ti�.;�" ti,F'� � f,.!'✓ � Professions Code): � P ESENi � " �?_5.5 0 � ❑ - � BUIL�7ING ' I, as owner of ihe praperty, or my employees wilh ADDkE55 ��5 O` i1 woges as the�r sole mmpensation,will do ihe work and � � ° �' '{ the structure is not intended or offered for sale(Section LOCALiTY �oaa,e�s��ess ond P�of�ss�ons code). nnoviNc rE� 0 2 2 3—8 2 �?) I,as owner of the properry,om exdusively mnir�cting �UNTRAQOR _ NO. �a � with licensed contraciors to construct tf�e pro�ect(Seo ADDNE55 � tion 7044,Business and Professions Code). , R[�UIRFD TOTAL SETBACK FROM EXIST. C.ONSTRUCTION LENDING AGFNCY SET B�CK YARO HWY pR(�P IiNf W�DTH I hereby affirm iho�there is a construction IPnding agency for pRON� the performance of Ihe�,aork for which ihis permit is issued P i � (Sec.3097,Civ.C.�. SiDE PL � Lcnder s Name .__ P C Fee$ Vermii Fee . �U� ����ders ndd��s.5 I cenify Ihat I have recd ih'is application c�nd stote ihat tha ` Iss e hee ��.7 �, � obove infor tion is mrrecf.I ogree to comply with oll County Invesrigaiion Fea ��� ordinance and State�laws relniing to building consiruction, � lo�al�ee '� <".�� �� ond herr y nwhori representa�ives of�hls Counry to entcr Q "on t above-� ntloned p�operty for Inspeclion purposes. ,��`----- /�"'%�?"�"�'�-- a � SEE REVERSE FOR EXPLANATORY LANGUAGE �� Si9n Iu e of Appli<nnf ar Agent Date � , � �- r^ . 7 T p r-�-_' m ' T (!i � �+ �-- _- -a 9 � i'.-O i 'n� r���i �__ _ 'i_._.� � C � �e;��> > � 08 0 0 � 'o o °, o"�° ° � ° o m `° � � i tu � 1� �m R � � S \ ,r�. 1 3 6' �G _' ' x i � n 1 n �- � •� ! Q � � ��___— — —� Y i L, ,o � ^ � �v ,c ' m �-. o o .�� ,o c ,-^�o � co _ ,a � ,3 c� �- � I � I^73 � Z x -.� - � � -•; x 3 -o � � J c � i '° � C7 � . I � 'i`'! 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