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HomeMy Public PortalAbout6267 LOMA AVE_Building__ WORKERS COMPENSATION DECLARATION I�yhereby affirm that I have a certificate of consent'to,self. P • -�:� ���'�O ay� , _�UMID ( insure, or,a certrficate of Worke'rs�'Compensation Insurance, p L/11 Ll L1 L1\1 V LI�/LI or-b'certified'copy;thereof (Sec. 3800,.Lab"°C.T. ' }. a. . COUNTY OF LOS'APIGELES BUILDING,AND SAFETY 4 Policy No. Company, ❑ Certified copyjss,herebyO�F ,furnished. �' FOR-APPLICANT TILL''IN =`T BUILDING; r ,• ADDRESS 0, • Certified copyis f,led,witfi t14coun buildih BUILDING;' �- ' ginsPec ADDRESS _ / tion department_ �.2 E. f—�`'9/� `Z T K P L:, c..I' CITYL 7/�4•�i •, '� ZIP' Date -' r.PPPlicant'� [' LOCALITY,•- NO. OF BLDG) NEAREST e _ CERTIFICATE"OF"6EMPTIONj.FROM-.WORKERS :' .512E OF LOT -NOW ON LOT CROSS ST •' +; COMPENSATIONbINSURANCE• ' i ASSESSOR 22 .(This`section--need not"be completed--if the:per'mit is fon'orie TRACT '.`; BLOCK LOT NO Y ;^ MAP BOOK �dk -' PAGE SOC PARCEL 'hundred dollars ($100)`or less.). ":r •' TEL. �/- a,- OWNER '� lJV NO. ��j '3� USE'ZONE MAP I,certif that,in the erformance`of'th'e work for which this c- NO Y_ a P. n, t_ SPECIAL-.: - .-a, .. _ .- _ � permit is issued, I shall not employ any person in any manner ADDRESS, r;. © +�' � ;-:- + \ /' a. so as-to become subject to-the Work'ers',Compensation,Laws. CONDITIONS 2.0. - 1a :r.: CITY. CST 7 ZIP:,, ro Date Applicant'•' = ARCHITECT OR TEL. - �! NOTICE TO,APPLICANT ;If -afteu„making this,Certificate of••.• ''t ENGINEER NO :_ s W PE DISTRICT', GROUP CONST �RE'E'- P CESSED BY O, ” Ex`erription, -you`•,should become_subject\to the Workers:•, 'r q, rf� '• g W Compensation provisioris ofrThelLabor Code;you must forth' -ADDRESS with comply,with, such�proyisjonsi,or;,this'permt'.shall be TEL STATISTICAL CLASSIFICATION•-• 'APT CONDO. r' ' deemed,'revoke 1. „A- s• CONTRACTOR'., NO 2 / N. • _ t LICENSEDG,CONTRACTORSDEGLARATION ;.f1• LIC CLASS NO' DWELL UNITS I'hereby affirm that I arrm'licensed under provisions of Chapter 9 ADDRESS __NO ' c SEWER MAP ' - LIC. r+'''� �• ,(commencing with Section 7.000)'of'Division,3 of the'Business �• � -- •'• - � t3-_i�i as and Professions Code;and,my license,is rri:full force•ond-effect. CITY CLASS BK, PG VALIDATION' s SQ'-FT. NO OF NO OF ` CHECK _ { '' 'SIZE }' STORIES FAMILIES ONE License Number L c. Class' '' - '• - - _.. VALUATION L I Cid: - 7, _ :I. _ .• - - •- DESCRIPTION OF-WORK. `' .NEW.' ❑ - ��[/ Contractor,' h` Date $ ' 'S I Icy+- (� '.� 1 ❑I.am exempt under Sec.- 1.�}I © ADD m P ALTER ❑ �_ _•R: fi. _'-2.2,�_ B.BP C. for this reason- - $ .REPAIR•❑ _• iffl'��� �E II� Date: USP OF„ - "DEMOL'"� EXISTING:BLDG. y —Signatures �L' :/: OWNER-BUILDER DECLARATION APPLICANT 'TEL. NO— � FINAL DATE I herb dffirm that I am exem t'from.lh'e Contractor's License ­L- Law ^ y` y- - / . pTI Y P ADDRESS FINALa _ _ _ s _••_ Law fo?'the following reosoni,(Section-7031:5,'Busin'es's'and !' 311 , Pro essions.Code): PRESENT, ,;;. By- BUIL 'a x `,- y DING :� :at.l r y j, as-owner'of the+'property, or my 'employees with ADDRESS :,; -•� wages as their sol'e'compensatson will do the worksand LOCALITY the struci"ure is not intended.or offered for sale(Section' 77f"i- 7044, Busine- 'and Prof essions•Code':,) ;d MOVING TEL ❑' ,I,-as owner of the property,am exclusively contracting CONTRACTOR-� NO -- --with•licensed contractors-to'construct-'the-project°(Sec- r ADDRESS` a. r, _ n .tion'7044, Business and Profess-ions•Code.) = y ,' ; ,. REQUIRED q• ..:.TOTAL SETBACK FROM EXIST, CONSTRUCTION LENDING AGENCY SET-BACK', YARD' HWY PROP LINE -WIDTH ��t s''4 {,:•� I`hereby affifm that'there is a cons'tru'ction lending agency for _,FRONT E`' != The performonce of the""work for.which this permit is,.Issued ' , P'L"'- i 4'. •` �:I'�� „ ,(iIi (Sec:.'3097;Crv.'C.): SIDE r P -Lender's Name P C Fee S Permit Fee Q, O LDMA Ref:#_ (_'•E !4i 3-€il fff. s - Lender's Address /{$1 n. o Issuance'Fee �J ? 'CDMA P/C#•c - I certify that j.have read this application•and-state that the x ' 8 above mformation is correct. I agree to comply,withal I County nyestigarion Fee. :' - t ,R ordinances and State.laws relating to building construction, Total Fee U •. •CDMA Perm # a• '-, and hereby authorize representatives of this Courity to enter _ '' ' ' upon,the a ove-mentioned'peoperT r insr')406n purposes. ; F. ` ' '" • - - ? . = - ` ` SEE REVERSE FOR EXPLANATORY LANGUAGE -, Sign of or 'ens, - Date of Applicm -` - • - - it T. /I f ERS'COMPENSATION DECLARATION certificathate of Workersrtificate of Compensdt on ensuran ent to lf 6r'��i®?? ,� , (OK."R u l d®5 M G - R�{x,11 .0�1 _,rt fiqd copy thereof (Sec. 3800, Lab. C.) - COUNTY',OF LO.S ANGELES BUILDING ARID SAFETY „ Policy No. Company `.'t 4 Cgtified copy is here-by furnished. FOR APPLIC'ANT-TO:FILL_IN,, ADDRESS G IjP_iLLO ma . Certified copy'is filed with'the county-building mspec- BUILDING' ` J ""' "d* ''v" tion department.& ADDRESS: .1' ? � • 6L�1,. D ' Date Applicant CITY ti ZIP Syl'- ` LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' r, ` p - ;NO'OF'BLDGS '' pNSt? n NEAREST COMPENSATION INSURANCE SIZE OF LOT-•" 5O NOW ON LOT " ` .CROSS ST Lo vt d evi (This section need not be completed if the'permrt is for one ASSESSOR' hundred dollars ($100)or less.) •„ TRACT _ BLOCK LOT NO. MAP BOOT( PAGE PARCEL T L USE.ZONE MAP - I certify that in•the performance of'the work for which this - OWNER / // .� g LltViC�ti O Z�s— �� NO' permit is isgued, I shall not employ any person in any manner ..ADDRESS tp, ID• , _ / SPECIAL CONDITIONS so as to become subject to the Workers'Compensatiori La j U '�W'"� CITY e lei Uf ZIP. ""1►7SV Date r Applicant' """"`""'" ARCHITECT OR TEL. NOTICE TO APPLICANT.'If, after'm this Certificate of _ ENGINEER NO. DISTRICT GROUP TYPE / FIRE PROCESSED BY O Exemption, you should become subject to the Workers' CONY ZONE U Compensation'provisions of the Labor Code„you must forth- ADDRESS• 3 W with comply .with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. fn deemed revoked. CONTRACTOR. NO. Z . LICENSED•CONTRACTORS DECLARATION w LIC CLASS NO. DWELL-UNITS. - I hereby affirm that I am licensed under provisions of-Chapter 9 ADDRESS NO (commencing with Section 7000)of'Division 3 of the Business and- LIC M SEWER.MAP' Professions Code, and my licenseJsinn full force and effect. CITY CLASS ' BK PG77 VALIDATION b SQ FT.,, 01 NO OF NO OF CHECK License Number Lic.Class SIZE - b STORIES / FAMILIES Pd Date DESCRIPTION OF WORK - Z bONE L VAL A Q . _. f(�i�G117S NEW � Contractor ' .Q ADD ,. I am exempt under Sec. C� ALTER 9'8 a 0 A B.BP.C. for this reason REPAIR 0 e # USE OF Dale: • EXISTING BLDG. I' ,`( - DEMOL0 ,.- ., _ •• Signature APPLICANT TEL, FINAL I ° 2 4 7 5 OWNER-BUILDER DECLARATION PRINT NO. DATEo 2 4 6 7 5 ' I hereby affirm that I am-exempt from the Contractor's License o: L'aw for the following *reason (Section 7031•.5, Business and ADDRESS FI a Professions Code): BY- �� 0 &D9:� 88• BUILDING j, as owner of the property, or my employees with ADDRESS :b•, i ti -wages as their sole compensation,will do the work and + r 1 the structure is not intended or offered for sale(Section LOCALITY t ' 7044, Business-and-Professions Code). MOVING - TEL �_,` ^•R I, as owner of the property, am exclusively contracting CONTRACTOR NO T with licensed contractors to construct the project (Sec-. ti Cr to` 'tion 7044; Business and Professions Code). ADDRESS _. _ �' �' p w 4.,':-t�;• - REQUIRED TOTAL SETBACKROM EXIST CONSTRUCTION LENDING AGENCY- SET BACK YARD HWY PROP LINE WIDTH I herebyaffirm that there'is a construction lending agency for 9 9 Y FRONT,.. ? d'.y the performance of the work for which this permit is issued P C. Y (Sec. 3097, Civ. C.). SIDE P.L. {. Lender's Name LDMA Ref # m P C. Fee S” Permit Fea J Lender's Address I certify that I have read,this application and'state that,the. Issuance Fee.- LDMA P/C# above information is correct.'I agree to comply with all County' Investigation Fees q ordinances and State laws relating to building construction, Total Fee- LDMA Perm. N and hereby authorize representatives of this County to enter - upon the above-mentioned property for inspection purposes. tL 0. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date �� '