HomeMy WebLinkAboutNo Permit Number (821) WORKERS'COMPENSATION DECLARATION ��
I hcfeL�/affirm ihaf I hove a terti(icata oF consenf fo,e�f � � �qpp��CATION FOR BUILDING PERMIT
ins�re,or o terti(ico�a of Workers'Campensotion Insurance,
or a certi ied c�opy th �eo� Seoc.500���A)L 1Nn,G8 g]�d j.10 � 31 Z • COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. mpany . L ' '
Certified copy fs hereby furnished. BUILDING s) A , /
❑ FOR APPLICANT TO FILL IN ADDRESS .c, u ��+.��
� Certified copy is(iled with ihe county b�ilding inspec- BUILDING
fion deporiment. . ADDRESS 2901 YuCatan PlaCe ��,iin.
NEAREST ,
oare nppi�canr an Di.at'��Dnd Bar ziP 91765 ceosssr.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. n55ES50R
� COMPENSATION INSURANCE SIZE OF LOTOIIe Ipt SU}J. NOW ON LOT NOI1C MAP BOOK PAGE 7ARCEL
(This section need not be completed if rha permit ts for one USE 20NE ^nna d Z—3�
hundred dollers(E100)ar less.) . TRACT BLOCK lOT NO. NO.
OWNERCdr�.SYJ2TCJ COT15t.CA. TEL. Q— C� SPECIAL }
I'cenify tha�in iha performance of the work for which ihis NO. - CONDITIONS O.
pelmlt is IssUed,I sholl not employ any person In ony monner DISiRI�T GROUP TYPE FIRE PROCESSED BY p
so as to become subjecr to the Workers'Compensation Laws. aoortE55 28�0 28�1 $t. .j �_' CO�IW V
CITY ]]1 d ZIP ''O "" �
Date' AppIImM 9O4OS STATISTICAL C1A551FICATION APi. CONDO, �
_NOTICE TO APPLICANT: If, ofrer mokin this Certificafe of ARCHiTECiOt�� T��•(213 451 tJ
� 3mprion, you should become subjecf to the Workers' FNGINEER Vl't0 �ttd �17I1 NO. ? Q 3
C1A55 NO. �WELL UNITS�� w
�mpensatlon provislons of tha Lobor Code,you mu:t forth- ADDRE55 1419 2r�d Street Santa hbnica SEWER MAP �
wifh comply with euch provisions or this permit shall ba �
deemed revoked. coNtRnttOe C3L'1Sb2L' COflSt.C#e. z� 0—
0K. pG, VALIDATION
LICENSED CONTRACTORS DECLARATION � liC.
I hereby oHirm thal l am licensed under provisions of Chapler9 ADDRE55 28�� 28�1 $t. NO. VAWATION - �
' (commencing wi�h Setlion 7000)of Divisto�3 of the Business and ���
.. Professions Code,and my license is in f�ll(orce ond effect. Ciiv Shcltd T'10711Cd (,'d. M55 t . � ,
317237 B-1 SOE`�.5749• sToa°Fs ?% F MROIE$ 3 �oN� , �2 1 Q�A
License Nomber Lia Class n
DESCRIPTIO OF WORK L, N� � S��G DOV V �� � � �G`� �`_ �
' Contratror �C. $�7�RS 1
�I am exempt undar Sec. ` S ALER ❑ FINAL f °6 3 1•O O �'
B.BP.C.for this reoson �[—, .� Q OATE — J • •6 3 1,0 0�
I . . . REPAIR
Date: USE OF 0 FiNA� . 0 fl 1 3-8 5
� FXISTING BIDG. DEMOL gY .
' � siqnature AP�pRir�T Cdrlsbex' ConSt.Co.No. 3 0 , . �� •
� OWNER•BUILDER DECUIRATION � . , � , �
I hereby affirm that I am exempt from Ihe Comroctor's Litanse . _ _ , .. . . . . . .
law for the foliowing reoson(Seclion 7031.5,B�siness and ADDRESS
Pro(esslons Codej: pREyENt
� � I,as owner of the ro er y P Y _ BUILDING _
\ p p ty, or m em lo ees with ADDRESS
J) wages as their sole compensotion,wlll do the work and i���n, - . .. �9 5 5 9 a
tha structure Is no�iMended or ofiered for so�e(Section , , -
7044,Bostnass ond Professions CodeJ. MOVING TEL Q'� � � ' � _ � � �. �� e �'� � ,�
� I,as awner of Iha property,am exdusively conlmtling �ONTRACTOR NO. � ; ,
wilh Ilcensed conlractors to construcl fhe pro�ect($e[- ADDRE55 _ � " - � �.�7�.��
tion 7044,Business ond Professions Code). ---- ��` ,
REQUIRED TOTAL SETBACK FROM E%IST.
CONSTRUCTION LENDING AGENCY SET enCK YARD Hwv pROP.LINF WIDTH � • �,U�I��O O�
1 hereby affi�m that there is a mnstruction lending ogency for FRONi �� � -
the perfarmance of the work fo�which ihis permit is issued P.L. i� �7 0 9�8 6
�s�c.soe�,e��.c.l• s�oe : ��'��.,'+
— P.L. . i
m Lender's Name .
8 , . ��\�',��'� ,
= Lender's Address � P.c.F�e S ���,� Permir Fea �GO- '- _. . � . -
� 1 te�fify tha!I have read this applico}ion and stafa that fha Issuonce Fea �0'S� I
� abova informatlon Is correct.I a9ree lo comply with all Co�nry Inves�iqotion Fea r� � �
g ordinonces and Stota laws relating fo building constructlon, Toral Fae �"��/ �' �
and he�eby aulhorize representafives of this Counry�o enrer
� upon the obova•nentioned erry for spectlon purposes. y��':_� �� �
s—(i"sy
� , -)3-�°jr— SEE REVERSE FOR F%PLANATORY LANGUAGE
Signarme of Appiicant or nl Do�e . Of
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