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HomeMy WebLinkAbout9270j Dom ------- CERTIFICATE OF EXEMPTION FROM WORXERS' INSURNCE {This section n ed#no NSATION i cal$ ed ,A# 'mit is for one hundred dollars ($100) or feu. ) I certify that to the performance a# the work for which this permit is issued, i shelf not employ any person in any manner sa as to become subject to the Workers' Compensation lows. Date ,?TtCf TO APPLICANTN; Applicant If, after making this Certtf€cote of •mphon. You should become sublect to the Workers' Compensation provisions of the laftm Cade, you must lorth- with comply with such lrovistans or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby offtrm that 1 am licensed urs Provisions of Chapter 9 (CO menctng with Section 70W) of Division 3 of she business and Code, and my license is to full force and effect, License Number Contor Date 1 am exempt from the licensing f'censed atchit•ct or a re aster require- trements as I am a acting in m g Prafeuional engineer Business and pr foisstons Conal ode). capacity {Section 7051, Ltc. or Rep. No. Date OWNER-BUILDfkf CLARATff-PI p heby off um that f am exempt from the Controctor's license Icwerfar the following reason (5eclton 7031.5, Business andProfessions Code): 1. as owner of the property. or my employees with wages as their ifol• compensation, will do the work and structure is not intended or offered for sole 7044, Business and Professions Code). (Section 1. as owner of the property. am exclusively contracting with licensed contractors to construct thpx ban 7044. Business and Profe$sion$ Cadae)oiect (Sec - CONSTRUCTION l herebY at#irmONSTRUCTION LENDING AGENCY Inst there is a construction lending agency for the p40(#ormance of the work for which this permit is issu {Sec. 3097, Civ C.). ed insure. of a CertificateI nave of war ke V Compsnstion Insurancent to * or a certified copy thereofS*c. { . Lob. C.) f€otKY4io.------- �Compony i ff..�J Certified copy is hereby furnished, Certified copy i$ filed with the county building inspec- lion department. BUILDrtVL; Wiper's Nome fe'eder's Address I certifythat l informationbora road t, I application and stats that the ordi a dSt is cared. t agree to comply with ail County ordinances and State lows relating tcibuilding construction, i and hereby au#tortzs'*Presentative$ of this County to enter upon the abave-mention*d property for ins /��-- pection purposes. t�_t!S<mtr* ��A..Opq is tSflenDot •� �► r! APPLICATION FOR BUILDING � a a e rit COUNTY OF LOS ANGELES PER MIT BUILDING AND SAFETY ©AS{CANT TO F{tt IN ffU€LDtF t� ADDRESS TSS � J .�- LOCALITY f,Jr f SIZE OF LOT NO OF I&DGS. ASSESSOR NOW Ott LOt C+V MAP 8CO tRACT BLOCKUSE ZONE fOT NO j.� 2DWNER 1�% i�r pia z� Tf TEL + _ _.^.• • v+cvur €YPE FIRE / CONST. Z 7 } ZIP ,7T1111® II , _ .. TEL _ _ - STAT€STtCJU CLASS€fAT€ ' ADDRESS tic. tett. PG, VAf tDATN NO CITY 14CVALU CLASS E OF , A j TEiRIts.�140. OF IE FAMtLSONE CtiECX r Z. 0 A OF WORk tKOW l '3 Is t ADD 0•' ••2v ALTER a FINAL [ • • Q l i USE Of REPAIR 0 DATI EXISTING BLD APPLICANT 13ErNOl FINAL e • ! PRINT) — - by NO, ' E PRESENT— bU€LD€NG ADDRESS OA jL a LOCALITY } MOVING, 1 CONTRACTOR NO ADDRESS v # REQUIRED SET BACK YARD HWY TOTAL lBACK FROM EXIST ' RUN T PI SIDE Pt P C Fit} s Investsgution TO€aI Fee SEF REVERSE FOR f"LANATORY LANGUAGE