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HomeMy WebLinkAbout0825A 1649A WORKERS'COMPENSATION DECLARATION � ., .I � • - - � �� I heieby_affirm that I have a certificote of consent fo se�F. .. �:� � APPLIC�TION F4R BUILDING PERMIT insore,or a cerlifitote of Workers'Compenstion Insurance,or I , �a certflied topy thereof(Set.3800,Lob.C.� _ � ' � , _ - � PolicyNo����S�ny ,.�. � ��D,U Y �LOS ANGELES� BUILDING AND SAFETY . � Certified copy�s hereby fumished. + ° FOR APPLICAN7 TO FILL IN Bunoirvc < ,/�4��*�J� �� � ADDRESS .U ��. fiY , Certified capy is filed with the�county 6oilding inspeo BU4owG � � � -1 /7�'�yG /r ,�� lion deparfinenf. - � ADDRE55 l� ����TY .Ly ,(�!' . � ' � - � /`. �'1 NEAREST /J� . -Do�e-� � � �Applitonl � � � CITY V V . iIP CRo555T. � � �/L.ti-�-�'� � - � ��CERTIFICATE OF EXEMPTION FROM WORKER$' � NO.OF BLDGS. /'� .455ESSOR � COMPENSATION INSURANCE� - � '� 512E OF LOT. . NOW ON LO7 �((/. � MAP BOOK ' PAGE PAR[EL �� �,/�, /��,{ USE ZONE MAP "(This section need no�be'campleted if the permil is for one TRACT.l) (/J BIOCK - LOT NO. �� , NO. �,��.3��V� hond�ed dollors($100)or less.) � �� . � . � � ' r { �f 57eUni . � a ' . ' I ,/ /� �-� � � � ��Q. . `�� CONDI710NS l terfify that in ihe performance oF the work for which ihis ,.. � �- �permit is issued,1 shall not empioy ony person In any manner ' Z �2J G, l 1 CG � p �yE DISTRICT� GROUP TYGE fIRE PROCESSED BV (� ' ADDRESS I�l�✓ ly ✓ so as to became subjecl fo the Warkers'Compensation Laws. I `D � CONST.� ZONE �„ p`/ � Ciet.t-t/ O �o1e 'App�i[anf ' . . CITY �I`y / � Z�P I� /,� 5lATISTICALClA551FICATION� � APT. CONDp. V NOTICE�TO APPLICAN7: If, o(ler making this Cerfifitate of ' ENGMEERTOR�NIM/i � N�Z�� �VJ�'� � W � Exemplion, yoo should become wbjetl Io the Workers' CLA55 NO.�DWELL.UNITS n. Compensation provisions of Ihe labor Code,you must forih- AD�RESS v • J SEWER MAP Z wi�h comply wiih such provisions-or this permit shall be " � /2 , � . deemed revoked. . � �ONtRnCTOR p��.� �¢I�s�,/3� sK. PG, VALIDATION • J UCENSED CONTRACTORS DECLARATION � LIC_ ' I hereby offirm ihm I am licensed under provisions of Chapier 9..._... .S qDDRE55 . �. 'v�n. NO. VALUATION �Q 8 2.5 A ' tommentin with$ection 7000 oi Division 3 of the Business and /1p^��� n J� /�1� . :Professions Code,ond my license is in fu�l force ond elfecf. OTY VI`y-+I�ICi�i Cj\• C1A55 E �-CJ�•(�/ � #�.• •�• •2 3 SQ.FT�/� NO.OF NO.OF CMEIX � ' - ' �ticenSe Numbe�22�2 �i�,�Ip55' SIZE /i(/ STORIES � FAMILIE$ ONE ��� 1 p g,-6 0 �, �/���� • ❑ S Conbactor 1 GM'1R�f�Ya'{G�7�c� Da�e ! DESCRIPTION OP WORK N� � e �Q 9 6�S � I om eeempt from the licensing require nts s I am o � IV� �M �y M ADD ��C � � licensed archilecl or a regislered professional engineer . _ .. _ . . __. . .. ALTER '� FiNn� / / y � I 1,Z 5,�8� .. acting in �my profe:sional capaciiy (Section 7051, � DATE (O �W p� . , � � � � Business and Professions Code). � . USE OF �-y �!Q REPAIR ' E%ISTING 9lDG.�1/LL Or f 1� DEMOL � FINAL li[.or Reg.No. Date � APPtiCANT'�/�� iE.�� B �� � � � �. � � -� ��OWNER-BUILOER DECLARATION� � � �-��� (PRiNT11Vi� � N . I hereby affirm thm I am exempt from the Gontractor's License I7I� 1 �R O 5 VE.5 � � � � - .�, Law for,the lollowing reosan(Section 7031.5, Business and AOORE55 Professions Code): . ,. v�t5eni � � ' ' . ❑ . .. . . BUIL�ING . . . . I, as owner o(Ihe properly, or my employees with AODRE55 wn�>s os the�r sele cen+pe.^.ta!i:n,will do ihc work crd �� 6�.9 A � � . - the srructure is not imended or offered for sale(Seuion - lOcnuTv� - - � , . ' 70<4,Business ond Professions Code). haOwNG TEi. , '#��� � � �1 • � I,os owner af the property,am exclusively conlracling fONiRAC70R NO. � � � � . wirh litensed contrac�ors fo construct the projeci(Seo AODaESS ' � 'I;' 1 4 a 5 0 . � tion 7044,Business and Professions Code�:� � � � � REUUiRED TOTAL SETBACK fROM E%IST. ' . _� CONSTRUCTION LENDING AGENCY SE1 BnCK YARD Nwv PROR LWE WIDTH . ,�• 1 4 5 5 0 c� - I hereby offirm rhot fhere is a construcnon lend�ng ogency for � � pRONi � ' - � � - ' ' �he performonce oi Ihe work for which Ihis pe�mit is issued P L. 0 2 2',3�8.`� . . (Sec.3097,Civ.C.�. . . �� � SIDE � - � - - . � � � � - � �� � - , P.L. - . _- . lender's Name � + ��J "" '" �' � � - � � Lender's Add�ess P.C.Fee 5 � Perm�r Fee . rU -� � � . 1 ceriify iha�I have read�his opplication ond slote tho��he � iss� ce Fee + ✓ ' � _, above informotion is torrect.I ogree to comply wi�h all Counly ; m�esi�ga��on Fee . - . a� �I� � � - � � ordinonces ond Stafe laws�eloling to building construclion,� To�ol fee � � � and hereby ao�horize repr sentotives of this Counfy�o ente� ; - ��.up bove-me io�e p perty fpr inspecl' n p rposes.�- �i � . . . � � � � � ' - SEE REVERSE FOR EXPLANATORY LANGUAGE � - � � no�ure o( PPlic. r , m �r I . . . . . . �s .o . ' '. . .. ... _. .. . . . . . . .. . .� ... .. . .. . ._ .. .. . . . .. . . 4 � . �T Uf T tf�O O � O m .a d. t� 0. � �q �; .. C O t� � r m �.C1 P � �� X I d n � .-�~� � � S n . � tn?? 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