HomeMy WebLinkAbout1559A 1651A , _ ��-
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,WORKERS'COMPENSATION DECLARAiION I � �� I �'�
I hereby offirm fhat 1 have o cerlifica�e oi consem ro,e�f. . ; - :. qpp��CATION FOR BUILDING PERMIT � ��
� . insure,or a certificaie of Workers'Compenslion Insv�ance,or �
.a cenified copy rhereof(Sec.3800,lob.C. � , �. �. "� ' � � �--'COUNTY�OF LOS ANGELES � BUILDING AND SAFETY �
PolityN6iwc�liyi q�ny � �.•--� . �- . - - ' .
Cerlified co s hereb furnished. ' � BVILDiNG/��s� �I�MoNP � LVP �
❑ PY' Y FOR APPLICANT TO FILL IN aooaess�alv
. a Certi{ied copy is(iled wilh Ihe munty 6vilding Mspet- �1 gUILDING l I,p . � �VD• �/ MvNY j�7�
lion deparlmenl. , AD�RESS lV IOCAUTY � -
Dale � Appliconl ' � � � CITY V I D D�!/ � Ziv� �� CRO55557.� I�V (/�S� U� �
CERTIFICATE OF E%EMPTION FROM WORKERS' - � '`� ' �� ��` G 2/lr'7u NO.OF BLDGS. �� ASSESSOR � r� �
� COMPENSATION INSURANCE -� 5¢E OF LOTJ :JIiC/✓ NOW ON LOT . MAP BODK PAGE 1 PARCEL
�(This 5etlion need not be[ompleled if Ihe permil is for one TRACT �✓ etOCK LOT NO. v . USE ZONE MO.P � 3_ / .
hundred dollars(SI00)or less.) . � - - I � I� � NO. �' .3�3 � I
. . , /1� TEL �7 ' SPECIAL � : - a
�1 certify thot in Ihe performance of the work(or which this, � OWNER C/Li � NO. li"rn CONDITION$ � O
I��/� 5T.5U �I Q �ISTRICI GROUP TYPE FIRE PR SED BY V
permif is issued,I sholl not employ any persan In ony manner qDDRE55 �O �.n CONSI�TT ZQNE �
so as m become subject io the Workers'Compensotion lows. L ,� J a
�Date � A licant � Ciiv S N � ZiP Z7OS - O ..
PP " STATISTICAt QASSIFICAIION �APT. CONDO. �
� NOTICE TO APPIICANT: If, afrer making fhis Certifitote of�- � ENG h� R Zj37�� ' C�n55 n10. �� U
i1 DWEII.UNITS W
Exemption, you shoold become :ubjeU-to the Warkers' J N .
Campensotion provisions of ihe Labor Code,you musl forlh- ADDRE55� � � �• SEWER MAP Z
with comply�with s�ch provisions or this permit shall be TE�
deemed revoked. . . 1 � � VAIIDATION
• - CONTRACTOR G p BK. PG,�
� Y LICENSED CONTRACTORS DE PLARATION P � �g2 N.�AT � n10. ,
I hereb ofiirm that I am licensed under rovisions of Cho ter 9. _ qooRESS � � � �
(commencing wi�h Section 7000)of Division 3 of the Businers and Q�A N6E �IC. VA�O��'DO � �' S�9�a ,
.Prolessions Gode,ond my license is in full force ond eFfecf. CIiY �`/l i C1A55 S #�� �'�'�•�3
' .�n.��`� �.. SO.FT.Io'L1 C NO.OF /� NO.OF CHEIX �.
, License Number_ L LiC.C�oss� SIZE T✓ STCRIES L... FAMIl1E5 ONE� � -. ' '
T S ;� . . � Qi4�_
Controclo �-�/��/'1I�f 1/Dafa �2 . .. DES i I N F W�K I N� ❑ �. . . � ' _ -
..❑ W1�1�I WNI l.l�Li`�L ADD � •;• • � �,�lOcl
I am exemp�from tha licensing requirements os I om a f/
licensed orchilect or a registered professional engineer„_ _ t, �y-� �y 1 Al7ER � FINAL / p �2� (��8 2 .
� acting in my profestional copaciry (Sectlon 7051, C! L�/ (�1�4 REPAiR -� DATE � �t0 O•3 �
� � BusinessondProfessionsCode). USEOF ����C ��7A�nO�lA�1i1 � FINAL . ' � - '
� � � EXISTINGBLD �.����-V�ty �.1 V DEMOL , B
. . . .: . .. ... .. . APPLICANTI\��TH IY"�IYL+1�� N .t Y 9 . . ..
Lic.or Reg.No. Dafe . , .,
' OWNER•BUIIDER DECLARATION � � " ' � (PRiNT1 . �
1 hereby afiirm fhof I am exempt irom the Contractor's licensa . ^� (iG/���
Law for the following reasan(Senion 7031.5, 8usiness and ADoeE55�5 1 ��('� � ' - � -
- Professions Code): � - � . �et5etii � � -
BUILDING
� �" I,'os ownei of the proper�y, or my employees wiih - ao�aE55 � � � � � - � � -
wo3e,,.,tie,,,�ie.�m�a�,�,;_�,,:,;!ia�,��.•:��k�-d �AUT� � �1 65,:1 A .
� ihe srrucfure is not imended or affered for sole(Section ' - - - �� - - - � �- - .
7044,Business and Frofessions Code). MOVING TEL. • �#� '� ��:.�
. � I,as owner of rhe properry,am exdusively contrac�ing CONiR,4C70R NO. � . � .
� with licensed coniractors�a construct the projeU(Seo qDDRE55 � I • •3 1,5 0 �
�ion 7044,Business and Pro(essions Code).�- - - -�� � . . . . .
REOUIRED TOTAI SETBACK FROM EXIST. . _
CONSTRUCTION IENDING AGENCY SET BACK Y�+RD HWY PROP.LINE WIDTH � - �'� •3 t 5 0 c.i
I hereby affirm Ihal Ihere is a construttion(ending ogency for �- fRONt . � � . � � � - �� �� - �
Ihe performonce oi the work for which Ihis permil irissued P.L � •�2'�[j••$.'Z
. (Set.3097,Crv.C.): . - . ._ . . _ . .. .. _Sioe ._ � .
- P.l. � . . . . . .. . .
Lender's Nome �/� �
P.C.Fee S� I I'`/"V Permi�Fee � " V ' � �
Lender's Addrers (7 /' � , � •
I cerliiy ihot I have read Ihis applicotion and slate fhot the � �ss�ance Fee� . 0•J v � .
above informotion is mrreU.I agree to comply wilh oll County , , Invesngorion Fee � . � � .. . _
oidinances and Stale Iaws relaling to 6uilding conslrucfion, ' Total Fee .J� �
and hereby authoriz �repr ntatives of ihis Coumy to e ter • , .
�`up t e bo �me��one p .rry for inspecfio purp es.-�' �� � _ . - �-� � ' , '' ' '
� �l- � SEE REVERTE FOR E%PIANATORY LANGUAGE � � - � '
' igna�uro o Ar„canl or Age Do� � � . ' � � �
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