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HomeMy WebLinkAbout0756A 0775A (4) � WORKERS'COMPENSATION DECLARATION • � � hB�ebY aff,rm ,ha, � have a certifimte of�o�=e�,ro se�f APPLICATION FOR BUILDING PERMIT insore,or a certificate of Workers'Compenslion Msurance,or - a certified copy Ihereo4(Sec.3800,Lab.C.) COUNTY�F LOS ANGELE$ BUILDING AND SAFETY �Policy No. Company Certified co is here6 furnished. euaoWG � � � �. ❑ Pv v FOR APPLbCANT TO fILL IN ADDRF55 ..f �•,:-���,' ��;lf_�`..r.—c_: r.e'��", � Certified copy is fi�ed with the couniy building inspac- BUILDING / �7 / /��, tiondepartmenf. ADDRE55 �b efi� F '�'�C+e+,- �[.�.�.�_„��'�a LOCALITY /.`/-e�'��*-�+"��.� �� Date Applicant CITY �y� ,-`��C�_ti.. ZIP /��1,.,3 CROSSSST. .�r4.C%_ve-<=4L3. `�°a:�-�t�`� - CERTIFICATE OF EXEMPiION FROM WORKER$' NO.Of alDGS. / ASSESSOR � ' COMPENSATION INSURANCE SIZE Of LO7 NOW ON LOT MAP BOOK PAGE PARCEL �(This section need not be completed if the permii is for one ^, USE ZONE MAP �{� � TRACT� � BLOCK LOT NO. NO. S e�..:5 "+�✓� - h�ndred�dollars($100)or less.) ,�'l � y - y`� TEL. ,/� SPECIAI. `I certify ihai in the performance af ihe work for which fhis OWNER .�C-, -s�-y,; +-r+ NO. �`�"��E- - CONDITIONS � 'ermit is i55Ued,(5hall not em I DIS�rzICT GROl1P� TVPE FIRE PROCESSED BV p p oy any person in o y manner qODRESS � � CONS ' ZONE / � �-so as to become subjecr}01he Workers'C mpen tion Laws. f� ��., j' /( � -�,t�ti.t.<-J--C../ o �aYe�����Applica. CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO. ~ ARCHITECT OR TEL. NOTICE TO LICANT: If, after making is Cartifimte of � � �' �� w fxemption, you should bemme subject lo the Workers' ENGINEER q�.�, NO. . C1A55 NO. DWELL UNITS_ 4 Compensation provisions af the La6or Code,you musf forth- qODRESS �� ��-tt- �''1d .. - �':� SEWER MAP � wifh comply with such provisions or ihis permil shall he � � �y s� deemed revoked. COMRAC70R _,i-a'^!/ .Gi,,�. N�n. �:��`/.>r BK.� P�, ` VALIDATION � � LICENSED CONTRACTORS DKLARATION / LiC. � I hereby aR�rm fhht I nm f�ensed under prov�isions of Chnpter 9 . ADDRE55/�� � �,� NO. VALUATION (commencing wiih SecYon 7000)of D v�sion 3 of ihe Buslness and "� / �G 7 s,U A j LIC. / Professions Cade,and my license is in full force and effcct C!iv /4"`'� -r ��" aass,���i� S LFT -7 C�"� � so.Fr �i No.oF �No.oF cHecK ##• • � •2 3 LicenseNumber � Lic.Class SIZE SfVRIES FAMIUES ONE - f New $ I • >4240 Coniracfo 1�' �ate` � � DESCRIPTION OF WORK .1 � m exe rem � ADD � •� °G-2�G�C s I a mpi fr rhe licensing reqw enrs as I am a �4�� � � .r'-.,, � licensed archlted or a registered professional engineer e� ALTER � FINAL ���.,� �� � ��2 J��.� octing in my proFessional mppcity (Sedion 7051, REPAIR � DATE � riC Business and Prafessions Cade). , USE OF "- ) PINAL EXISTING BLD . x'Q.=(.L� " DEMOI. ❑ B , ��/�� $� Llc.or Reg.No. Date APP�iCANT ,{� ' j,r �/ 1 � TE�. OWNER-BUILDER DECLARATION (PRIM) �� /L ( (F��/1/ NO. �� �� I hereb affirm ihat I om ezem 1 from the Controctor's License 7 �� ����� Law for the following reasoopSedion 7037.5, 8usiness and ADDRESS���'� 4.j��� � � � i t � K: ' f 'J Professions Code): PRESENT � q� y�/ S�,9r � � I, os owner of the BUILDING ^JG���(.�"' � . property, or my employees with AD�RE55 �V�' wages as iheir sole compensation,will da ihe work and � � . ihe srructure is not intended or offered for safe(Section �OCAliiv ' , �� �oaa,e�s�„Pss nnd a,o;ess�o„s code>. MoviNc it�. z 0 7 7.5 A � I,as owner of the property,am exclusively confracting �n�uTRACTOR �(�. with licensed r,ontmctors lo construd the projech(Seo- � '�e • s.r • ' iion 7044,Business qnd Professions Code). ADDRE55 � REQUIRED TOTAL SETBACK FROM EXIST � • •S L 5�^� CONSTRUGTION LENDING AGENCY SFT BACK YARD HWY pROP.LINE WIDiH v I hereby affirm thai ihere is a cons+rucrion lending agency tor FRONT� - ihe performance of the work far which this permit is issued p.�. � °:° ���.�'�c=i �se�.sa9�,a�.c.�. s�oe i 12 4—8 1 �ender's Name ) � Lr.nder's Address P.0 Fee 5 ,;y. ��C��� Pcrmn Fcc � �� I certify that I have read ihis application and smte that�he Issu ce Vee , �� � Qabove informallon is mrrect.I agree b mmply wilh oll CouMy „es�;gaiion Fec �n ordinances and State laws relating to building consiruction, ic�al Fee �r�� ...���� and here6y outhaYiz:�repre setailv.=s of ihis Couniy to enter upon the abov -mentione properry forinspeUion p ose- .- -y� � SEE REVERSE FOk EXPLANATORV IANGUAGE _ SignoNr ot plicant or Agent Dotc C�s � � o, . s � u a.^� �� o - s. ��'.g.,"�'' 6�v�,3- w �j y.� o � o a� o� ���°+> a u ��'s'.a^ 3 °�va �u ;'� '`a" m °V °�� � m �, ,n , ��o m � � w �- �a,.*-, C� w N �(y U'� 1w � ��y Q�,,,{ ��A y O N n�'l^Q � 'O w�:"'� N S,'.i. 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