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
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