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HomeMy WebLinkAbout1336A (7) WORKERS'COMPENSATION DECIARATION � �7 insure,�orafcerlifca�teofWorken''Compensaloolnsorancef � APPLICATION FOR BUILDING PERMIT . LS or a cedified copy thereof�Sec.3800,(ob.C:) : ' COUNTY OF LOS ANGELES. , BUILOING AND SAFETY PolicyNo. ' Company � - � Cer�iRed copy Is hereby furnished. FOR APPLICANT TO FILL IN nooeEss 7.2 �l.._e �+c� � Certiiied copy is filed with tha couny building inspec- sURowG -fion department. , qo�aESS� l iocaurr - �*-�,�rn..G - , NEAREST Date Applicant [IN nP 1 �RO55 5L _ ' ' . � � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. .455ESSOR � � COMPENSATION INSURANCE SIZE OF LOT Now ON LO7 ^nnP aooK � PAGE PAR�EL (This section need no1 6e completed(f the permif fs for one � USE 20NE MAP h�ndred dollan(E100)or le:s.) TRACT 7 � BLOCK LOT NO. �/ NO. �6� -��3 TEL. SPECIAL I eerlify that in the per(ormance of tha vrork for which this OWNER �"-� No. rrD CONDITIONS� ��d pBfRli1 IS ISSVOd,I shoil not amploy any penan i ny manner � DISTRICT GROUP TYPE FIRE PR SSED 8Y � so as to beeoma sub'ecf fo Iha W mp s on Laws. ADDR 55 CONST Z�E .U ` /O !°-.3 � /v ct� � Da1e�ApplicanF i . CITV �1 - � ZIP. S7ATISTICALCU1551FlC4TION . ....__ AW. CONDO. 'u NOTI�E TO APPIICA T:.If, afie�mnk thi Cer1(fico 'of� . ARCHITEC70ti -'.:TEL,� ..�... �Exemption,'you shauld becoma'subject-do the Work�rs ! . ENGINEER�: � �.�NO. ���GLd$$NO. a��-� DWELL.LNIiS a Compensation provisions of the Lobor Code,you mvst forth- � - qD�RESS���� � SEwER M.aP N with comply with soch-provisions or this permit shall ba - '� � ' � " � � ? deemed revoked. � � � CONTRaCTOR - Np . aK. . PG, VALIDATION �� -�� LICENSED CONTRACTORS DEQARATION � � ' � { p�, r - � ' I hereby affirm thot I am licensed under provisions oi Chap�er 9 ADDRE55 �� 11 �NO: �4� � - VALUATIDN �� �- . . (commerxing with Section 7000)of Divisio�3 of the Business and-�. � � ��� , � I �e �Ls'(7 � � Professions Cade,and my license is in full farca and effect. , CITV �— C1A55 S Q �� ► . - �� � '�''�� `1\ SO.FT. NO.OF NO.OF CHECK LiCCnSB Nu r Li[.Class—S�.J \ SIZE STORIES FAMILIES ` ONE � . ( N� � S Conha[tor Dale�'��1 DESCRIPTION OF WORK _ �I cm e:empt under Sea � � - -� noo " " ALTER � FINAL � L .. . . . . , . B,RP.C.for this reoson � . . . ... . .... . - -. . . . . ._ � �DATE 2 � ' t -- . REPAIR � use oF � FINA !� � �ate; EXISTING BLDG. - . DE/v10L ❑ BY n �' . .Signature � A7PlICANT TEL. . . . OWNER•BUIIDER�ECLARATION . PR�NT NO I hereby affirm that I am exempt from Ibe Contratlor's License � law for the following reasan(SeAion 7031.5,Business and` ADDRESS � � �, �� 3�j,b A � Professtons Code): . � � pae eNr � � I,as owner of tha properiy, or my amployees with qDORES�S � #• • • • •;�, wages as iheir sole compensmioe,will do tha work and� � . . . iha structure is not intended or offemd far sale(Section� ����TY � .I • •3�'�5 � 7044,Business and Profeesions Code). _ • MOVING TEL. , � I,ae owner af the property,am exclusivaly contraciing� �ONTRACTOR NO. , . •3 6 7 5�� with Iicensed mntmcmrs lo conelruct the pro�ect(Sec-' ADDRESS • • -lion 7044,Bosiness and Professions Code). . , � . . . . O 2 O� —B D .. REWIRED TOTAL SETBACK FROM EXIST. CONSTRUCiION LENDING AGENCY � SEi snCK YARD HWY PROP.twE Wi�TH . I hereby oHirm thet�here is a construction lending agency for; prtONi � � � ��- ►� � - � � - - � - - � �- - ' the performonce of the work for which this permit is issuad': v.l.. , . tSet,309�,Civ.C.). . . SIDE ._ _ . - . � P.L. . . . _ . . . . Lende/s Nama � � . Lender's Address P.0 fee t Perm�r iee � �.�J`/ I�tertify Ihot I hava reod this opplicotion and stale that the - � Inoance Fee O...f� ebova inform ion is conect.I agree ro comply with all Counry i„�,+;qm�on F�e - �ordfn ces a State laws relatlng to building tonstrucNon, � To�al Fea 3G. �� � 6 d er by ut ize raprezematives of this County to enter � . apo the bo e- nt oned property for inspection pvrposes. � � _ �� � � � . - � SFE REVERSE FOR EJ(PUNATORY UNGUAGE � , _ . . Ignat Applimnt or Ag nr - - pore � . �. . ..�� __ .._. . . . . . . .. . . . ._ . / �._ _. j'^ (1 2 r r � T N OT uf O � O (1 N �n� � � _T = '�' _. '_ � _ _.. 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