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HomeMy WebLinkAbout0376A , �1�� WORKERS'COMPENSATION DECLARATION Qj h insure,�orafcertifca'teof�Wokers'�Compensa�o�s��;�.a��'f - � - � APPLICATION FOR� BUILDING� PERMIT� � � zS or azertified copy thereof(Set.3800;Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. ��� � Campany " � Certified copy is hereby furn�shed. FOR APPLICANT TO FILL IN nooaess z���'r ��f=/-% ? � Certified copy is filed wilh tha tounty building inspec- gUILDiNG'7J �j!- � tion dBpOrtmeM. � ADORESS!I� cY� r/L/7"y�-- LOGUiY .�/�¢ / ' - � � � �� NEAREST /� //� Dafe � l�pplicant CI7Y � Zia � �ROSS ST. G /� �• ��-.CERTIFIGATE OF EXEMPTION FROM WORKERS' � � NO.OF BtDGS. n55E5SOR . • � ��GOMPENSATION INSURANCE< � . � SIZE OF LOT � NOW ON LOT MAP BOOK PAGE PARCEL (Thls setfion need nol be�completed if the permit Is�for one�- . � �,�/Z ' -- �S � u5E ZONE rnn.P � � hundred dollors(5100)or less.) . � .. . � . � TRACT BLOCK- � l0T NO. �L /� No. 'los �3 3 � � . . , .. . . -. . . .� TEL. �y SPECIAL. .. . ! 1 certify thot in the performance of the work for which rhis OwNea w� Na � - � CONDITiONS '�� �- � a pe�mit fs issued,1 sholl nof amploy ony petson in any mannet ' � r`� - �' DISTRICT GROUP TYPE . FIRE PROCE D BY d _ so os lo become sub(ect to the Workers'Compensotion Laws. ADDRESS 7 Tz 'Lt� �L , CONSt� 20NE � V � - d' . . . . //t.�- Dote - qppljtanf � - � ' CIN Z�P STATISTICAlCLA551FICATION APT. CONDO. .O ARCHItECT OR /�� TEL ! NOTICE TO APPLICANT: If, offer making thfs Certificota of •W,Q.($TA/j ��NO.� � CIASS NO. ��"� DWELt.UNITS� ' � W ENGWEER 'Exemption, yo� sho�ld become s�bject to the Workers' a. Compensation provisions of the taber Code,you mvst forfh- _ aooaess SEWER MAP . y �with comply-with such provislons or this permit shall be TE� . �z deemedrevoked. � � � � CONTRACTOR NO. BK. aG, - VAt1UATION -- � LICENSED CONTRACTORS DEQARATION uC. � 1 hereby aHirm that I om Gcensed under provisions of Chopter 9 ADDae55 NO. VpLUAT10N - � (commencing with Setlio�7000)of Division 3 of the Busineu and ���, ��'�.,�y-� . Professions Code,ond m licensa is in full forca and effect. �ITY aq55 S V�— , - - - - - � - � � � � SQ.FT. NO.OF NO.OF CHEIX � � � License Number � Uc.Class�� � � SIZE STORIES FAMILIES ONE NEW s Confroctor pote DESCRIPTION Of WORK � /cT�. � � ❑I am ezempt under Sec. � �,v G �L - ADD _ , AIiER ❑ FINAL _.. . . B.SP.C.for this revson . �� ��' -�- � REPAIR � DATE � .. . � USE OP FINAL Da1e: EkISTING BtDG. ��'I'a ❑ Br . . . . . - Signoture � �. APPLIG4N7 TEL. n , .. � . OWNER•BUILDERDECIARATION � ��M NO. �,��,�Y(� J'A-rD , I hereby affirm that I am exempt from the Comractor's Licensa . `� 37(o - Law for the following reason(SacNon 7031.5,Business and . ADDRESS �G3,r/ � V Professions Code): � . pee N � I, as owner of fhe ro e y P Y BUILOING . .. . '"C�6 A p p rty, or m em lo ees with ADORE55 _ woges as their sole compenzofion,will do the work a�d � . +l']� 2 j . . .the structure ts not in�anded or offered for sale(Saction ����TY � � � � � 7044,Business and Professions Code). � MOVMG , TE�• ' � •3 7 4.9 5 � � I,as owner of�ha property,am�exclusively cantracting MRACTOR NO. , with licensed wntmcbrs to consiruct the project(Sec- /�_ • +3 I 9.9 5 c=.� tton 7044,B�siness and Professions Code). ADDRESS �/ -� �� - REQUIRED TOTAlSETBACK FROM EXIST. CONSTRUCTION IENDING AGENCY SET BACK YARD Hbvv PROP.LiNE WIDTH O���,�-H�7 I hereby affiim thaf there Is a conshuction lending agenq(or FRONT y� � � ��� �� the performance of tha wark far which this permif is issoed . P.L �/• i5ec.3097,Civ.C.). SIDE . .. _ .. ' _ _ ' . . ' P.l. - lender's Nama n � �. Lender's Addren � P.�.Fee E 3�9.�7� � Perm�t Fee � � . � I certify thaf I have read this applimtion and sfata that the � - issuonce Fee � �� obove informafion is corcect.I agree ro tompiy with all Counry ����i�igofion Fee � ' ' - ordinancas and Sra1e laws re�oting to building eonstruction, � Tmal Fee � - ond hereby authoriza representatives of this Couny to enter . - �-upon the a6ove-mentioned property fvr inspection purposes. � -� � � �� � � . SEE REVERSE FOR EXPLANATORY UNGUAGE . � , _ � Signvlore o1 ApplicoM or Agenr pote� � . ��� i ' � oo ° ° ' o o ° m° ° ° n� m� m � -�' -�- -�- —: — --- - - �o o . mo � c �- \ � 3 0' � �o ic' v � � � m o a; .co . p � +.. �I -�.. 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