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� � . ���
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