HomeMy WebLinkAbout07_08_1982 - 1817 PEACEFUL HILLS RD �u,� �., r �/7�•� �y�� , _ _ - ' �L' � l
� � WORKERS'COMPENSATION DECLARATION � " �
I hereby affirm�hot I hove a certif a� of�o�=e�,�0 5e�� . . .. _. APPLICA�TION FOR BU�LDING PERMIT
insuie,or a cer�iiicote o(Workeri C m nstion Insorance,or� -
a certified copy rhereof(Sec.3800, .C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
. .PolicyNo. ComponY S . . . . �
� Certilied copy is h�re6y tumished. FOR APPLICANT TO FILL IN Apo� JJ�
�/( Certified copy is filed with the�county building inspeo- gURDING �
�[� tion deportment. � � A��RESS / �� LOCALITY (�T^ ��• ��" �
'�oie � APPlicant�-'-��`-�`�'S��- GITV � F?'� L(,.T - CROSSST. /7��/��G/�-�
- �CERTIFICATE OF EXEMPTION fROM WORKERS' - !� NO.OF 6iDG5. ASSESSOR - - �
' � - COMPENSATION INSURANCE � � � . SIZE OF l0T O�OO NOW ON lOi •� MAV BOOK � PAGE FARCEL
��'(This settion-need not be completed if the permit is for ane . � n u5e ZONE M/+a r} 9 �
hundred dollors(5100)or Iess.) ' . . , 7RA �/ BIOCK LOT NO. NO. �J 'J�3 � } . .
�. �J(y� $PECIAL y
� OWNER � � O 4"-�D CON�ITIONS �
'�I certify that in Ihe performdnce of the�work for whicH�his�. _ � - O _
�permit is issued,I sholl nol employ any person in any manner / �/ DiSTRICi GROUP TYPE FI2E PROCESSE�BY (J
so as l0 6ecome subjecf fo the Workers'Compensofion Laws. ADDRE55� lr���7"' � �� CONST.. // Z �� O
CITY � 71P oZ��� V F•
Oate ' � �AppliCaM�- ' � STATIS7ICALCLASSIfICATION APT. CONDp. U _
ARCNITECT O � TEL.CS A�
.�IOTICE�TO APPLICANi: If, ofter moking this Certificate of�� -�- � f�- � No.b � fi
—�empfion, you shoutd become subjecf�to ihe Workers' ENGINEER ClA55 NO. w DWELL.UNITS �
- ompensation provisions of tbe lobor Code,you must fath- qDDRE55� SEWER AM7 Z� -
wi�h comply,with such provisfons or �his permil sholl be TE� ��� -
deemed revoked. �� - CONtRACTOR � No. � - � BR. PG. � . VAIIDATION -
� LICENSED CONTRACTORS DECLARATION - LiC. . . .. . �
�hereby oFfirmihof I om Ilcensed vnder provisions of Chopter 9 ADDRE55. - NO. . VAIUy TIp N � ,� '
(mmmencing wirh SectionJ000)o(Division 3 of rhe Bus�ness and � . . ���, p y !�° , +�;�3 5��` � �
-Professions Code,ond my licens is in full force d effeU. � CiTV . CtnSS S ('G� 1��� - � � -
ty� 1 50.FT. NO.OF NO.OF -CHECK '
Lice se1IVLi��m�be�r��� G�1 V Llc.Class �1 � SIZE . STORIES FAMILIES � ONE � � ��•��'�?7� j�,.�� �
C Mr a c lot' � `-'s�J Date . � �ESCRIPiION OF WORK� I�t9 E �L N� � S , . . ., . s A�n^`�j z �
�a � . , . . ..�. � ADD- � �
I am ezempt fram Ihe licensing�equiremenls as I am a {�- � �O��� 2 s��� ;
licensed orchiled or a registered professional engtneer .. .. _ ._ . , , AL7ER _� FINAL � - -
� � OATE��� -
. atting in my professionol capacity (Section 7051, . RFPAiR ' ��
Bvsine3s and Professions Cade). � USE OF DEMOL PINAL - � .
� .. . E%ISTING BLOG. . .. ❑ ,By - �.
Lic.or Reg.No. DO�e APPIICANT TEL -- �
'� � � OWNER-BUItDER DECLARATION � � - `� PR�NT1 -�ES NO.�� � �'v �/,J} o'f„7 . Y
�I he�eby o(iirm thot I am ezemp�from the Contractor's License - . _ � � . .. � � �
Low for ihe following reoson(Section 7031.5, Bosiness and ADDRESS - � '� � � ,
Pro�essions Code):� , . . . PRESENi , , �
_.^� . . . . BUILOING -- - . .. . - - � . . . -
,� I,•os owner of fhe property, or my employees wiih AD�RE55 � �
J � woges os iheir sole compensation,will do the work and ' �,-.
LOCAUTY .� - . -.. _.. � -. . ... -
- the sirucrore is not intended or offered for sote(SeUion - • , , � .
7044,Business ond Professions Code). , MOVING - � - TEL. - . � � - �• � . .
� I,as owner a(fhe property,-om exdusively coMrocfing CONTRACTOR - NO. � ��- - .
, wiih licensed contractors ro conrruc��he project(Seo- . AppgE55 � . . � - `3 3�'2 A .
_. - tion 7044,Bosiness and Professions Code).� - � � � . . � �
� � �CONSTRUCTION LENDING AGENCY REDUiRE� yqRD HWY T�T�`�SETBACK FROM E%IST. ' . _� . � , �• • • • •�� .
SET BACK PROP.IINE WIDT - � � �
I hereby affirm�hof there is a mnsiruction I nding ogency for - FRONT � '� • �I •�4 ti 9.0 0
Iha performance ot Ihe work for which Ihi permit is issued p,t. ' . � '
($ec.3097,Civ. .. . .. .. . _ -.. . _ . . SIDE- . . . ..'_.. ._�.. . __ . . � . ' _ ' � .
� P.�. . • •489,Q0�
Lender's Nome � a - �
.. . . P.C.FeeS � 7� PermitFee � p 5 � .. , �'.. . � . � I.QDb-�? .
Lender's Address _ . _ .. _. _ / 3 _ _ � , , _ " . � �
: I cerfify that I have read rhis applico�ion and state that the . � Issuonce Fee /�� -� �
' obove information is torreU.I ogree to comply with,all Counly _ . ���esrgouoo Fee � � - �p� (' � � . - � . � �
ordinantes and Stole laws relating fo building conshutlion, - � Toioi Fee O � f
ond hereby'authorize re reeenlalives of this County�o enler
'�pon 1 e ove- ' ed proPerfy for inspedi� -�. � . � . . � �
� SEEREVERSEFOREXPLANATORYLANGUAGE
Signorure ol Appli<onl or Ageni Dole . . . � -
. . _. __. . _ ._ . � _ ��_
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