HomeMy WebLinkAbout0407A 0447A (6) VJORKERS'COMPENSATION DECLARATION . i � - . � . ' . . ._ . �
insureborafc�eHiftatelofWorkerseCompen�i�°���°o�°eso': - � APPLICATIQN�� FOR BUILDING PERMIT ,
b�er�ified copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. - Company� - �
Cerlified co is hereb furnished. BUtL�iNG
❑ pY Y ' FOR APPLICANT TO FILL IN AD�RE55 l�I� ��G �s
� Cerlified copy is filed with the county buVlding inspec- BUILDING /j /� �� � �
tion�deporlmenl. ADDRE55 � LOCALITY/cY��rNMa.�� �7-CLj/�
� � - � � � � NEAREST JA� _ �/
Daie - �Applitan�� � - Crt�� fa�j��fL. Ziv - CROSSST. iClii-r� '�•— �
� �CERiIF1CATE OF EXEMPTION FROM WORKERS' y � ! NO.OF BlDGS. ASSESSOR • .
"� � - �COMPENSATION INSl1RANCE - . 512E OF l0T G„ � , NOW ON lOT MAP 800K PAGE PARCEL
��(This sec�ion�need not be completed if�he permit is for one - � Q`1�.1 u5E zONE MnP �3�/,r
hundred dollors(E100)or less.) �. . -� TRACT BIOGK LOT NO�—i �i NO. �.J , }
� TEI. ��3 ' SPECIAL - y
OWNER � NO. � CONDITIONS
'I terlify ihat in the pe�formance o(1he work for which Ihis � �
pelmii i5 i55ued,I shall nol employ any person in any monner � .�,n oi51RiCT GROUP TYPE FIkE PROCESSED BY �J
'so as fo become sub'ect to Ihe Workeri Co AD�RE55� � �t�c CONST. ZONE
� mpensation laws. !Q O
�7 ��,.1� <
Date ` Appli[anl CITY �• Q+�+]V Z�P STqT15TICALCV.551F1 ION APT, CONDO. U
ARCHITECT OR � �� TEL.
�NOTICE O APPIICANT: IF, afrer making this Certificaie of�' �-� � n � w
Exemption, yov should become sobject to the-Work rs' ENGMEER NO. C1A55 NO. DWELL UNiTS y
Compensation provisions of the labor Cade,you must forth- � � � �
wilh Comply w�lh suCh provisions or ihis permif sholl be AD�RE55 SEWtIt MAP _
f'� TEL.
deemed revoked. - � � � � - ��� COMRACTOR K-S ' NO." � � BK. PG, � VALIDAT�ON-
�� LICENSED CONTRACTORS DECLARATION� - LiC. ^� � . . . .
1 hereby olfirm�hol I am licensed under provisions of Chop�er 9 .... ADDRESS ��Z('� N� NO.Z 6�Q�i VALUATION �
(commencing with Seclion 7000)oi Division 3 of Ihe Business ond � ��� /�O .
Proiession4 Code,and my license is in full force ond effecl. ❑TY CtA55 S � �0 4 0;.7 A
� . .. SQ.FT. NO.OF NO.OF CHECK ' ' - �
License Number�Z�O Z Lic,Class � � 5¢E STORIES FnMiUES ONE . .
. �p . � ''(��� 5. . �,�.�.• .2.�
Conlroclor��Y�S � Date � DESCRIPTION OF WORK�'�R� �� N� , ,
❑ � . . � ADD - I.�.���-R.LL�
I am exempt from the licensing requirements os I�om o �'R �L�
licensed architect or a regisiered professional engineer _ _, _. . . . . .. a.LTER_ � FINAI .� �',�� �(i Q� .
oding in my professional copacity (Sec�ion 7051, .� REPAIR � �ATE / �� p� � �
B�siness ond Professions Cade. �
) USE OF � I Q 2 a, B��
-7Q,� EXISTING BLDG. . -� OEMOL FINAL
Lic.or Reg.Na. `� wZ_Dote APPLICANT ' TEt. p 6 - � �
� ��- �-OWNER-BUILDERDECLARAitON � '� �� � PRWT) �-'n10. �7�9-I � . �
I hereby affirm Ihat I am exempt from the Contwctor's License �` A't�n-, d , . �.
Law for Ihe following reoson(Section 7031.5,Business and� - AooRE55 �[J��I�F�'T�e�y.Ca _ �
Professions Cade): � . F�ESEtii � �
_ a - �. . .. BLIILOING . . . . . . ' .
I, as owner of Ihe properry, or my employees with qooRESS
wages as their sole tompensotion,will do the work and � � .
� the struc�ure is no�intended or o(fered for sole�SeUion �aA��TY � : �
- 7044,Business and Professions Code). MOVING TEI. '
� I,as owner of the property,am ezdusively tontraUing � CONiRaCtOR NO. . - � � . �
with licensed contrac�ars to construcf the projecf(Sec- qoDQE55 - �
-... tion 70d4,.Business and Vrofessions Coda). - ' � - �� � "
REOUIRED TOTAL SETBACK FROM EXIST. ' �
CONSTRUCTION LENDING AGENCY SET BAIX �AR� HVJY PROP.linlE WI�TH � � �
� I hereby affirm that Ihere is a mnslructian lending agency for fRONi � - � � � � '
the performonte of the work far whith this permil is issued P.l. � $'0 4��4.7 A �
(Sec.3097,Civ.C.).. . . . . SiDE . . _ . . . . . _ - � . . . . . � -- . . .
v.i.
Lender'sName ' �•� ���'� �'�
lender's Address v.c cee s . �� Permir Fee �.3 � 1•• •3 1.5 p
I certify thot I hove read�his applimtion and s�a�e thal the � issuance Fea Q� v� - . •�• �J�,Jr Q�
above iniormation is conect.I agree to tomply with all Coon�y_ in�esrqm�on fea � � � / . - - � � - -
-�ordinances ond S�ate laws relating lo building construt�ion, To�al Fee ��'`�� '� Q J 0;$;�
ond hereby outhorize represeNolives of Ihis Counly to enter
�-"upon�he obo�je•mentioned property(or inspec.tion purposes. - � � � - � _ � �
O� 'C�'J$ � � � SEE REVERSE FOR E%PLANATORY IANGUAGE - � �
Signoture of Applicoi or Agen�� fDaia _ . . . , . � ?�
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