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HomeMy WebLinkAbout0915A 0916A I WORKERS'COMPENSAiION�ECLARAiION . � � � I hereby offirm ihof I hove a certificate a,conseM fo 5e�, APPLICATlON FOR BUILDING PERMIT � insura,or a rertitimle of Workeri Compenstion Insuronce,or a cenified capy�hereof(Sec.3800,Lab.C. PolicyNo.h13 ��tA�S'C�mpany_� ��ZI ��UNTY OF LOS ANGELES BUILDING AND SAPETY n � Cenified copy is hereby fumished. � FOR APPLICAN7 TO FILL IN ADDRESS Q�!/� • �.�i ' � Certified copy is filed wiih ihe coonly building inspeo eUaDiNG � � � tiondepartment. AD�RESS QyU S ��jQ��RL�-- p6 .� oYjd iocnury � Dote� Applicon✓/1�� �� � CITv ��'1�JN � ZiP Co599i. �T��`�/ �� � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. ASSESSOR � � ' COMPENSATION INSURANCE � SIZE Df tOT NOw ON LO7 MAP 600K PAGE VARCEI �� � (This sedion need not be compie�ed if tha permil is(or one ; � , u5E zONe MAP hundred dollars(5100)or less.) , � iRnct BLOCK LOT NO. . NO. Y � iEl. - 57ECIAL . y OWNER '��II� Mf!Q D NO�/�✓ G I�'� CONDITIONS 1 certify thai in ihe performonca of the wark for which this . � 'permil is issued,1 shall not employ any persan in any mpnner DISiR�CT GROUP TYPE FBE PftOCE55ED BY -sa os to become subject lo fhe Workers'Compensolion Laws. �� ADDRE55 'J'U`� S �J CONST, �ZON/-E- /]� � ' � . . . 1 UiV � ZIP /%L / . �'C '� � GCf! /�l�" " 0 Dafe Applican� StAiiSTICAlCLA551FICA710N APT. CON00. V �. NOTICE TO APPLICANT; If, o(ter making Ihis Certifimte of - ARCHITEQOR � � iEL. . - y� � Exemption, you should become subject lo Ihe Workers' EN�iNEER No. ClA55N0. � DWELt.UNliS_ N Compensarion provisians of the Lobor Code,yau must forfh- A�DRESS � SEWER MRv � ? - with comply with:such provis�ons or this permil shall ba . � - deemed revoked. p � TE�' VALIDATION � � . CONTRACTOR �J � NO. 7 7���j/ BK, PG. LICENSED CONTRACTORS DECIARATION ' ' iiC. . . ' I hereby offirm�hor I om licensed under provisions of Chopfer 9 �. . aoDeESS /(7� . L j Q n10. Ol �/ VAIUATION �, (commencing wiih Sec�ion 7000)of Division 3 af tMe Business and UC. � . Professions Code,and my licensa is in full iorre and effec�. ' CiTY }�l�� - CLn55 L SZ_s0{/• � • ' � � ' SQ.Fi. NO.OF NO.OR CHECK Licensa Number�'�J f��1 �i�,[�azs C� rj SIZE STORIES FAMIliES ONE � ,3/ NEW � ' S Confrotlor�S �+.+^� �^ �ato�� DESCRiPiION OF WORK . � � I am exempt from the licensing requiremeNs as I om a /.C�L I�/!1/ .(- - L I s ADD � . � licensed archirect or a registered professionol engineer, , , . , � ALTFR � FWAL acting in my professional capatity (Sec�ion 7051, � ✓i 0✓. < Q r REPAiR � DATE ��. � -�/ `�9.� F A Business ond Professions Code). � � u5E OF - �EMOL � FINAL � , - E%IS71NG BIDG. BY � `r ` '� � + �'Z 3 ° Lic.or Reg.No. Dofe APPIICANT 7E1. ' ' � - . � - � OWNER-BUILDER DECIARATION PRiNt� ' � �-- NO.� - I hereby affirm thor I om exemp�from ihe Contrauor's License � � .'�'� ��3'�� Low for the following reason(Section 7031.5, 6usiness ond n�oaess � � , •2 3 2 0� Professions Code):. � Hkt ry � BURO�NG O G.C 7—8 1 1, as owner of Ihe property, or my employees wiih nDDRE55 ages as�heir sole rompensotion,wJl do iha work ond " -�Q 9�.(�}� ihe srrucf�re is not intended or affered for sole(Seaion ��A��rY � � 7044,Business and Pro(essions Code). MOVING 7EL. }#� • • o� � � 1;os owner of ihe praperry,am exclusively contmcting CONTRAC�OR NO. � � - � wi�h Iicensed contmUors to construct tha projetl(Seo pooaess �.I f�3 7.�'� . iion 7044,Business and Proiessions Code).- -� - � . � REOUIRED TOTAL SETeACK FROM EXIST. � _ CONSiRUCTION LENDING AGENCY 5er eacK YARo Mwv pRpV.lWE wIDiH . �Z"�� I hereby offirm�hat thera iz a construction lending ogenry for FRONt � � � ihe performonce of tha work for which�his permit is issued a t ' ,7`��- (Sec.3097,Civ.C.). _ . . - sioE � ' � 0 4.0 P.L. Lender's Name a Lender's Address � P,e.Fee 5 �� a� Permif Fea � �— . ' I cenify that I hova read this appiiwtion ond stote fiat ihe � issu ca Fee ^ �rd a6ova informalian is correcf.I agree+o comply with oil CouNy_ Invesnqoiion Fea - a� � a �J _ ��, ord�nances and Srore laws reloting fo bullding consrruct�on, � ioiol Fee („! / '�� � '�, ond hereby ovthorize represeNalives of this Couniy�o enter , _ , . . _. . upan the above-mentioned properry for inspection purposes.� n g��y+.��,/-�j,�,�L��{P �(yt�,p SEE aEVFRSE FOR EXPLANATORY IANGUAGE � � Sig�iure of Applicanl or Agent Doie , . �� _ . . ._ . , � . . .. , . � � yuwj uo�aw3 � � ' �� —�oui3 . , . , . _ . _ .. pa�md g 7�auo� � . .. .- - � —�aqwnN osnoH � � � . _ � �vpalx3-4��1 � - . �a��ayu� —��OMIJQ/4f�� . . . . . . . . .. uoilojn'su�FB�au3 . . . . . � .. . , awo�� .. . . . . . � ' - . ,�941S � � � � . � � � ° suoi�epunoj (SP�OA a'''IJO4��S1 � � - � —uoiyo�o� . 5310NS,N0173dSN1 � � o�nyauB�ys�oyoedtu� o�op �.s�sieiCdV �awv,p_ . eiop . . . . . . . , , . • UOSD3l � � � ' a ` ^ � sit{I+o�•)•dg•g' •�ag�opun�dwoxewol .❑ . � . � - � � . � ' 6ui�iod '— � •/ma7 arw77 s,1ol�a�auv,�. . .. . _. . � . , � oryi of tuvnvnd p�+ua��t(r�so»v�tuon v qprm tp�afo�d - o6ouio�p�o� ff]rtf JOJtt�apuoa ogin pun�uo�.wy!ra.ao�d�ur�o sp�mq . . � oq.n St�+adofd j�aumo vo ul 61JJv pou saop moq asua77 . . 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