HomeMy WebLinkAbout0277A 8653A (4) � � JJORKERS'COMPENSATION DECIARATION
�insurehorafcertifha�teof WorkersrtCom�peosation Insu•an elf APPLICATION FOR BUILDING PERMIT �
° `or a cerJ1fied copy thereof($ec.3800,Lab. )
�j ,t'�' + /� COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo�����'^'��Company_,j�-•�-��t l.-�^�'�
� Cerrified copy is hereby furnished. " FOR APPLICANT TO FILL IN ADDRE55 r� ,'l b�i.�' c��.% �''S�=�ti
OCerfified copy is filed with ih o nty 6uildin insper BUILDING /L/,f 1"1 \1L 1 A �✓l� T�D A !� j� ��
fion depart ent�./ I �i] AD�RE55 �6 6 ( Y.ti 4�r V � t«t d,J
C�ate�APP�licanl , � ^ GTY����Y ���` LWK '��� LOCALITY
CERTIFICATE OF EXEMPTION FROM WO 517E OF l07 � O UD �✓�NOW ONLIOTs `T��E CROSSSST.
� COMPENSATION WSl1RANCE
(This section need no�be�completed if the permit is for one �7 /J ASSESSOR
hundred dollars($100)or less.) TRACT�(/a � BLOIX LOT N f' AMP BOOK PAGE PARCEI
TE�' USE ZONE �P
I certify that in the performance of ihe work for which this OWNER�Y �.�r7. �s'L�1u�`�'NO. j N� /fi.y��,-��' y
permit is issued,I shall not employ any person in any manner � �p �r�� p �,t r SPECIAL d
so as to become subject to the Workers'Compensafion Laws. ADORESS �' ! ""! �l`���,_` `��E Um>C�. CON�ITIONS ,�
C�TY�/�M�l�D f/K� ZIP I 7� �'
� Dale Applicant M 0
NOTICE TO APPLICANT: If, ofter makin this Cerfificafe of �+RCHI7ECT OR r TE�� DISTRICT GROUP TYPE FIRE PROCESSED BY
9 ENGINEER �G� RC{�'7ECe�yp CONSTr"' ZONE V
Exempfion, you sho�ld 6ecome subject lo ihe Workers' ��..� W
Compenso�ion provisions of the La6or Code,you must forth- qDDRE55 Z e. � w O �� �`� /�.� `�, �� �, v._ y
with comply wi�h such provisions or this permit shall be x1 '�'�
��. S7ATISTICAL CIASSIFICATION APT. CONDO. �
deemed revoked. coNiRACTOR NO. -�� )
IICENSE�CONTRACTORS DECLARATION - ���, CLA55 NO.�UWELL UNI75�
I hereby affirm that I am licensed under provisions of Chopter 9 ADDRE55 NO.
(commencing with Settion 7000)of Division 3 of the Business and ��� SEWER MAP
Professions Code,and my lirense is in full force and effecL CITY CLASS BK �� �� VALIDATION
(('� 5�.F,y�n NO.OF �$ NO.OF CHECK
License Number -'v�d �� � Lia Qass� �SIZE (V STORIES ,J FAMILIES�� ONE
VALUATION
�)y n � ' DESCRIPTION OF WORK � NEW
Contraclor�V�.+�\�1��LC.� Date '�"�� '�� S
� � i�i -!-"I 61��t'L•I�t�•� ADD p❑ � ' ^'?.�'�
4! 1 am exemot under$ec -
ALTER � /'�ti.
�9�� �
�� B.&P.C.for this r on � �` REPAIR � S ���L �,�' a ° B 1�-
� Dpfe: ' USE OF DEMOL
�j exisriNc ei��. 7 LI C+L��i ❑ i 'I.�8:;.9 3
� $IgflOtUrC �" """"�""�t.° � A7PLICANT TEL FIN/�I. � .
PRINT) �• � NO. � �^f :.�^,.J i z�
;� OWNER-BUILD ECLARATION DATE f � �� �� � �
j� I here6 y affirm ihat I om exe from�he Controctor's License - Z CaTTa�� C '
� Law tor the following�reason(Section 7031.5, Business and A RESS V FINAL �7,�y"t��
� ProfessionsCode): ' PRESENT BY .�j��
, ❑ BUILDING —
I, as owner of fhe property, ar my employees with ADDRESS
'3 wages as their sole compensation,will do the work and .
�j ihe structure is not infended or offered for sale(Seciion �OCALITY , '
g 7044,Business and Professions Code). ' MOVING 7EL -- �
d � I,as owner of the proparfy,am exclusively confraciing CONTRACTOR NO. «`�1��P� .
wilh li<ensed contmtlors to ronsiruct the project(Seo- qDDRE55 a:u a a e A �
� tion 7044,Business and Professions Code). � �
.REQUIRED TOTAL SETBACK FROM EKI �.
CONSTRUCTION LENDING AGENCY SET BACK YAR� Hwv PROP.uNE WIDTH � �,� � d,O l l
I herehy affirm ihat ihere is a wnsiruction lending agency for FRON7 �
t the performance of fhe work for which this permit is issued - P.L. p Vr o }.,h�j [�,(;!;��
(Sec.3097,Civ.C.). Pioe I � / Y �
D(,07'.—�;�
Lender's Name p �
� + P.0 Fee S f�(J �J� Permil Fee � LDMA Re^:�# , fl -G
Lender's Address .-. ti�� � �
� a � - � �� � � . , .
I cerlify ihat I have read ihis application and state ihat ihe i �V. 4� Issuance Fee �LDMA P/Ck - �:i - O�
above information is correct.I agree to comply with all County� In�est�gntian Fee ;r
ordinanc and$tate laws relaling lo building consiruction,� � �� To�ol Fee � ] J LDhM Perm.H � �•
v and b oufhorize r resentotivas of ihis County�o enter E a�
:�J y-
m upon ove-m ed property for inspection purposes. ��i1'�� `-�jS.OG ���� �
a Z �./"� ��� SEE REVERSE FOR EXPIANAiORY�ANGUAGE -
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