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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 - � � Signoture o� p i nt or Agen1 Da�e ' ' ' ��� 1 Z o o .. � . � � � G� � n co �r �`°o,. � °� � o m q o •- n�Dcc � � ,°n � o -�p _ v m -q O O ^^ a O ✓O ''� O 3 � � � �D � � w -,� �n� � � �,w ��O - � � ' 2 u� o co a o p v � o w -n .�j c 6.. 'ji � �` -O io .1 � � fl 6 a o b -o M1 . �^. 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