HomeMy WebLinkAbout1074A - WORKERS'COMPENSATION DECLARATION . ��
I hereby offirm tha�I have a terfifitate of�o�,e��,o self , , - �� .APPLICATION FOR BUILDING PERMIT
insure,or a certi(icote of Workers'Compenstion Insurance,or
a certified copy�hereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY
PolicyNo. Compony
� CerriRed copy is hereby fumished. FOR APPLICANT TO FILL IN nooeess o?//� �iu��
� Certified copy is iiled with ihe county building inspeo BUiL01NG !p n / � /J �
lion deparlment. ADDRE55 �I/ /�N Le��7� LOCALITV �«..w�+e�� ,p s(�(/
� / NEnREST � ��
Dale Applicanl � CITY � Hph�/ Qr ZIP fROS55T.
CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR
� COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MA7 BOOK 7AGE 7ARCEL
(This section need no�be mmple�ed if the pe�mit is far ane //n n u5e zONe hwP .
hundred do�lors(5100)or�e55.) TRACT �(/(+d/ BIOCK lOT NO. /Q �/ Np. }
TEL SVEGn.L d
OWNE ., rhPr NO. ��d CON�ITION$
I cerfify that in the performance o!iha work for whi<h ihis 0
permil is isz�ed,I sholl nol employ any person in any manner DISiRiCT GROUP TYPE FIRE PROCESSED BY V
AD�RESS � � //�S H!� CONST. ZONE
so as�o become subjec�to Ihe Workers'Compensation laws. �/ • �
� 1/ � CITY � /11D/�L/ /� ZIP /a '�3 � � ,
Do�e AppliCont STAi1511CA1 CLASS�fICA110N APT. CONDp. V
NOTICE-TO APPLICANT: If, oifer moking fh icaf of /RCHITECT02 � 1EL � W
Exemption, you should betome suble[i fo fhe Workers' � ENGiNEER NO.- CLASSNO.�� DWELL.UNITS_ f1,
. Compensoiion pro��sions of the Lobor Code,you mu5/forih- ADDRESS SEWER MAV w
Z
with comply with such provisions or �his permit shall be TE�
deemed revoked. � CONTenCTOR(/fF •No. BK. PG, VALIOATION
LICENSED CONTRACTORS DECLARATION �J i��, �
I herehy ofFirm thot I am licensed under provisions oi Choprer 9 A��RESS /�� �'¢ NO. � VALUATION
Pmmmencin wilh Section 7000 of Division 3 oi the Business and /�/�
rofessions Code,and my license is in full force ond ef(ect CiTv/�.C+• 9/73v c1A55 C—�q S �U'¢'�
/ $Q.FT. NO.OF NO.OF CHECK
li[ense Number ��Oa �ic.Class L � SIZE ' $TORIES FAMI�IES ONE
Contracto�V�r�T����'f Dofe Z�� DESCRIPTIONOFWORK / �P NEW ❑ s .
� I am exempt from the licensing requirements os I am o G 7�as � ADD � �
licensed archi�ecl or a registered professianal engineer _ , ALTER � FINAL
acting in my prafessional capacity (Sectian 7051, REPAIR � �ATE
Business and Professions Code). USe OF DEnnO� FINAL
� E%ISTING BLDG. ❑ g
Lic.or Reg.No. Date nPPIiCANT iEt. Y
OWNER-BUIIDER�ECLARATION (PRINT) NO. w�� � _ nn_
I hereby offirm Ihol I am e�empt from the Contraclor's license _ /�=�+'�� C�� �� ��],�j A
law for the following reasan(Sec�ion 7031.5,Business and ADDRESS .
ProfessionsCade�: -��'�n,; ��„�, ,�/vt�z-C�Gi.. ���`• • • • �
OeUiLDING V �
1, as owne.r oI the propeny, or my employees wilh ADDRESS � • �3 1,5 0
woges as�heir sole compenso�ion,will do Ihe wo�k ond L N 7(�• GJ�Z��f1L
fhe structvre is not inlended or offered for sole(Setlion LOCnuiv
70d4,Business and Professions Code). MOViNG TEI. �p/�/�z �h,��V��� • • •3 1,5 0 c=i
� I,os owne�Of the properly,om ezclusively Contracling fON7RACTOR NO. ( �/- '
with licensed coNrodors to[o�strucl the projecl(Seo- qDDRF55 YLU'1�� � C 7.{— �2 2� �a'�
lion 7044,Businesz and Proiessions Code). J��� �
� REOUiRED TOLAL SETBAIX FROfd ExIST. at �:
i, CONSTRUCTION LENDING AGENCV SEi BACK �AR� HV"Y PROP.uNE wiDiH �p �� '�+" � ��e..�. '
' I hereby af(irm�hoi ihere�s a construction lending agency for FRONi '
�he performance of the wo�k for which Ihis permit is issued P L. � — /� �
(Sec.3097,Civ.C.). SiDE � 'K/,� it_�/y�
P.L. V
Lender's Name _ ��� M/�j��j�
.-. /v G
m ' Lender's Address . P.C.Fee 5 Permii Fee `,
W I certify ihal I have reod this appiimrlon and sraie�har the �ss�o�ce Fee 6'�v �v�v �(/l��T� ` .
Qobove in(ormotion is corred.I ogree ta comply with all Counry i„�esngonon Fee y7
g ordinances and Stote iows relating to building mnslruclion, � Torol Fee ��(/ '
and hereby outhorize representolives ai this Counly to enter
mopon fhe bove-menfioned properfy�or inspeclion purposes. � .
a �����/Ji� _1,(�/. . . SEE REVERSE FOR EXPLANATORY LANGUAGE
ctr�
� Signmo I A a�olyR9en� . � 2t
G (/
>> o o ° ° � o o �' m.°(� o o n� �� r1 G) '! o Q o 0
-�. n 1 � S —� A � � �� C'o � F � n n � m p �' p � -�,
� � I� � � � �C W ('i: �- O.O c� , � O �� � : 1p � n S
rn o n � � �p � (1
� x � �c.� Ti �; � o n' � .
T R,� � '� 3 � o' I 4� o �� n� o ° � �9 T'+
, o o g � °.o c -, N� {. b � o °� � � 3 � = v
� H � � � o vJ • o- �n` � � � o � 3 0 o v
a i o :�� + a• w - • V a .� o m 4 � o
� _ J 7 N O
�. v p
� 3
O
Q . �
�
�
�j o � � z
� o v�
✓D o � �
�C Q
,� � m r
i+ A �a
c � �
- C r
'e n
' °' 0 � D
� U a G Z
�D �-1
ti I
�
n '
: ' • O
� r ° n
�^ D°
�: . � A r
� � v o 9
n o o v
e �
o a ii °
a o
a
' z
�
. .�
T
- ' .. , �
• o
- �
� N
.• Z
i 0
�1
� - m
N
. f
�
p nbc�� - acr �� �� �-eTf '� ; ;n~.; �c�; � � r-
. � 0 0 O � n'A� m� a F O `�i � p � f��p ❑` �e n�C..O � w n �L .�. m S
� •��. '� �,p (y � O .�� � N � � A ..' 7 O
Q � cti. N `" � �£. � x�� `�v�yoh � t:� F.00N..�b °.Mu �N �
� � S-!? � �c �O 'i N � O - �� � O .�..� N �
� � � ...C�" =Q �`O ti � L..,� h A C O �A ` �`h�q A A � p� Q
� H. •' � s'� o �,b � a h ��N ° �fD. �o ^ � � o n ����c� R. f �.<
. � t�po �" �o � hC.�ce'�. � �+se�� ' � � c^.�C� �c-i � ba3 �
� � � c V F o.m o a ., ..• & n'tr�o.° ° � `o � o N c•t�.0.� tt .:� _ �7
� � o � �$ o, `.g a �� Y s��N � � �, o b ' y � A'o � � o N "'d
� �a _ o a y � -., e o•� � � To
a. c � b� e'` p� 'mo c•� �=" til.� � o c �
n � �^ �b�� v �o�.�0 0.� � ��� a �'C«o A��'� '^ c' °3 C
-� �n �° �c."'� o o ° o � �' � o o a� `'^ \':a a o'� o o r"•
� . A n `G�o ° '^ � �`fi 4 A M o� �° o'v �`v-c n C•ti p �-� ., �C � f� x
x
C p �� ^ �
' � � `�.l � O �G X � C b O`7 I.i � � t � O•`~t G7`C`O O'��.10 � �
` "n' � oo� a : 7 ' coM � C��?:� � � s � M ���,N ��`e v" r
a i
0 '^ fi �iQ � £ o � _.o "�•� � �'
� �-�„ ,Z, o .��' 0..� 3 fi .,��„�.= x 4 [�a . � o�.o .. 'o �' k ., o o Y
�n O .�.e � ,�� ^ S� Z'y 0.C„e = ° a�c 0.,� � 0.N „ �,h � `c ? 3 a
� f _ � x ��s c p a � � y � o m o� a a o'��'^,� ti s►i
' � m H fib " co. _ � g o 0.C,,°��e .^� � �'3 a n���0.,�.H � a c o in� O
� � � � n o �1'D m �•^r`o° 7°' o n �'9 N a o' a o a,�,= � o n.
� v wN'J ° o F • �'E"�•v'f� �"�� b�`�, oax � oL
n .. .`C �CT L"' • �^ .�.'N � O O F_ q ,�,�
�T
� n o� � � ^ o A C,c n � O �.,n � M �o W�� .�p � �4 V
Q � o e N ir ►• � e w o
O O ~� n ? � � 1�!o a'� ��V' 0` y�i � �'(� t � �, [�.��
fi � 0(!N � O .�:.kp�,� �� f � . p'y O m y'�' . O
N L�.`�1 L:``1 n � O fe``W~`� 't (n'Q �.A..Q.S`w:�C�Q N i� �i w ti �C'v N
. ' q L"'C M` •
�