HomeMy WebLinkAbout1029A 1264A (9) � WORKERS'COMPENSATION DECLARATION . . . . . - . ' . . . � ��
iere6y affirm that I have a cerlifimte of�a�=e��,o,e�F . . � qpp��CATiON FOR- BUILDING PERMIT -��
�we,a�o cer�ifico�e of Workers'Compenslion Insuronce,or ,
rertified opxihereof(Sec.3800 ob.C.) COUNTY OF LOS ANGELES BUILDING ANO SAFETY.
��2S��E°/ �11/ j . -
dicy o. Compony� � +'� gUILDING
�' Certified copy is hereby(urnished. FOR APPLICANT TO FILL IN ADDRE55 2Ci�.7 d�'K�a
JCertified copy is Tiled with ihe co�nty buitding inspec- BURDING � �„t��O ip�q�iTY- �LA�M O/�� �J��-
. fion depariment. ADDRESS
NEAREST
ita��Applitant CIiV � bl.'� Zi� CRO555T.
CERTIFICATE Of EXEMPTION FROM WORKERS' � . � NO.OF atDGS. a55E550R
- �' COMPENSATION INSURANCE SIZE OF LOT NOW ON LO7 MAP BOOK PAGE � PARCEL �
�his section need not be corriptered if ihe permit is for one , USE ZONe MnV ,
�ndred dollars(5100)or I¢55.) TRA�T BLOCK LOT NO. NO. �� 7 3 • �
� T L SPECIA� a
ceitify Ihal in the performance af Ihe work�or which this, _ OwNER ' -��1[��G F � ti� � CON�ITIONS Q ,
ermif is-issued,1 sho�l not em lo an erson in an manne� ��� t� f;r DiSTRiCT GROUP TYPE FIRE PROCESSED BY (J .
P Y Y P Y AODRE55 J CONST. ZONE �
��as to betome subject l0 1he Workers'Compensation Lows. _, �
(D" � o
ale APPlicanf '� ARCHITECT OR�•� ZIO TEL. STATISiICAI CLASSIFI TION APT. CONDO. V
IOTICE TO APPLICANT: If, after making ihis�Certiiicale of � W
ENGINEER NO. CLA55 NO.�DWEII.UNITS C.
xemption, you shauld become subjecl �o �he Workers' v�
:ompensation provisions of fhe Labor Code,you mvsl forth- ADDRE55 �� � SEWER MAP Z
ith tomply with such provisions or�Ihis permit sholl be TE� - .
leemed ievoked. . -. coNTRACTort r�� NO. bZ. eK• �• VALIDATION
� � LICENSEO CONTRACTORS DECIARATION -` uG` pr� . �
he�eby affirm that I om licensed under provisions ot Chapler 9. . AD�RE55 � . �.. ��(eN NO. ` -t �. VALUATION �1 0 2�.9 A � {
commencing wirh Sec�ion 7000�of Division 3 of the Business ond �i�, ]�-7 �.+,p0
'rofessions Code,and my litense is in full force ond effect. GITV �7�� O� CLA55 �� s F L � �
' , ^��;� � „� SO.FT. NO.OF NO.OF CHECK #'��•'� �Z`3
.IcenseNumber �� Lie.Class�-��' � 512E STORIES FAMILIES ONE �S .. .�I •-•-� 8�10
d� e!r �� �/� �� DESCRIMION OF WORK S% NEW
:ontractor M({.�/����GV Dote 1.L�SL� . ADD ~ ��.� a�'�_
] I am exempf from the licensing requiremenis as I om a 7'�X y� ❑ p / � U
licensed archi�etl or o registered proiessional engineer..... . - y� A�TFR a DA EL O/'�J/iPa �2'� 5,�a�. ,
. acting in my professionol copaciry (Seclion 7051, � ��'���w� 1 aEaniR �
Business ond Proiessions Code). USE OF � FINA��/� /--� � '
. , - � EXISTING BIDG. DEMOI e }� �_, . '
Lic.orReg.No. . . . . Daie A7PLICANT tEt. �/1 --
�OWNER-BUILDER DECLARATION�� - ���-�' � fPRiNT� - ` NO. - ,U
I hereby affirm Ihat I am exemp�from the CoMractor's License - . � - �
law.for the following reoson(Section 703I.5,_Business and ADDRESS �
ProfessionsCode): . ; �� , Fii�'N� � � ' .
❑.. BUILDING - . . ' ' '
I, as owner of ihe property, or my employees with ADDRESS
aaes os�heir sole compPnc��ion,will do Ihe wcrk and .
- ihe structure is not intended or aftered for sole(Seclion - " �aA�iTY .
� '7044,Business and Professions Code�. MOVING . TEL. - �
� -I,as owner ot Ihe property,om ezdusively conhaclinq � CONTRAC70R � NO. �� � �
with licensed mnrractors to consirucl the projed(Sec- qoDaESS � -
.- - tion 704d,Bosiness and Professions Code). - . �� �
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SEl BACK YARD HWY PROP,IINE WI�TH '
I hereby affirm thol�here is o mnstroction lending agency for- FgONT � � �
the performance of the work for which Ihis permit is issued v.L � � � �� 2�l 4 p �
� .(Sea 3097,Civ.C.�. . , _ . . . . . SioE . . . . . .
P.L
Lender'sNome � . .. - � ��• • • • •;�
P.C.Fee 5 Permi�Fee d � ' �� � 3�.5�
Lender's Address �y ��
, I certify tha�I have reod ihis opplication and s�ate�har ihe � issuo�re Fee J � •
above informaiion is mrrect.I agree to comply with'all County _ � �nveaYgo�ion Fee � � r � � .- �� .
ordinontes and Slate laws reloting ro building conshuction, iotol Fee J �
an �he�e y o orize prese �es his Counly lo enter • • •3 1,5 0�
�ap n I 6C e meNi ed pr pe ry r� specli6n purposes. . , , . - �
i-z���'� ,' •
SEE REVERSE FOR FXPtANATORY LANCVAGE
Signalure of Appliconl or Agem Dote , , ' . � - ' � � �� '
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