HomeMy WebLinkAbout11_16_1981 - 20948 MOONLAKE ST , . _ _,... .._. _ __ .._ __ . __ - _..
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` ��NORKER$'COMPENSATION DECLARATION' � . .� ' '..... - .� -. . - . . . . . _ . .
� insureborac�ertifimtelofWorkeseCompanslionln�°a��a°o'�� — � .- APPLICATION: FOR BUILDING PERNIIT �
�
a certified copy the�eof(Sec.3800,Lab.C.) __ . - - � � COUNTY OF L�OS ANGELES� � BUILDING AND SAFETY • �
PolicyNo. Compony ��.�`�; � �� � BURDiNG -
�, Ce"rtified topy is hereby furnished: ' ,' FOR'APPUCANT TO F,ILLIN �- nooseSs �OG
.� ��Cerlified copy is filed wi�h the�county butlding inspeo- eURDwG �' .
tian deparfinenf. ' _ ADDRESS 1I oN�!}.Y LOCAUTV l+�
� - t - _ ` - _ NEAREST /w/� ��G/
Dote Applimet � ' -�'�' �ITY"�- 1JT j !'.:ZIP' CROSS ST. �V 4 �
�� �CERTIFICATE OF EXEMPiION FROM WORKERS' � � �`-�• � NO OF BLDGS:-��,� q ASSESSOR
� � - � �COMPENSATION INSURANCE� � � SIZE OF tOT'f"a��'��j"•i--��--�1�NOW ON LDi��L`��1 MAP BOpK PAGE PARCEL
��This settion need-not be tompleted if the permif is for one � / O u5E ZONE nwP �
hundreddollars(EI00)orless.) . TRA�T�27'3�J -. BtOCK, iorr�o. �J . No. ��� ���.J 3 �,
t /. � 1GL. . SFECIAL o„
I te�tify Ihat in the perFormance of the work for which this; OWNER P�p T l(I/1v0. - - � CONDinONS �� � � _
permit is fssued,I shall nol employ any person in any manner� e j�§TgyQ GROUP TYPE fIRE PROCESSED BY {,J
' sa os 10 6ecome subject to the Worke�s'Compensotion Laws. ADDRE55 Q Q L/T �/1 i`/� CON�- ZONE ` �
, . �� �3 ,I /h yP.�� o,
Date -� APPIiCaM � . . � .� CITY (J! 21F. I STATISTIGI�C1A551FICATION� . APT. ' CONDO. V
NOTICE TO-APPUCANT: If, ofler moking ihis Certificote of' � ARCHITECT OR -� - TEL. ��� W
Exemption,�you'should become subjeu �o ihe Workers' � ENGWEER NO. CLA55 NO.' �WEIL UNITS N ,
Compensation provisions of ihe Labor Code,you mvst fonh-�� - qDDRESS - � � � � SEWER P - i ?
with comply with suth provisions or Ihis permit Sholl be ' TEL. � /a�
deemed revoked. . . . • �, •- - � �ONTRACTOR � �-�- � � � �NO. ' -- - e���• � VAIIDATION
�-LICENSED CONTRACTORS DECLARATION . - - �I�. . . .
I hereby affirm that I am licensed onder provisions of Chapter9 �. �. AD�RE55._ __ �NO.- yp���� "!
(mmmencing with Settion 7000)oF Division 3 of the Business and , i��. Q .
Professions Code,and my Iicense is in full force ond effecl. . _ _ CITY ClA$$ S '
- - ' - . . $O.FT NO.OF NO.Of CHECK - " � -
License Number � Lit.Class SIZE STORIES FAMIUES ONE � . �
" . N� O .S . . .
Conlracfor pofe ' DESCRIPTION OF WORK .
� I am e empt from the licensing requirements as I am a � -" ADD � � �
licensed architeU or a registered professlonal engineer'- _ _. __ _ ALTER Q FINAL � G� h�
actlng in my prafessional capatity (Settion 7051, � � � � DATE �.�^ —p� .� �� ^�; -
� Business and Professions Cade). � � USE OF . � REPAIR ,��
n t s t
� EXISTING BIDG. �� � � " DEMOL � FINAL � . � n�r t:(�
�i[.Or Re N0. DotB APPIICANT Te�. t7 er q;,�i�7���je!'.
9 ' PRINT' J�/5�7� ' .
- '`�- OWNER-BUILDER DECIARATION - ' � , � T � ' "NO. �n, „y'^ � j��lj ��/�
I hereby otfirm thaf I om exempt from the Contractor's License. oC /V F
Low ior the fallowing reoson(Section 7031.5, B�siness ond� � /+�DUE55 �9� dd��fr� /�`C r/
Pro ssions Code): � � - . _ ckESENi , . _ . . ' ' ,
BUIIDING .
I, as owner bf fhe property, or my employees wifh ADDRE55 �x ��_lQ—��-
wagez as fheir sole[ompensafion,will do the work and � ,
- the strucfvre is not(ntended or offered for sale(Seclion- - � �OCAtI7Y - �- - �� - -- - - ----��-- - � ' � � - -� '
7044,Business and Professions Code). MOVING iEL . .�� -��f•+ � � ,
- � I,as owner of the property,am ezdusively conlracling, ' �ONTRACTOR NO. �
with licensed cantractors ro constroct ihe project(Sea qDDRE55 � ' " � �
tion 70d4,8usiness and Professions Code). -� - - �
REQUIREO TOTAL$ETBACK FROM EXIST. { � � �, I
CONSTRUCTION LENDING AGENCY SEi BACK �AR� HWV pROP.linlE' WiDTH � . � , �' . . �
- . ';... • i, ,`
� I hereby a(firm ihat ihere is a constrodion lending agency for �" FRONT q � ,� � �
Ihe pe�formance of Ihe work for which lhis permit is issued P.l. L'���GA/C _� ,,,.�,- _ l �� � .
ISeC.3097.Civ.C.). , . . .SIDE. . . . . _ � - �_ . .., --i `'�. ��. :! .
� _ . .._ ._ . . � • � -
' F.L. .. __. ... � .
Lender's Name � , '_ _ _ '__. . , . _ . . . ..
� � � P.C.Fee S Perm�t Fee � '
lender's Address � _ . . _ . _. _ _ ,. ._ ..� . . /
I certify thot I have reod ihis opplimfion and state lhat the Issoan<e Fee 'S�U /
obove information is correc�.I agree to comply with all Counry . in.esrgai�on fee � �� � - �� - � �� � � /
ordinonces and S�ate bws reloting to building constructian, Torol Fee /� s� � �
� and hereby authorize represen�aiives af this Coumy to enrer: , ' - I
:'"upon ih above-mentioned properry foyr(i/nspection pu�poses. � � � � ' � , ' , ',r�'
Ly��a.�.lMaL �LLl�-�f SFE REVERSE FOR EXPIANATORY LANGVAGE ' " . , �Y
,Signorure af p limnt or Agm� Do�e ! � � � � (
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