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HomeMy WebLinkAbout11_16_1981 - 20948 MOONLAKE ST , . _ _,... .._. _ __ .._ __ . __ - _.. y , ```. GI,� G ` ��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 ! � � � � ( . . .. .... . ... .. . ., �- ._. . ..,.. , ' .. .,.. .. _ . .. . �. � �� �• - _.. ,'�' - � o - c . . � �"?� tZa O�� �. . 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