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HomeMy WebLinkAbout1036 S COGBURN LN (6) WORKER5'COMPENSATION�fCLARATION / 1.(/K�^G � I hereby offirm ihot I hove o�e�,�f��a,e oF consen�ta self APPLICATION FOI� BUILDING PERMIT insura,or a certifitate of.Workers'Compenstion Insurance,or ayc'e tified gco�p,y Mthee(re�oyi( et.3800,l�aby.yCy.f)�> COUNTY OF COS ANGELES BUILDING AND SAFETY Voli�Na+LY/Y/G'7/�Company%�//.GC7� ���j' � Centfied co is hereb fomished. BVaDWG ��. . av v FOR APPLICANT TO FILL IN aooRess /��G � ��V�/Certified copy is filed with the rouMy building insper BUILDING �v. � tion departmenl. AD�RE55 ��3� � IOCP,IITy � NEAREST Date�Applico� CITY ZIP CRO55 ST. CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE � SIZE�F LOT NOW ON LO7 � MAP BOOK PAGE PARCEL (ihis section need nat he comp�eted if�he permit is for one USe ZONE MAP l/ hundred dollars�$100)or less.) . TRACT BLOCK LOi NO. �� NO. ���ji"� T El SPECIAL � p, I certify thot in ihe performnnce of the work foi which Ihis OWNER D ?� CONDITIONS (j permil is issued,I shall not employ any person in any manner ,Q�� �'),`t r DISTRIC7 GROf1P 7YPE FlRE PROCESSED BV V so os to become su6jecl�o ihe Workers'Compensation Law:. ADDRESS[70� 1�pY � (�{♦ �O �� CONS� ZONE O Da1e Applicant ��TY Z�P STATISiICAL CLASSIFICATION APT. CONDO. V �TICE TO APPLICANT: If, ofler moking this Cartificote of AFCHIiECTOk TE � 1' mpfion, you sho6ld become subject ro the Workers' ENGWEER N CLASS NO. �� �WELL UNITS� � � Campenso�ion provisions of�he labar Code,you must forth- AODRESS SEWEk MAP Z wifh comply w'th such provisions or lhis permif shafl be deemBd revOked. CONTRACTOR N BK. PG, VAIIDATION LICENSED CONTRACTORS DECLARAT�ON I here6y offirm thot I om license�-�...e.-r._.s__ns_of.S.64pter 9.,__ ADDRE55 ~f �� �O. "'"'""'""' V ALUATION (commencing with Se�lion 7000)of Division 3 of the Business ond �--""�--��'--�------ -�--- y— - Professio�s Code,and my license is in full force and effecL GTY QA55 S�/' +���Q -+�� SQ.FT ND.OF NO.Of CHECK Li[e�se Num6er W�� lic.Class SIZE STORIES FAMILIES ONE >� DESC&IPTION Of WORK NEW b Conlract � ��Dote ❑ � I am exempf from the��censing repuirements as I om a ADD licensed architect or a registered professional engineer ALTER ❑ k�A7� �C 0 L 9 A acting in m,y profess�onol mpacity (Section�7051, � REPAlR Business and Professions Code). USE OF N �'� • •2� E%ISTING OIDG. �EMIX � B Li[,or Reg.No. Date APPUCP,N TEL n��h � •G 7�,v� OWNER-BVILDER�ECLARATION IPRINT N •"7V �,L I hereby offirm Ihat l om exempt from the Contraclor's license� �'�'� •.�2�]1,�2 czi Law for rhe following reoson�Section 7031.5,Business and ADDRE55 'ZF professions code): raeservi I ��� 5-$3 . � i, as owner of Ihe property, or my employees with ADORE55 wages es their sole compensotion,will do fhe work and - � •� the struUure is not intended or offared for sale(Section ��CA��TY . 70E4,Business ond Crofessions Code). MOVING TEL �Q 0 Z C A � f,os owner af the property,am ezciusively cont�octing CONTRACTOR NO. rt•� � � �1 wi�h licensed coMraUors to conslruct ihe projetl(Sec- AD�RESS . tion 704q Business ond Professioos Code). I •/1 6�L 5 G RE�UIRED TO7AL$ETBACK FROM EXIST. CONSTRUCTIDN LEN�ING AGENCY SET BACK YARD HWY PROP.LINE WIDTH I hereby affirm�hai there is o mnstruclion lending agency for FRONT . • �Q(,+F:F(�� ihe performance of ihe work for which fhis permit is issued p.L. � � (Sec.3097,Civ.C�} ' � ,�. � sioe I �,� 5—8 3 �/,/���� � � P.(. Lender's Name�[�if � a/ . � - Lender's Address///ll�N�f��/T1��✓/1 � P�C.Fee S Permi�Fee �t jrli. P'� ' I cerlify Ihat I hove reod this applimtion and stale thol the Isw ce Fee �0•J`' � above informotion is mrrect.I agree to comply wilh oll Counry Invesi�qmian Fee $ ordin d S�ate laws rela��ng to building conslruUion, tomi Fee ��L• .��, , and ereby uthorize p sematives of Ihis County to enter a upo ih ove(1�i e io roperry forinspection purposes. . °� (/ a ,1/d SEE REVERSE FOR EXVIANATORY LANGUAGE n_.., @s o ° �, Z o � �y a' � .c m o Q S t� p G � r+ �(1'�6 �R O m Q @-p� �. � A� 'p O,. 0 �' ^ � �' O n � 7c Q ✓� r'ry 9 �t0 �j � m N 'Y r G' �"} 4 �O 3'` 7 �n N � �Q � � �� 9 O .i m � d �' j d O� O' n 9 9 � ^ � �`p �O r q a 3 g � ..{.� � !v �a T n S Q ` � � O 4°\ �t r �r i R��• p O S\ N� -G N „{ O �L .0 '�6 �'.a n �^Oi i�.y � � 'cr, C ' a M � ,N C. 6 O. 9.Z.i Q O O 0 ✓ � ,. � 4�G � � q W o °�3a 4 \ � x � T m a o a� Q . 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