HomeMy WebLinkAbout1753A • .- ..",. . ....�.li- � ...._..;..._t . �..e„ .. .:. ..� . . �I , __ __ " __ _' _- -..... "_ .. ,..WORKERS'COMPENSATION DECLAR.4TION'.�.. ...' .�� �'. .� �.,�` '��� ... . .�. . . . . � . � �� , � ,I hereby affvm ihat I have a certifimte of tonsent to'self � � - �� ��,��,��e,oracertifica�eofWorkers'�amPe�,a�,o�,�,�.o��e, ; APPLICATION FOR;BUILDING ;PERMIT � �or a certified copy thereof(Sec.3800,Lab.C.) . - :� � �'. COUNTY OF LOS ANGELES BUILDING AND SAFETY f�'�folity No.� � ��- � Company . . . � .-... ' , . . .. ,. . . . ., . . �`+ .Certified copy is hereby furnished. � ' "- � ,.., BUILDING ^y �,. t,ti � r - � . , - i� �'�, �I '�FOR'APPLICANT.TO FILL IN�' n�oaess ,�.: � - '.,, ��O ��-Con dapartmant filed wi�h the covnry b�llding Inspec qoDRE55, -1 '' ���� �� �.�'_. . �ocn�m - � r i' '• f��.a.. . � . . t" .� . . ' �I � . � i.' . . NEAREST , /� �� .. � � Oate:.. ' � � ..Applicanf �� � � CITY ':� �1.. - ZIP �� � CROSS ST. - �`^ �(��/ - � 1� �`:-CERTIFICATE�OF EXEMPTION FROM WORKERS'�� �� ' ' � ' '-�F� :NO.OF BlDGS. � � nssessoa . . .� a �� � °;'�' ,.,-"�� COMPENSATION INSURANCE SIZE OF lOT ��'�NOW ON lOT ' MAV BOOK � � �. PAGE, r �'iARCEI� � O (Th�ssectian need nat ba completed if ihe parmil Is for one � ' � : � _ _ tlSE 20Ne � MP.P - - . �� � V ,h�Jndred dollars.(E100)or lees.) �� .- �� � � . TRACT y BLOCN • l0T NO NO. �' ` � -�� I . W v,°N � � - '� . ' OWNER L.t ..��1�•7 '- NO. .:'i%, 1� //SCONDI�ilONS.. - . . . � . ..' � �certify,that In the performance of ihe work ior whith This � , , _ � � ': LL ermd is Issued,I ihall not employ any person In any manner � ','� ^"-�� � DISTRICT ,GROUP�, TYPE FIRE •PRO�SSED BY } A�DRESS : t� . �� CON51 ZONE,. .�t so m�tob,etome eob�act to the Worken'Compennation Laws. � � ; .�r '" a . . �-J.,� ,.~ . .. ,.. . i..� . .�. CIfV :� . f i_.:...1 : . ZIP.:.. . ; ./ -•_-� ,. . . J : .. .!•�..ti� Qd' ���.� Date + � ' APPlicant`. � � � ' ..• - ARCHI7ECT OR ' � TEL StA715TIfJ1L QASSIFICATION .� . , - APi. CONDO. -O ��,�' NOTICE-�TO APPLICANL•�If, after making this Cartifimfe af � � �/ � . d . �Ezemption,.you ah0uld become.subjatf-10�ihe .WOrken' . ENGINEER NO. QASS NO:' �WELL.UNITS .� , � �.. Compansation provislons of the Labor Code,you musl forih• � � ' . . � - , . , , . , . F •� with�comply with such provisions or this permit shall be �DRESS -..'�. SEWER MAP ,t ;�,; daemed revoked. - � � �� ,.f,=,,,,,...�"" � � . � VALIDATION ` � CONTRACTOR I��� �NO � �BK. PG, `� '; IICENSED CONTRACTORS UECLARATION �- � � � � � ' . �� ,� ��: I�hereby offirm that I am licensed under provisions of Chapler 9 ADDRESS ' ��''� i NO. �'�� ,VALUATION � � � ` � • .. - (commencing with 5ection 7000)of Division 3 of the 8ueiness and � —^� + �, � .. , ��C . � � � . '- Profesaions�Code,and my license Is in full force and eifatt. ' Cm' <�� : '' � " �' CtASS ' ' t�'� S �'O r '" �� � '. � . �. . . . ..:. . � � - r - 5� R."'. • �. NO.OF • . NO.OF CHECK , . ��?Lfcense Number � I� � r Lic.Class � �'� � SIZE � STORIES �� FAMIUES ONE � '� � � � - �� � , � ,. . ... . . .. . . � . :.o�Contmclor•���• `i, pa�e �'�: i' � . DESCRIPiION OF WORK � � NEW � s � � � .. �' . . . . . ,� �— ' C ADD � � � . ,. ❑I.pm eaempt under Sec�:� . - . , • . , . � .' - �. . .. .� ALTER � FINAL . .. , . .B BP.C.for ihis reason � - �' �. � � � � � REPA�R � ' DATE � .. . "., . - , � Ddte: USE OF ' � ,i� � . FINAL . . '. �� . � � a �4I�� , � �. E%ISTING BLDG . � . . DEMOI� ❑ B � , ���,/1 F�p(t,, . � �Signature`. � �� � - ' ' - APPLICAM. �,.:"• iEL. r . . . . � !�TI��� �P��•� .. � OWNER-BUII�ER DECIARATION' . ... 'PRiM � t�� f ��.i NO � �- .i . I�,��r�'�'���.��- . - `�I Fiere6y affirm Ihat 1 am exempt fram tha Contracmr's License ���� r �, ' : � .. � . , ��r•t r t 4�"t N�+ Law for.the following reason(Sedion�7031.5,'Business and ; ' ADDRe55 l...� � � .t%" � � - . � � :�{�j�a�,►4�a.��h� ..Professions Code):� . � .. , � �� Pae eNt � � .,.. . . ' . . , - .."r1F�S��H C S� ,'❑ . .. .. , . . . � . � BWLDING ••1 � .�t ;��, .. i,f � ... . � . �� . � i���.:�.� d�r%��$ . - I,�as owner:of Ihe proparty, or my employaes with ADDRE55 � � .waqes as their sole compenwtion,will do ihe work and� . ' ' � ��4,}�^i��,. � ihe strucfure is not intended or offered for sala($ettion �OCAIITY�� - - . , ' ���.��� � . •*�,� �-70d4,Business and Professions Code).'� � � MOVING � � � �� � � TEL ' ' � ' � ,�� i,as�owner of the property,-am azclusively contmcting , �OMRAROR� ' � NO.- . , . . , . / , ' . wifh licenoed confmctois to construcf ihe projecf�Sec- qpDRESS � � � � � � � "- �tion 7044,Buslness ood Professions Code). �.� . � ' - ' ' ' � ' � , , ,' . � '� � .REQUIRED TOTAL SETBACK FROM EXIST. � � � � �CONSTRUCfION LEN�ING AGENCY . � - sei enCK� YAR� H�"!Y PFiOP.IINE WIDTH '� � � � . � I hereby affirm that there is a construction lending agency for�, . �FRONi . � .�� . _ . , . � . . - � Ihe performance of the work for which this permit Is Iss�ed V.L � � ' . .� � . � � � . � , tSec.'3097.Civ.�C.). . . � .SIDE. _ . , . . .. � . . _ i. . . �'P.l:. . . . ' � . : . lender'a Name ' : . . , . ' .. , � - ; �:. }, � , . � � P.0 Fae E ��� :i ' Perm�t Fee . , ,�..1, - . . . .. . . - ��'lender's Address' , . . ' • � _ . ' . > , . ' �I certify thaf�1 have read�Ihis application�ond state ihaf ihe '' . - � luuanro Fee� /.' �:�:� � � � � . �� �� �� ' -. � . aboJe informotion is correct.I agree to comply with till Covnty� I ves�gmion Fee � � ��./ . � . � �' '. � � ardinances and State laws relating to bullding construction, � ' � - ^ " �� . ' i - . . � , f dnd hereby ao�borize reprosentatives of Ihis Coonty to eMer � � Total Fea . ,'_�,. / � ' . :. , . � ,� upon the above-mentloned property' for tnspaction Jpurposes.; - -.-i� , , , , .�.�� �; . � . , . -� ' ; ' � ' ; �� �� y� ~ � � j/!'�7�� � � .-SEE RFVERSE fOR EXPUNATORY LANGUAGE � � . � , � � � � � � Signature of Applicant or Aqent .. �pofe . � � . . ' . �� I � , . - '. ; _ . . .. .,� ;. . , 1„ -� _ _ . - __ . _ _. . _ � _ st ' '� � . ` : _ _ _ _ ___ ; — . .. .. . ..��. . .. . . ... . k .. . . . . . . . .. .:� . . . . . . . � . i..� -. .. . . . . ' .. .. . . _ . . . . ..' , .. ..._. .. _ . � . 'A , . . . ' ' . _ _ . .. . . . ,. .