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HomeMy WebLinkAbout1325A WF3RkERS CDINPENSRROA 6FCLARATION Sq insureborafcarfifcotteofWokesrrCompensatoolnsuronce` APPLICATION FOR BUILD�ING PERMIT �s or a ejrtified ropy thGereof(Sec.38W Lab.C.) COUNTY OF lOS ANGELES BUILDING AND SAFETY P❑oli�N���y-a 3 Campan Certified copy is he.eby tumished. FOR APPLICANT TO Flll IN ADDRE55 /S � � � Cerlified copy is filed with the county building inspec- BwtDin�G �i �ion departmeni. ADDRESS f� �r.� �i G pc,�s�G LOCALI7Y � NEAREST n_ - Date Applicaat Cliv ��!G .�'-.c ZIP G� 7 CR05S 5T. 7t�� -[.� CERTIFICATE OF EXEMPTION FROM WORKERS , NO.OF BLDGS, / aS5e550R COMPENSATION INSURANCE � � SIZE OF LOT NOW ON�OT / MAP BOOK GE PARCEL 7his sac�ion need noi 6e complefed if.fhe permif is for one� USE ZONE /�P � � TRACT '�7 BLOCK LOT NO. C NO. �3� �3 mndred dollars(E100)or leas.) � - .. .�/ }- rei. r saeaai �_ certify Ihat in the parformance of rhe wo.k for whicA this OwNER eydE .e.K y+,'� No. �dE-'� CONDITIONS C. �ermif is issuad,I sholl nol employ ony persan in any manner DISTRICT GROUP 7YPE FIRE PROCESSE�6V (i 0 os to 6ecome subject lo the Workers'Compensafion laws. AODRess �' CONSi. ZONE ! G' (€1 .C'3 � / �ieu�e.a tii ]f0 AppliConf CITY Z�P STAi1571CALCLAS5IFICATION APT. CONDO. � ARCHRECT OR TEL. OTICE TO APPLICANT: li, after making ihis Ce�tificare o4 ENGINEER NO. �� QA55 NO. DWELL,UNITS_ �� emption, you should become su6ject ta ihe Workers' C. ompenaation provisions of ihe Labo�Code,you must forth- A��� SEWER MAP °�.' ih comply wirh such provisions or ihis permi�shall be TE� p p _, emed revoked. �CONTrzACTOR 4- /✓G .L O.dG�'i.5^C BK. �, VAi1DAT10N LICENSED CONTRRCTORS DECLARATION / ���. •,p sre6y aff'�rm that I om licensed under pravisions of Chapter 9 AD�RE55 S-��.�C.�s�.✓6 �'a k'N ��7�d VAWAiION mmencing with Secrion 7D00)of Division 3 of fhe B�siness and LIC. � � fessions Code,and my license is in full force and effect. CIiY oA a-� i� L- CLA55�� E � / �� . SQ.FT. �.,,�f NO.OF NO.OF CHECK �nse Number��'7'��/�/1ic.Class�// SIZE ��`"STORIES FAMILIES � ONE trpcfor��`�'��/f�`�"'�`ba}e,��.�ll�S DESCRIPTION OF WORK i�� Q �i< NEW � S 1 am ezempt under Sec. �r 'dib �}���.$rC 4� .r ADD � Q O ALTER � FINAL� ? n� B.BP.C,for Ihis reason � X � � � REFAIR � DATE ✓4 G• �� use aF � FINrAL ' L=:�. E%ISTING BLDG. � ��'�� � � �� APPLICAM , �/ TEL D BY� _ ^.C.� � �OWNER-BUIL DECIARATION PRINT l`C-N �Sc+.✓NO.Q�SP7.B .�-�"c." � pby affirm that�am exempt from ihe Cantroctor's License , / .�fQ A��� , " 4 � u For fhe 4ollowing reason(Secfion 70.31.5, Business ond ADDRE .37� a /t " `� ° � ss;ons Code�: � I e c���O r Bt11L01NG � I, as ownar of 1ha property, or my employaes with ADDRE55 , .:t�;����,7�� wages as lheir sole compensalion,will do ihe work and � `� the struc�ure Is not intended or offered for sale(Section LOCnurv . 7044,Business and Professians Cade). ntOV�NG Tel. l� �i.�� -`���`- . I,os owner of fhe properly,am axtl�xively confracting RACTOR NO. with licensed contractors to constroU�he project(Sec- Ao�RE55 tion 7044,Business and 7rofessions Code). � ' REQU�REO YARD HWY TOTAL SETBACK FROM E%I5T . � CpNSTRUCTION LENDING AGENCY SE7 enCK PROP.LINC WiDiri , , ' , , �- � _ y affiim fhat fhere is o mnsMuction lending ogency for FRONT � ' ' �formance of Ihe work for which Ihis permit is issued P.t. �97,Civ.C.). SI�E . " P.L. s Name / i Address P.C.Fee S Permn Fee �7.,,7� , ' �het I have read�his applimtion and sia�e that the issu ce Fee �•�� formafion is correci.1 agree to comply wiih.all Coanly Invesrigation Fee �n - �es ond Store laws relating�o tuild�ng consrruction, ro�ai Fee .���• 6� rb authorize rap esenfaTivec af this County to entar _ �bove- enfi�prope 'for inspecfion purposes. �� G{ SEE REVERSE FOR f%�LAN/�TORY IANGUAGE narur Appllcanr or Ageni Da e j �1 ,.,,� ,.�.___.—_..__�-- �---._..._-......_._...._...._ . . ..�.,. ..�....� ...__ _.... . . _ ...__ ...., T(47► - . . - .. r, ., ., z .. _.._. _ -a---��- ". �----- .+ - . '� ,� a ' � -, w..��,,...4.Fs To: � :•+�iYic+.3.� . _'__ .�__._ _�._� -..,_._�_ ._._.___._. � .. � 1;:+.�c 7031 S) l+.Fw'• ••� . . r,:•$ic1 �_._ _.��___. .___._ ..- � . . ' .:�:�;.£isi�, ,.. . .. i � . ... .. .. .�._�., f'«.� .. i���.� ;.?�ra- � - -- . � --�..-,rw. � `.-,�.�.�� .__.._ _.._. ._...._. 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