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HomeMy WebLinkAbout1691A 1893A i WORKERS'COMPENSATION DECLARATION � I hereby affirm�hot I have a certificate o,�o���„o Se�f - APPLICATION FOR BUILDING PERMIT insure,or a ter�ificate of Workers'Compensation Insuranca, ' or a MerijfiadYopy thereof(Sea 3800,lab.C.) �OUNTY OF l05 ANGELES BUILDING ANO SAFETY P❑olicyNo. Company Certified copy is hereby fumished. FOR APPUCANT TO FILL W oo�ss '3�/I �N% �►^'7G'.ZN'. � Cartified topy is filed with the county building inspeo BJILDING fion deparfinenf. A�DRE55 •� �NT �Tw'7G ,�N iocaurv Tial"JQ Kb ,�.�2 CA. NEAREST Date Applicant CITV " !d M• CKy� ZiP I �S CRO55 57. (`Q-+��.���� �-�-�' '��"��t,�' CERTIFICAT€OF EXEMPTION FROM WORKERS' � NO.OF BlDGS. ASSe550R r� ! COMPENSATION INSURANCE SIZE OF lOT NOW ON lOT MAP 800K � 7AGE JC .sG pqRCEL 7J (This section naed not be complefed if 1he permit is for one TRnCT 3:��f BtoCK LO7 NO. p U� NE � f� _f2 hundred dollars(5100)or less.) r� � 1 ��� .._, TEL)i..�. - SPECIA� I certify thaf in the performpnce of ihe work for whith this OWNFR �.. �/�LL'tLLl�. NO. �G� I / . � CONDITIONS s� DI TRICT GROUP TVPE FIRE PROCESSE�BY � permit is issued,I shall not amploy any person in any manner ADDRESS.�-�i/f �E�`T 7'1..�'j [b�. CO ZO v so as to bawme sobjetl to the Workers'Cqmpensation Lows. , .--� ��.. ��,y�,� ciTv ria�vr .r?Arz. ziP �4 3 . �' Chx � Dale���Appli[ant��"'` � •�'- ` J 57ATISTICALCLASSIFICATION APT. CONDO. t^ NOTICE TO APPLICANT: If, afier moking ihis Cartificafe of ARCHITECr OR TEL. �,� Exemptian, you should become subje« m the Workers' ENGiNEeR NO. aa,ss n�o.�DWELL UNITS Compensation provisions of the Labor Code,you musl forth- qDDRE55 SEWER MAP with comply with such provisions or this permit shall be __ deamed revokad. CONTRACTOR � NO. BK. PG, VALIDATION LICENSED CONTR.4CTORS DECLARATION LIC. � I hereby affirm thof I am licensad under provisions of Chapter 9 ADDRE55 NO, VAWATtON (commancing with Section 7000)of Division 3 of the Business and ���, Professions Code,ond my license is in full force and effecL CITV C1A55 E ���0� ► SQ,FT. NO.Oi NO.OF cNea �1 6 9,1 A License Number Lit.Class SIZE STORIES FAMIUES ONE ConlraUor Date DESCRiCTION OF WORK � �PA�kth`L NEW � b �� � � ��3 �I am axempt undar Sat. 6✓ALL G��F)�GN .�L�S ADD � I e •2 5.D 0 AITER � FiNAI � � �'vfE� .Y�TA.�oirG:=/G°�!f%6H REPAiR � DATE � � • n •G�J.O G� 8.8P.C.for ihis reason - Date: USE�E�OF�-0�E"S/Gk� FCr3 F'urv4C: wIl- DEMAL ❑ eINAI ° ,/�e� D 2 L C�FS 4 APPLICANT ^ iEL y Signarure PRINT �.Awi'..�NcF HAX��w No. b"4!�fJ2/ t, OWNER-BUILDER DKLARATION '�� W(7 -� I hereby affirm that 1 am exempt from ihe Controctor's llcense pD SS '-Z/1 ��-XT '7iF:"iG-j.N• _ J,�3��;t�. Law for the following reason(Section 7031.5,Business and ► C�i.� Profassions Code): � . BUIIDING I, os owner of the property, or my employees with ADDRESS wages as Iheir sole compensation,will do the work and the structure is not intended or offerad for sale(Secrion � ��TY � 7044,Business and Professions Code). MOVING TEL � � I,as owner of ihe properfy,am exclusively contracting c N7RACTOR NO. � with Iicensad contractors ro mnsiruct 1he project(Seo- qD�RE55 tion 7044,Business and Professions Code). � - r� �C�3� REQUIRED TOTAI SETBACK FROM EXIST. " CONSTRUCTION LENDING AGENCY sei ancK VARD Hwv �pP_i�NE wiorH I here6y affirm�hat�here is a construction lending agency for FRONT , � �+• • • • ' � the performance of the work for which this parmil ii issued � P.l. (Sec.3097.Civ.C.).. . � . ' . �SIDE � ' � . . . � � J o •J 6.7 S . . . . . . .�P.L - . . . . . . . - lender's Name � � �/ ) e •J E 7 Jr� � Lender's Address �P.G Fee S Perm�t Fae �If . wt.�J � J �C2-84 , I certify that I hove reod ihis opplitation and state ihat the Issu ce Fee �. J u above infarmafion is conecf.I agrae to comply wifh.oll County Invas�iga�ion Fee �n ` / , ordinonces ond Stote laws ralating to building mnatrottion, TotalFee �y'. �.� � dnd herehy aufhorize representalives of ihie County�o eMer opoa�he o ve-meotioned properfy for inspectioa purposes. - ' � � . G��„" �r�� '� � �� SEE RfVERSE FOR E%KANATONY LANGUAGE Signofura of Applicanl or A snl p�le � ._ . . __ .__ ._ _ . . . _.__.... f�� __ . _..�� — � __. .. F! 7�r YfA F.RLKAf�d INS�Tt7!'S Nitfl�f O' . .�. !,: �� .. .. .:.�. .._...�._.__._.._�_....._......__..�.- . ._. __..e._._.._._�..... I h;,_� �.:�. � .-. !. � ,:'�I r<-....tL,-Coovocto,'s �O: I RYtfIP�1�1� -_ � �i ' �1�: . � 1. � aC 7��i�.�J� ._.^ Apprewd � .. ... . � :��...� o �c.. -� �fiirh .""^�. - [, I P:•,. 6ero v _ � .. .. , . �. 1'sb, ...... .. ... .. �.-�-- _.-- ,. -,;:.. j . � . - ,.�: .. �..r. �.� 'raa � ___ .� �t�.� �.� ,� „ r , �•r „fxr c�,;- � ------ i , �r� q, r s.<_ ., �,,. ,rr_r�5,ons � _, ------I-- „ ,.. r ,�'�� ,i„ �o �trt.=lwsasforfbe 1 _____._...�_ ' -----__�. , �, ,, . .�: „ � .t.,,,7031.5 by "'� _ . .. _�� �:��-rr�ac«��r , �.' t -Nirc2 Drt�R�cNve� � ,.,.:; ����� . r_ ._.._..:,� ' , _,.. . Yrs No or Apprev�d . ----------..--- i . p,' .. ..�, •` r�. F:.;, , �.,�fk:rs(.^.500J.J: __-_... - __._._.,__-..._'_.- . 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