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HomeMy WebLinkAbout1319A 1427A .5;41T6R 6€CLARATION ,e a certificaro ot tonsent ta seli APPLICATIC?N FOR BUILDING PERMIT � ,-'�.�' %Warkers'Gompensa�ion Insurance, `�7rp�' �of(Sec.3800,lab.C.} COUNTY OF LOS ANGELES BUILDING AND SAFETY p��,�.��o' _Campany �j ``'�� ,py is hereby furnished. FOR APPUCANT TO FIIL IN qooe ss '�ti^ �/� ti`9� � �copy is filed with the counry buiiding inspec- BUi�oiNG r -}�� partmenl. ADDRE55 2231D G.�irds � � {X LOCALITV NEAREST Da� Applicanf OTY Q.✓ ZIP [ROSSS7. �..CERTIFICATE OF E%EMPTION FROM WORKERS' p� NO.OF BLDGS. ASSESSOR COMPENSAiION INSURANCE S¢E OF LOT^rp�/C [� NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one � l'� U5e ZOraE /.Wv J�7 hundred dollars(5100)or less.) iRaR /���` elpCK LOi NO. .'f� A� n10. �� '" .�7 / Q TEL. �/, ��" SPECIAL y- I cartify that in the performonce of the work tor which�his OWNER �G �� P�LLGd NO. "( � CONDIiiONS � permft i5 i95ued,I 8hall not employ any person in any manner / �ISTRiC7 GROUP TYPE FIRE PROCESSED BY � so as lo become subject to�he Work rs'Compensailon Laws. ADORE55 �. � 1 PS CON57. 20NE °� , �} • �o ,�' �r- , �_ Dote `�^��" Appliconl ' ^� '^�.f"a CITM � Z�P � � STATISTICAIClAS51FICATION APT. CONDO, � ARCH�TECT OR TEI. NOTICE TO APPIICANT: If, ofier making�his Cerlifimte of ENGwEER NO. C4ASS NO. d� DWEtI,UNiTS_ � �Exemption, you shauld bacome subject 10 ihe Workers' �n Compensotion provisions of fhe Labor Code,you musf forth- s", �ADDRESS SEWfk lM1AP with compty with s�ch provisions or this permit shall be _, deemad revoked. COMRACTOR Np, � BK. PG, VAUDATION LICEN$ED CONTRACiORS DECLARAiION LIC. I hereby offirm that I am licensed under provisions o#Chaprer 9 ADDRE55 No. yALUATiON (commencinQ wi�h Section 7000)oi Division 3 of the Businass and �i�, �1 3 1.9 A Professions Code,and my license is in full force and effetL CiTv . CLA55 E-��'s� SO.FT NO.OF NO.OF CHKK ► #• • • �L� Litenu Number Lic.Class S2E � STORIES � FAMILIES ' ONE I • •59.5p DESCFIPTION OF WORI( E ����� Conirattot Oate N�W O x ,,op • ••59,50� �I am exempt under Sec AUER � fINAL„� � � p�,3� _g� 8.8P.�.for ihis rea5on REPAIR � DATE USE OF DEMOI ' � ' Dote: E%IS7iNG BIDG. ��r+�l P..� ❑ 8y A r $ignafure APRICANT ( TEL. ('Q� OWNER-BUILDER DECLARATION PR�NT � f7� G�CCO NO.��I�l�7 I hera6y offirm thaf I am exampt from the Contronor's Litense ADDR �Z':�1� � T71( �1 V , Law for Ihe following reoson(Section 7031.5,Business and � � Professions Code): h�,:. L - ,y ❑ �-BWL�ING /��� '�'-'� I, as owner of the property, or my employaes wi�h AODNE55 wages as iheir eole eompensafion,will do Ihe wark and �e'� �.tuL��' ' ' � the atrut�ure is not intended or offered for wle(Section �aA��T� ��.wj✓�{ � �� ���2 7� 7044,Business and Professions Code). MOviNc Tei. � � �l,�,w+!�.� A -� ] I,as ownar of ihe property,am exclusively<onfracting NTRAC70R NO. ,�w�r-6� i� , - ' � �• • • • � wifh licensed contractors to construct tha project(Sec- qpDRE55 tion 7044,Business ond Profassions Code). r.o •Jr ra rJ O REQUIREO TOTAL SETBACK iROht EXIST. � CONS7RUCTION IENDING AGENCY ' SET BACK YARD HWY PROP.LINE WIpTH !here6y offirm�hot there is a consiruc�ion lending ngenty for FROM � ► ' ° °J���7 aTi �he perfarmance of the work for which this permif is issuad P.�.- � `sa�.��,eiv.e.>.. sioe 0 2,0 7�-8 4 ' . . . ' . .-P.L .. . . .. � . .ender's Name � � � � ender'e Address P.c Fee a ��O Permif Fee �,�uj �"'�� cenify�hor I have reod this opplica�ion ond state that the iasu ce Fae ��..:� �J bove infoimalion is correcf.I ogree to comply wifh oll County Imestiqaiion Fee �� rdinances and S�ote lows reloting�o building consiroc�ion, toml Fee ,i✓�✓� nd hereby ou�horize reprecenlatives af this County to entar Pon ha obove-mantioned property for inapaction purpoaes. � ..C.(L -1-.� � SE!REVERSF FOR EXiLANAiORY LANGUAGE Signa�ure of A pliconf or Agen� Da�e �� ___ ,._.. ._,_.. �„r,ar�ie�s.rv��Rwa ietse[crtfe's r�na� �� „�';.••�•`�w • .� .�_ _ __.. . ...__ �h �;: � ,� ,, r To• ._.._.�_ PeEweed ic ' l i I��� � "�i � . {.., APprev�d ----- J , � t ! h�.}...,.. : ' �t2::. . 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