HomeMy WebLinkAboutNo Permit Number . ----"-7� ,r . �++/Y --- .
WORKERS'COMPENSATION DECLARATION � '*�+ ��
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I hereby oF�;,m thar��o�e a tertificoie of�o�5e�„a=e�t �APPLICA�ION FOR BUILDING PERMIT�� �
�nsure,or a certi(icate of Workeri Compenstion Insurance,or
/ a certified copy thereof($ec.3800,Lob,C.) � '
� Poli�rNo.�y�j�72S�ompony AC�/l.� ���u:,JI�` COUNTY OF LOS ANGELES BUIIDING AND SAFETY
Q Cert'rfied copy is hereby fomished. ' r FOR APPUCANT TO FILL IN ooR[ss d
� Certified copy is filed with�ha cc m y 6uilding inspea BURDING " �/� �
tion deporlmenf. , ADDRE55 .�.Q (� IOCALITY� �Yra�t.(�/
Date�-�'fr�' App pn1- NEAREST !�C`�CJ l� ,
UTY IP CROSSST. �f.�> ar S� tJ-+��4'c
� � CER7IFICATE OF EXEMPTION FROM WORKERS' ' NO.OF BiDGS. ASSESSOR
COMPENSATION INSURANCE � . .- SIZE OF LOT NOW ON l0T MAP BOOK " PAGE PARCEL
(7h�s setlion need noi be completed if�he permi�is for one �ppj u5e ZONE MAP
hundred d011or5($100)or less.J - iRACI� �i BLOCK LOT N0. NO �Q"+�3, �
. TEI. � C�l SPECIAL y .
awNea SG e No.7�4 3 -7� CONDITIONS
I cerlify fiat in tha performante of the work for which ihis v
permit is itsued,1 shall no1 employ any person in any monner DISTRICT GROUP iYPE FIRE PROCFSSE�BY
so os io become subjec��o the Workers Compenso�ion laws. /oDRESS �i �d � �OR�D %O CON57� � _^� O ,
.1y ���
Date Applicont : CITV N Z�P �' � gTq715TICAL GLASSIRCATION . APT. CONDO. V
NOTICE TO APPUCANi: If, af�er moking�his CertiFicate af ARCHITECIOR TEI. 7t
Exem tion, ENGINEER NO.'� 0 W
p you should become subjecl �o the Workeri CLASS NO.�DWEII.UNITS_ 6.
N
Compensotion provisions of�he Labor Code,you must fonh- aooRe55 ^f . Sewea r�nnv 2
with comply wifh such provisions or this permit shcall be TE�
deemed revoked. . . 6K. PG, VALIDATION
� CONIRACTOR NO.
LICENSED CONTRACTORS DECLARATION - . ���,
I hereby oifirm�hat I am licensed under pwvisions of Chapter 9� ADDRE55 _ NO. VAWATION � ��Q��A
(mmmencing wi�h Section 7000)of Division 7 of the Business and ��C. y�_����+� . . .
Pmfessions Code,and my license is in full force ond effect. Ciiv CLASS S_y�ii�7V '— '
� ' SQ.FT. NO.OF NO.OF CHECK , #� ���.�2`3
liCBnSB NUmbef liC.CIO55 512E $TORIES FAMILIES ONE
NEW $ ��,�1-�� I�� � 4 Q S O
COOttOCtOf - Date � DESCRIPTION OF WORK � ADD � � .'.�� 4 S.8 0�
� 1 am e.empt from ihe licensing requiremenls as I'am o �l:AYL L �G ►L � �
licensed archited or a registered professional engineer i. AliEe � FINAL . I'2'� 7�8�
acling in my professional capacity (Seclion 7051, FL)V11'7 REPAIR � DAiE
Business and Profeszions CodeJ. . ' USE OF � FINAL �
/ "Z�yIrI !f��.�Z Ex15TING BLOG. ' DEMOI ❑ B
�(' Lic.or Req.No. Dala APPLICANT iEL. Y - �
� OWNER•BUILOER DEClARATION I�RiNT� NO. -C ,
I hereby offirm that 1 om exempt from the Contractor's license A�oRESS ?�2, G7RI.�d�j'� 1�yE• '(�� / G n
law for Ihe following reason(Seclian 7031.5, Business and
Professions Code): . � Fet eN � ����`� 2 2 0 9.0 A
� I, os owner of Ihe property, or my employees wilh- AD�RE55 �,v`��
#• • • •23
woges as the�r sole compensaiion,will da the work and L«AIIT� J � ¢� .
the structure is not intended or offered for sale�Section p� �,• �b a�Q
7044,Business and Professions Code). MOVING 1EL. �
CONTRACTOR NO.
� 1,as owner of Ihe propeny,om ezclusively conlracting " � •6�O Q�
with licensed mntractors to mnslru[t the prolecl(Seo- qppRE55 • • ' �
. tion 7044,8usiness and Professions Code). �
REOUIRED TOTAL SET6ACK FROM ex�sr. 0 4 0 6—8 2
CONSTRUC710N LENDING AGENCY � �SET BACK 1'ARD HWY PROv.uNE WIDTH /� n
I hereby affirm that ihere is o construciion lending ogency for FRONi �2 V 9� /�
�ha performance of+ha work for whkh th�s permit is issued a i �
(Sec.3097.Civ.C.J, . .. , . SiDE � � #�,• • •t .
P.L.
lender's Nome
Pe.mi�Fee � n.O� � °Z 7 4.S O
$ Lender's Address P.C.Fee E � • �2 7 Q 5 Q� �
W I certify tha�I hove reod this opplication and stme thm�ho � .�(� iiso ce ree � � � �
above information is correcl.I ogree to comply wilh oll County In�ese m�on Fee '+ c,� 0 Q��7�$2
� ordinances and 5 ate laws relating to building wnstruUion, 9 �� Toial Fee `�' .�U . .
and hereby ui rize represemo�ives of this Couniy to enter .
� vpo Ihe a ioned property for inspec�ion p�rposes. .
� I �Y'Yy"c�j L SEE REYERSE FOR EXPIANATORV IANGUAGE '
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