HomeMy WebLinkAbout5655Aby affirm .that I trove a certifca a f corse -
ORKERS' GOMPENSAFI6N D CL`ATI ON
of consent ro self COUNTY OF LOS ANGELES BUILDING ANS $AFEi
ulb:orac hcoteofWorken Compensation[ ce, _ s ArnPLICATION FOR BUILDING PERMIT
a certifie 'y the (Sec. 3800, Lab.
Polic N m n
Y o D°Y
., ..Certified copy is hereby furnished. - -
(�' Certified copy is filed with the Bounty building Inapec-
�a� t_lon deportment
;Pate - Applicant
- CERTIFICATE OF EXEMPTION FROM WORKERS':
.COMPENSATION INSURANCE
(This section need not be completed If the permit is for one.
hundred dollors'($100) or less.) -
I'certify that In the performance of the work for which this
permit is issued, I shall not employ any person in any manner
to as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICETO APPLICANT: If, after making this Certificate of -
Exemption,. you should become subject to the Workers
FOR APPLICANT -TP FILL IN4
BgoWlEs"sc'Z%
- ', SEWER MAP(A
/s/O
�[,V
CONTRA tt
TEt' -'BK ' PG -
ADDRESS La//
ADDRESS i
Jr
LOCALITY .. c o -
-.
CITY .. �J -,
Yip
NEARE
CROSS ST. 11rkt viol�(�.✓�
NO. .7J31 Y UATI00�
NO. OF BCDGS..
ASSESSOR
UC
S Qs
SIZE OF LOT
NOW ON LOT
MAP BOOK - PAGE
PARCEL
License Number W f Lie. Class ..
U5E ZONE P
FAMRIEf S ONE
TRACT BLOCK
LOT NO.
NO. -
TSPECIAL
s
f S NEW
OWNER %Y%
?El.. �...
NO.
CONDITIONS
.
ADDRESS .G
6.&P.C. for
DISTRICT .GROUP TYPE
to� - /
FIRR�E{BE PR(O{aSSSEED�B,Y�
`•
CITY
ARCHITECT OR
ZIP
-.
STATISTICAL CLA IFI TION
- -
APF.. ONDO. ..
- Date:
CLASS NO.:. ,.' DWELL. UNtTS�_,
;.
Compensatlon provisions OT the Labor Code, you must forth-
with comply. with such provisions or this permit &hall be
ADDRESS
- ', SEWER MAP(A
I Z
deemed revoked.'
CONTRA tt
TEt' -'BK ' PG -
VALIDATION -
LICENSED CONTRACTORS DECLARATION - `-
- �^'
LIC.�r•L'"
I hereby affirm that l am licensed under provisions of Chapter 9
ADDRESS
-
NO. .7J31 Y UATI00�
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, is in full. force and effect.
CITY'
UC
S Qs
and my.l9ceenE�e
-
SQ. T NO. OF
CLASS
NO. OCHECK
License Number W f Lie. Class ..
SIZE RIES
FAMRIEf S ONE
Contra Date ...
DESCRITtT WORK
s
f S NEW
0 I am exempt under Sec.
-f
A00
.'FINAL
6.&P.C. for
lAas
ALTER
DATE ••-L7 f
-
this mason
"
r REPAIR
- Date:
USE OF
BLDG.
DEMOL Q ..FINALEXISTIN
-
Signature -
APPLICAN
By
.. OWNER -BUILDER DECLARATION
RT
-
Cl5
6 S. 5 A -
1 hereby affirm that 1 am exempt from the Contractor's License-
Law for the following reason (Section 7031.5, Business and -
....Professions - - .. -
-
ADDRESS-
-
Code):..
- pr p rty, or m -wkh
Cl 1, as owner of the a e - yemployees-
PR NT
BUILDING
ADDRESS
,
wages as theirsole compensation, will do the work and
- the structure Is not intended or offered for sale (Section
LOCALITY
5 S.'J� ,1 V -,
lJ.--,
70",, Business an d. Professions Code), -
MOVING
TEL
��
_❑ I, as owner of the property, am exclusively contracting
TRACTOR
:'�
9. 1 1-84
with licensed contractors to construct the project (Sec-
ADDRESS
-
- - -
,Ron 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
REQUIRED YARD HWY TOTAL SETBACK FROM pclsr.
5L7 BACK PROP. LINE WIDTH
1 hereby affirm that there is -a construction lending agency for
the
FRONT.
-
performance of the work for which this Permit is. issued
Sec. 3097, Civ. C.)•
P.L.
SIDE -
�a�
_
.. ��:
• T.
Lender's Nomelende
. _ - ... ss
P.C. Feb$
Permit Fee .J
%%% Q)I
,� �(, - ^
//.
rtrsiha�lev ohe
c*Zdin
.
- I". Fee ' - �Q
l /ZC/
e tortect��! agree tocomply with all
ote laws relating to building construction,
Total Feeee
rize representatives of this Countyto enterentioned
propery for ina�fon purpoeSs.��'
SEE REVERSE FOR EXPLANATORY LANGUAGE
Applicant or Agent Date
t
N, • ,., 1 :. e s �'NP i5U 4prR'L IC1N ,,, .:
..jw ,, .... , .., U < , �. -,. -.,1 eb o km tl' am exeryyat��M.ibe eetntr tor;
To: „ ftWuPaed ., Lif'er�so LQwr for the (lowing -r
t•, Approved 'r.'fmfl ,Cod ,A `+n yer�eknty wblctl. Ij!
or repair any n. at
NP. .-..'Dale' go.._.`�Tia-fo a vn�t.. r ".tat.` _ -'regtatresrc?nix to cdrs ), titre, tnproue-d mole' f
-th. applicant
that he is is�emieelpursumant'to tba'yxont}se� of th8-k�x-
y�� „- . t actar'a License Leor a % � apter 9)(co&mmencin whb S t r
as
ai16:'C
i Fl1ro Dep
r. Grading
Pedestrian Protection
(Pence) (Canopy)
Special Inspection
(Cont.) (Masonry) (Welding)
Lot Drainage -
Parking
h } f
( xpirdvalse Date
Locations- -_
Ztback,& Yards) r
Foundatlens 1
0
M. l: j
Energy Insulation
' Lot /Drywf 1= ,
' Intortor `
Loth -'Exterior p.
House Number- '
Correct & Posted
• ': ''. t �. -..:'�• ,' 000 D )'° 7b B udXr 1`-
Code)-4hat'he'ueklWipe!berbfnotii'and'the'b7islsfortbe ,
\ ,, �TT td'all ed e—fiOw,a 4llny, bi laeioti of`SeeNon 7031.7 6y
OO,�e Recelvod }kl C• ' _ _ rl �..... 5 r'ali4&ph1l Ffnrf •+Oddwf
penalty of not ntorc than fiire bundrad alnIM�i MM..J.
-Jib
asaheir.cele-mmoensahon;:!wi,ll Edi the work, and -
+
-the structure offered forsole:(6ec. 7044)
Bus z ss and Prof- inns Code The Contractor's License
r ✓ F---rs,-+ t- _ �� j:.,t' t- ' �� s 'ar intro ,es thereon, and'>}I! « r35sir 5 W6r6Jbidr3elf or
throtgObis' our; 'c4nfil6yees,` }i�oi4ded =that iiieVitn-
,.+, ._4 -_- n�' tot �nenis ere noC to i¢nficd df�'affared for i'd&:lf,
`'i f otcmontls sola witbttt,one
Year of cc»,,hte ao aP tai cu enbikicr eplJd ,6aue the
burfle; of proottt,� t6�+i'ii �a'i3 n-t-'brulld 6Y i>ttprove fpr
t �=, au k,,,befµrpo:e�d,%alJ ,,� c:.n rn•:, .�::'
.i -D I,aswwrihroi thepreFertyan excM»ivelymnlin
,.` '—' "i r tiny witf I c� ec' 'ono a cofi5lr�tt the project (Sec.
_..-.,7_QA 4).•Gy..t; rte J -S.iYAi;V'4 • Tbe.':G'oIfownrk
,� License Law does nod fly to an ownehnf b arty wbo
�dra t wti, re��t �� for. sorb
pralrmts w.eb a con tracet+d�tf} eased pursuant tq lsbe_•,r�
'Eotstrector+s-L care Lcw).-
S LP C forth Is
r
`1
Date
' aJ , ._ is ,ort ,a• .°i 3 v.
seder's SiSnoture .". '
Pl�.7YFS .__._..
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