HomeMy WebLinkAbout5655A (17)by affirm .that I trove a certifca a f corse -
ORKERS' GOMPENSAFI6N D CL`ATI ON
of consent ro self COUNTY OF LOS ANGELES BUILDING ANd $AFET
ulb,orae hcoteofWorkers CompensationI ce, ArnPLICATION FOR BUILDING PERMIT I
a certifie 'y the (Sec. 3800, Lab.
Polic N m n
Y o DaY
..Certified copy is hereby furnished.' -
U(�' Certified eoo�y is filed with the county building Inspec-
_ f_lon deportment
;Pate - Applicant
- CERTIFICATE OF EXEMPTION FROM WORKERS':
.COMPENSATION INSURANCE
(This section need not he completed If the permit is for one.
hundred doIlars'($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 INzJ
Bgo�FSiNsBUILDINc'Z%
- ', SEWER MAPtO
O
�
CO CT
TEt' -'BK ' PG -
ADDRESS
�a
LICENSED CONTRACTORS DECLARATION- `-
LOCALITY
-.
CITY .. �J -,
Yip
NEARE
CROSS ST. 11 t ✓L 01
NO. OF BCDGS..
ASSESSOR
UC
S
SIZE OF LOT
'NOW ON.LOT
P BOOK � - PAGE
PACEL
R
Licence Number W f Lic. Class
USE ZONE P
FAMRIES ONE
TRACT BLOCK
LOT NO.
NO. -
s
f S - NEW
OWNER %Y%
?El.
NO.
SKOAL
CONDITIONS
.
ADDRESS .G
B.&P.C. for
DISTRICT J.GROUP TYPEZREE.
PROCESSED By
,
CITY
ANGINERCHITECT OR
ZIP
STATISTICAL CLA IFI TION -
- -
APF..
r
- - Date:
CLASS NO.:. ,.'DWELL. INTIS�_,
:. DF�r101 Q ;FINAL
Compensatlon provisions OT the Labor Code, you must forth-
with comply. with such provisions or this permit shall be
ADDRESS
- ', SEWER MAPtO
I Z
deemed revoked.'
CO CT
TEt' -'BK ' PG -
VALIDATION -
LICENSED CONTRACTORS DECLARATION- `-
- W^'
LIC. �r•L'"
I hereby affirm khat l am licensed under provisions of Chapter 9
ADDRESS
-
NO, Y UATI00�
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, is in full. force and effect.
CITY'
UC
S
'.
and my.l9ceenE�e
-
50. T NO. OF
CLASS ,
NO. Of CHECK
Licence Number W f Lic. Class
SIZE RIES
FAMRIES ONE
Contra Date ...
DESCRITtT WORK
s
f S - NEW
0 I am exempt under Sec. , -. -
A /p
"A00 11
FINAL
B.&P.C. for
s
Z, ALTER
DATE ••-L7 f
-
this reason
r REPAIR 0
r
- - Date:
`. USE OF
BLDG.
:. DF�r101 Q ;FINAL
.,
Signature -
APPLICANT /
By
11 TEL,. f�
,.
- i ..
.. OWNER -BUILDER DECLARATION
-
Cl
5 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-
-
Cade):..
I, as owner of the
- a e - yemployees-
pr p rty, or m -wkh
PRESENT
BUILDING
ADDRESS
,
wages as theirsale compensation, will do the work and
- the structure Is not intended or offered for sale (Section
LOCALITY
5 S.'J� ,1 V -,
lJ
7044; Business and.Professions Code). -
MOVING
.':,
TEL y
z,' -,
_❑ I, as owner of the property, am exclusively contracting
2ZtIZACTOR
1'1 -84
with licensed contractors to construct the project (Sec-
ADDRESS
-
- - -
,Ron 7044, Business and Professions Code).
CONSTRUCTION (ENDING AGENCY
REQUIRED YARD HWY TOTAL SETBACK FROM pclsr.
SET BACK PROP. LIN WIDTH
1 hereby affirm that there is -a construction lending agency for
the
FRONT.
performance of the work for which this permit is. issued
t$ec. 3097, Civ. C.).
F.L.
SIDE
P.t
Lender's Name
lender's ' ss
P.C. Fee $
Pormit Poe .J
cborteha�leo v aou he
e torte l��l agree totcomply estate 11 mY
Invesfigaflon Foe
- ordin c s rota laws relating to building contraction,
Total Fee
-
and r y; t rize representatYea of this Countyro enter
u h mentioned property for ins�fon purpoeSs.-
r.�^'•r.�`•r
SEE REVERSE FOR EXPLANATORY LANGUAGE
signature of Applicant or Agent Date
/
,
• '+ �. ,., 1 :, . <-�� 1 ' if t p. '�, P�'Nrr i5U1f.4R'LARA7JCIN ,,,
,;
jw a, .... - U < �.., o xeryy�t-fcoMe°t,be ee+ntr tor;
Ir
�- ,,..,1 hereby ',ikrn *,at i,am a 9c
- { Lic`er�so LQw, for I the :faltawmg .repson (S .:, 7981 ,S I
To: �,, ,+ F x. °pared y ,
--+ Approved' ,Cod ,A +n yerieknty wblclt.
NP: -.'Dela _ - qo 'Ue.. T.-` .`7 , .f-- .\ -'re xctre d c?nt: to cdrs ) te, rrs roue -d. o i'1 I
' _ ,... -' orr ran �ruzY trd sato {2ts3'aane�on," also io ut
\ a v n ;1 9 p d? P lu
rqj
r 'the p 1 cast or tach H to. iloaras ed stdte stet
—, that he is lscenseelpursuant to tb 'ywoet}som of tb !
i _ f rt - .•, (, tractor's License L—/Cb—ter 9) (commencin witb Sea t
ai16:'C
i FlIre Dep
r. Grading
Pedestrian Protection
(Fence) (Canopy)
Special Inspection
(Cont.) (Masonry) (Welding)
Lot Drainage -
Parking
h } f
( xPoni-6, Dat.
-
local a" • • --
(Setback.,& Yards)+
Foundatlens 10
M. l: j
61-41W,l
Energy Insulation
Lot /Drywf 1= ,
' Intortor `
Loth -'Exterior p.
House Number- '
Correct & Posted -.
• ': ' ` � t �. :'� • , ' 000 f D )'' 7b B ud Xr f 1 "
t' T "� ; � J. ` ,� - Code)nr'th6t'be'u ekblripe tbenafroWvand'tbe'NiAfor the -
�'� r all eu+ex-fiO tar Awl bi latiosi of`SeeNon 7031.7 by
60,1 Recelvod i,I C• ' _ _ rl �..... 5'"'alit' t� lifcoitf •+d}�e -!ts bl ets$he �0110flif6 Fail
.'erEApproved ( r t , *`_ penalty of not nsorc than/fire bnttdred dalhiii M..):
,_.. _ �..:..__ __ __ _.�_._ t.Y�`.._ _ `__. _ ' -.. - .<'a :'. � L,o§.gWno. rrnf.tbgpipP rfYr::.mrmy emploY4o{:wJfh
,ut:^ 7-7-77 - 1 -. , ;.-,wages asaheir.cele-eornO.-.Hon,!!wirlI Edi the work, and _
-the structure offered farsole:(6ec. 7044)
and Ptvmfe inns Code The Contractor's License
__.. 1—daess:at-apply Yn ear waat'r.fp e t
o rap y--whn�mlds
r✓ F---rs,-+ t- _ ��j:.rt' t- '�� i 'ar"pr i,es theremo; anuF>}I! «r35siu.5W6r6Jbidr3elfor
Lbrntgb'tb&' citux pibye is,' Pi ai4ded=lbaC'afi2b 'fm•
°: � ,.+, ._4 -_- �n�'�tos �nenis ere noC an i¢nficddf�'ajfered jar asfi¢t :lf,
bouet r to tcmont is sola witbatt,on.
yea of cc»,,hte aro aP tai cu enbflder eplJd ,6aae the
burffen / firoontn"t tb�+i'ii )a'i3 n - t -'brand oY iritprove fpr
t=, au k,,,be fµrpo:ed,%alf c:.n rn•
.1a 1,aswwrihroi theprorerty�,,. aka exchisivelycntstrac--
,.` tiny w;tf - ec'ant u cofi5lr�tt theproject (Sec.
„7444)' T5., to rte J -S.iY� aa>r �4 • Tbe.':G'orisr66tnrk
License Law does nodly to an awashnf b arty who
bu ld r , ss t1 etfe
do t wti, ret for. sorb
prafrmts °tarb a con tract+d�tf} erred pursuant tq{sbe_•,r'�
-.. a __,
'Eo�ector+s-L care Lcu+j
TUWe7xFinpt Undar bec.@LPC for this
r
`1
Date
' aJ , ._ is ,ort ,:1.• �.�! 3,_, v.
il.'{. w�J
seder's
3 _,. ... -____ ... _. _._ _-_. _.. -___ ____.. _.. .... _.. _.._ •' :.(,..ro` ...: rr" l ..rix. c n•,l.
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