HomeMy WebLinkAbout1501A 0119 0120 (8)Y)RKERS' COMPENSATION DECLARATION
. affirm )hat I have a certificate of consent to self
rine, or a certificate of Workeri Compensation Insurance;
ria certified copy there f (Sec. 38 ob. nC.) L
P licy Nd-'�i4 company
r '
Certifie copy is hereby furnished.
Certified copy is filed with the county building inspec- ,-�
tion department. A"/
Date S V Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE `
(This section need not be completed if the permit is for one
hundred dollars (5100) or less.)
I certify that in the performance of the work for which this
permit is issued, I sholl not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after'making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my licensee is in full force and effect.
License Number 153 �J Lic. Class /53 -7-
Coniroctor/c Y /AeM1— _Date
I am exempt under Sec.
B.BP.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's license
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, or my employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
In performance of the work for which this permit is Issued
(Sec. 3097, Civ. C�.)j
Lender's Name Y �/YI2•Ct r 1'v' /,1L
Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with oil County
$ ordinances and State laws relating to building construction,
R and hereby authorize representatives ofthis County to enter
.a upon he above-me�Jntionneddproperty for IInspection
nppurposes.
Sianoture of Aoalimnr or Aaent Dore
_AP_P,L T N-fPR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
. • FOR APPLrgNT TO F,I1,L,1N
BUILDING
ADDREss .Q
�
BUILDING '•" ¢� -
'
ADDRESS (/
CITY N ZIP
LOCALITY
,N
' ' NO.'OF BLDGS. t � • -
N �'
NEAREST
SIZE OF LOT 176 NOW ON toy O
CROSS ST. Z '�
`
ASSESSOR
TRACT m677 BLOCK L&NO.
MAP BOOK PAGE
PARCEL
TEL.
OWNER NO.
USE ZON
r ')
P
MAP1
NO.-6----4
---
ADDRESS fAN D
tl
CONDITIONSP 1 R+�
LIAL -FCITY
�7 q
k5
CITY V ZIP 1
ARCHITECT ORTEL
ENGINEER N
DISTRICT
GROUP
TYPE
T.
IJ
FIRE
ION
PROCESSED BY
$ [ C
ADDRESS . NV SAND S
CONTRACTOR ✓C)5,/h2l «- 15L rjt a 7 7/
STATISTICAL CLASSIFICATION
CLASS NO. DWELL UNITS
CONDO.
ADDRESS/ /TILL{()17 " a/ jjp,733f1 -•C%3
LIC.
C
SEWER MAP
CITY -' CLASS
�
ti.
VALIDATION
SO. F Q NO. OF NO. OF
CHECK
SIZE 8 STORIES FAMINES
ONE
VAL ATION'91a,Q�
� 1 5 01 A
DESCRIPTION OF WORK I 11,T49YL
NEW
$ ,
9- e e -23
ADD
W
REPAIR
$
_
1-891.23
-891.23E
-TimlwALTER
USE OF 061111147 57 967CMK
EXISTING BLDG.
DEMOL9,
FINAL
1 2-88 '
APPLICANT �t/ TEL.
TN f
PRINT O sC -
""`v
DATE S 22-40
ADDRE55
FINA�PRESENT
sy
BUILDING
ADDRE55 �i.� L -4:f -L U',.11(
a
,;
Uul�
LOCALITY / ,c- . ✓L/
� _
.
( U
2 1 D 2 f�0
MOVING r' TEL.
CONTRACTOR NO.
ADDRESS"IO2.:•'�-
REQUY IRED TOTAL SETBACK FROM Ibl.
SET BACK YARD HWPROP. LINE WIDTH
FRONT
P.L.
LDMA R.I. M
G I O
L , I
SIDE
P.L.
P.C. Fee S Cf. Permit Fee
/,570, ®
/ Q nr O
F• 1
)-r Issuance Fee 10 • 5
LDMA P/C N
I-
1. 17, '
tnvestipotion Fee ,1 /s
Total Fee . V V
LDMA Parm. R
t. Z rA q 10030 L r) m �zsr w
SEE REVERSE FOR EXPLANATORY LANGUAGE
U.? Ll ) Ts '
T\
4
_ J
P