HomeMy WebLinkAbout1665A `.. WOHKERS'COMPEN�AT�bfSDECLARATION . R/'-�"� �c.[l7� Z�7Z Q:L�+3 �
I hereby affirm that I have a certificate o,�a�sa�,�o se�f APPLICATION FO� BUILDING PERMIT
insore,or a certificate of Workers'Compenstion Insurance,or
a certified copy�hereof(Sec.3800,106.C.) COUNTY OF l05 ANGELES BUILDING AND SAFETY
Policy No. b�'f�fCCompany�j t�P �Lc YL� Bua�iNG
�''CerNfied eopy ishareby#emei�i+ed..p^� .f.�/� � � FOR APPL�CANT TO F�LL IN nooeess �
❑ Certified copy is fi�ed with ihe county building inspec- � 6UILDING " . .
� tion deparfinent. - ADDRESS �pCAIITY
f.LAREST
Date Applicont CITY - � ZIP- -� �' ���� CRO55 ST.
�CERTIFICATE OF EXEMPTION FROM WORKERS" NO.OF BLDGS. . ASSESSOR .
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT- '' MAP BOOK P PARCEL
(ihis section need nor be completed if�he permit is for one USE ZOnle nn,4P ��
hundred dollars�$100)or less.) rencr B�p�K � LOT NO. ! No. }
TEL. �S�� SPECIAL , � � y 9 / d
1 certily that in the performance of the work for which this OwNee � /� S NO. CONDITIONS � Q
DISTRIQ GROUP TYPE FIRE PROCESSE�BY
permit is iuued,I shall not employ ony person in ony manner • qDORE55 7� CON57. ZONE V
so as to bemme subject ro ihe Workers Compensation laws. � � p�
Date AppliCanl CITY Z�P 5?ATISTICAL GLASSIFI�ATION AVi. � CONDO. O
ARCHITECT OR TEL. V
NOTICE TO�APPLICANT: If, after"moking lhis Certificote of � W
fxemption,�you shovid become subjecf fo� the Workers" ENGWEER NO. �CLASSNO. �a'�DWE0..UNITS�
a
Compensation provisions of the labor Code,you must for�h-� �-� � - �� �� - � � � .. y
with.comply with.:svch.provisi9ns 9r this permit shall 6e ADDRE55� -- . .-.-- . .... ..C_: . : SEW€K.MAP .-....-� --�� . � .. . �'L'
deemed revoked.. . ...... :...... .. . _ -...-- EOh7rttAGiOrt_ �... c3 ..�tw0. - � .�...:. _ e��.-. PG._ ... . � � YALIDATION
LICENSED CONTRACTORS DECLARAT{ON � � uc. �
I here6 affLrm�hal l am licensed under avisions of Cho ter 9 PDDRESS � ��� ��������- -- �' ���� -��� �-� � �
Y P� P �- 3 �n10. -C.7-��(� YALUA�ION .
(commencing with Section 7000f of Division 3 of the 8usiness and �p uC.
Professions Code,and my license is in full iorce and eHect. CITV `-0 �Z C � � CLA55 ` �� ��-E-�j�fl"T'--LT��- �
�eS /� —' 5�-FT. NO.OF NO.OF CHECK
license Num6er �¢��3 ` ,L�i[.CTlo-ss� StZE STORIES - FAMILIES ONE
/ J'� C DESCRIPTION OF WORK ' NEW � s �-i ��'r r
conrractar�.�ue�.t /s0 r r p�e N �f/O�p'/
❑ .
❑ ADD , c • a�
t am exempt from the 4icenaing roquiremente ae 1 am a � r�71,d�Y1�}'� . .. .-�.- -.. . .. .
�icensed orcbi�ect or a ragistered professionol engineer - -�- -��� � Al7ER �� . FINAL�j
oding in my proEessional cepocity�(Section 7051, . � • ..�L,o. � -DATE �[' L�`Q� � .�E.?'-^
REPAIR
6usiness and Professions Cade)�. � U E Oc DEMIX .FINAL y'
� EXISTINGBLOG. ❑ B - "'��� '�- -
Lic.or Reg.No. Date , APPLICANT TEL - -y
� OWNER-BUtLDER DECLARATION PRINT KO DO M� NO, — 1 � � - � �Q�F^r�
I here6y affirm that I am exempf from the Conhactor'S License /
taw for the following reason(Sectian 7031.5, Bwiness and p.DDRESS�C �/p / ,f; �e s���
Professions Cqde):_... : �=. �
� � BUIIDING . �7.
�, 05 owner of the property, or my employees wifh A��RE55 �/4�y/
wages as lheir sole wmpensalion,wi�l do ihe wark ond . ��
fhe sfructure is not intended or offered for sole(Section IOCALITY �
7044,Business and Prafessions Code�. MOVING 7EL.
� I,os owner of the properry,am exdusivefy conirqcting � CONTRAC70R NO, �A�
with licensed coniractors to conslrocf the projeci(Sec- qDDRE55
tion 7044,Business and�Profess�ons Code). �
RE�UIRED TOTAL SETBACK fROM EXIST.
CONSTRUCTION LEND WG AGENCY � �7 gq�K VARD HWY PR07.uNE wIo7H . � - � i
I here6y affirm fhat ihere is a mnstruction lending agency for � FRON7 , �
the performance of the wark for which this permit is issued � p.�. � -
(Sec.3097,Civ.C.1. � SiDE �
P.L.
tender's Nome .
� Lender's Address i P�C.Fee S •� Perm��Fee � � f
W I certify�hot I hove read this opplication ond s�a�e that the . issuance Fee 6,u � �
Qabove informarion is correct I agree to comply with all County Invesngoiion Fee � � /�
ordinances and Stare laws relanng to building tonslrucfion, To�al Fee �-y
m and hereby aothorize repiesentaiives of this County to enter � . `i.
a upon fhe bove-mentioned properiy for inspection purposes. . f
i
�a ����„���Z�:1.�,( � � � SEE REVERSE FOR E7(PLANATORV LANGUAGE
^TS*gnai�re of Appl'�cant or Agent Dote '
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