HomeMy WebLinkAbout0846A ` -�-.�_.. _ .
WORKERS'COMPENSarti,.. - �� -"' ��"'�--''�"�'"- -��-
I he�eby affvm tbm 1 hove a certiFicafe of consenf to 5g�f`. -. . �APPL�CATI4N� FOR��l�U1LDING P�RlVt1T' � �'�
insure,or a cert�f cote of Workeis'Compensfion Insuronce,or
o certified copy gIhereof(Sec.3800,Lo6(.yC�.) COUNTY OP LOS ANGELES BUILDiNG AND SAFETY � -
Polic N . �u �' �Company WV�� ���n� '
BU�LDING ,
�Certified copy n hereby f�rnished. FOR APAUCANT TO FILI IN annnsess
� Certified copy is iiled with the county bollding inspec BUILDiNG � �u � �
iion department. ADDRESS � �[� � F���TY
NEAREST
oare Applicam CITY ~/ p,7A •G ziv CRlS55 ST �+� v
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLOG. ASSESSOR
COMPENSAiION�NSURANCE SIZE OF LOT NpW ON LOT � MAP BOOK . PAGE PARCEL
(ihis sectian need not be compleied if the permit is for one u5E zONe MnP f�� f�3 s 3
hundred doilars(E100)or kss.) teacr aiocK �oi No. � seEciat Y
I[erlif ihol In Ihe erformance oi Ihe wo�k for which this OwNER TNO.�7Q � COND�TIONS p
y P DISTRICT GROUP TYPE -FIRE P ESSE�BY V
permif is.issued,I sho��not emplay ony per5on in any monnar qDDRE55 (iR(U CONST. ZONE
� so as�o become subjed to the Workers'Compenwtion Laws. �+� � �-� �� i`/ �
Oa�e Applican� air �..�[- zio QpY(�jZ O
� STAT1571CAL QASSIFICATION APf. CONDO.
NODCE TO APPLICANT: If, after moking ihis Cenificafe o1 /+RCNitECT OR TE�� � �
ENGINEER NO.'�I� CtA55 N� DWELL.UNITS�_
Ezemption, yau should become su6ject ro the Workers' N
Compensotion provisions o4 the Labor Code,you must forth- aDORE55 SEWER MAP ?
ith mmply with such provisians or ihia permit sholl be �pi. / BK. �, VALIDATION
deemed revoked. �pNTRACTOR L�C NQ. -
LICENSED CONTRAQOItS DEQARAT�ON �( d t
1 hereby aSSirm thot 1 am licensed under provisions of Chopter 9 ADDRESS��'J �'�� �O.� f� VALUATiON �/{ •
�commencing wilh$edion7l)00)of Division 3 of ihe Business ond IC Q�/ E ���4���
Professions Code,ond my li<ense is in fuU forte pnd effect, Q7Y CLASS F-/
y�tn /�Y1 � $p FT�L NO.OF NO.OF CHECK
License Num,b/�er ^�`����v Lic.Class��,L_L_ SiZE V��70 STORiES FAMiUES ONE ,
�(JA,J ���,�� �� � �ESCRIPTIOfJOF WORK ' NEW � 5 .
ConlmctorLl.�JI 9ote ADD �
� I am eze�npt from the licensing requiremenls os l am o ALTER F�NAL L� �
licensad architea or a regisiered prafessianal engineer DATE `� �/��
octing in my professional mpaciry (Section 7051, REPAIk � . -
Business ond Profeesians Code). USE OF FINAI //'
Ex�Siit�GB�OG. �/' . o�M�� � � sy., . '��.�'-"�� �
Lic.or Reg.No. Date APP�iCAN TEL �
� � OWNER-BUILDER DECCARATfON� ��- � � - - .'PRiNi� - o. V
I hereby affirm thal I am exempt from tha Contrador'e License _p�� � �' ���.r�?�r �����- � � �� �"fals
Law for the following reason(Section)031.5,Business and� / �
Professio�s Code): . �_. � vKeser�e- -- -. .-.....--� . . � � �
og�,�o�ti� , _ � ,�� ,
�i, os owner of the propeny. or my employees wifh ADD - i-[� � . F�`�� �
wages as their sok mmpensation,will do rhe work and .
Ifie structure Is not iniended or ofiered for sole ISectian iOCnUiY w . t
TEL. , R
7044,Business and Professions Code). MOVING �
� I,os owner of the pioperty,om excVusivafy coniraUing CONiRACTOR NO. � e�.{;:c r
wilh lirensed coniracfors fo conslrucl ihe p�oject(Sec- qDDRE55 �
tion 7044.B�siness and Professions Code). � , - � -�
REQU�RED yqRD HWY T�TAL SEIBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SEt BAC� PROP.unlE WiDTH
1 hereby offirm Ihat there is a construction lending ageocy for FROY7 ..i:i:F'`. �
the performonce of the work for which tFiis permil is issued P.�. ,
(Sec 3097,Civ.C.). SIDE '
P.l.
lender's Nome �/ � �
g � ' P.0 Fee$ �� Z� Permii Fee ��7' OO - ' . �
� Lender's Address �� - � '
W I cerrify that I have read this dppiimtion ond slote that Ihe Isso e Fee �/
" above informaiian is cortecr.I agree to comply wilh all County Invesnga�ion Fee � anc � Q
$ ordinonces ond Slale�ows reloting�o building mnstruction, Toral Fee — .
and hereby outhori represe otives of fhis Counly to enter
mupon above-m lioned erty far inspett,ion!putposes. ._ �
y . �T_!-Q � SEE NEVERSE FOR EXPIANATORY UNGUAGE '
_f_��
^ $ignalure of Appl��wnt or Agem Da+e
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