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HomeMy WebLinkAbout1296A 2077A 2078A wvKK[kS COMPENSATION DECLARATION � ,�j:�., I hereb affi�m iho�I have a certificote of conseni to seif �� � insure,oracertifiwteofWorkers'Compenstioninsurance,or� �PPLt�l�►TION FOR BUILDtNG PERMif � - a cerfified copy ihereof(Sec.3800,Lob� / �(Z � {� COUNTY OF!OS ANGELES 9UILDING AND SAFETY 'p_�� P�olicy Np,� ��Company ' CerNfied copy is hereby furnished. FOR APPLICANT TO fILL IN eunoir� ^ b�(/ A�DRE55 t7� 1 Lr � � Cerliiied copy is filed wilh the nty bu'Id" sper BUILDING � lion deparfineN. �C(� ADORESS � �� tOCAU7Y�i ��"�'ti� NEAREST n Date ��-i 3-�'! APPlican CIT CRO55 57. I�+..�RS... CERTIFICATE OF EXEMP710N fROM WORKERS' NO.OF eLOGS. ASSESSOR COMPENSATION INSURANCE SIZE Of LOT NOW ON LOT MA7 BOOK PAGE PARCEL �This seciion need nol be completed if ihe permit is(or ona USE ZONE MAP +.Z� hundred dollars j$100)�or 1ess.) TRACT BLOCK LOT NO. � NO. ✓ � TEl SPECIAL p�, I rerfify Ihal in ihe performance oi fhe work for which lhis � OwNER �•��NO. CqJDITIONS � ermif is issued,1 shall not em lo an erson in on monner q�RE� !9O�� � � . O p_� . DiSTRICI GROUP TYPE FiRE PROCESSED BV a P P V ���Y;;;PCCC��� Y ( (�O'.w•1raa4 r�'YY� CONST. ZONE so as to become subject 10 1he Wor '�mpensarion laws. . '}�� � �� � O �e APP�.�/�b Y� . CI7V �"^+'' Z�P S7ATR11CAL C1P.551FICAiiON AVT.� CON00. (~,J NOTICE TO APPLICANT: If, �dfler making ihis Certificate of ARCHITECTOR iEi. � � - w ENGWEER ND. C1A55 NO. DWELL.UNITS_� d Ezemption, you should become subject to the Workers' tA Compensofion provisions of Ihe Labor Code,you most forth- AD�RE55 SEWER MAP � � with comply wifh such provisions or this permit shail be T41 deemedrevoked. CONTRnC70R � s (,-( '� eK. �, VAtiDATfON LICENSE�CONTRACTORS DECIARATION C u �,��^� I hereby affirm ihat 1 om licensed undei p�o�isions of Chopler 9 ADDRES � ?.� �l�G`�� YACUAT�ON (commencing with Sectlon 7000)oi Division 3 of rhe Businessand /± � . Prafessions Code,-and my litense is in full force ond eHect. � CiiV � LL1A�1 CLaSS C'4� 5 �7j Sq.FT. NO.OF NO.Of CHECK Licens umbe � � [ic.C�ass � �� SIZE STORIES fAMILIES ONE �/ NEW 5 -/ CO ra[lo ` � Dafe ���` � �ESCRIPfION Of WORK � ' � am exempt fro licensing requiremants as I am a � �u(, ��• "Vd�°YL�- cj/(�l1}/DD � . licensed architecl or a regislered professfonal engineer , � ALTER � F�NAL z9_�/ a� '�[�h� octing in my professional capacity (Section 7051, R�pA�R DATE S - 8usiness and Professions Cade USE OF � �',� • • • �2� E%�STING BI�G. �1• DEMOL ❑ fINAI Li[,o/Reg.No. f APPLICANT '` TEL 6y .� ,•<.'� n y.�i OWNER-BUILDfR DEC AiION PRMT� ':- _' �� K{ NO � � ��� � � 1 � I(;c. I here6 affirm ihat I om exam t from nc�Connacror a Litense . r S '� ��� C • • � � law for the foilowing reoson(Section 7031.5.8�siness and /DoaESS `�.-'S�r''P 7 \�Y Z% J ��J�8/ ' Professions Codep 'esetii � 0(�� �—Q� ❑ 8 �L��NG I, as ownar of ihe properfy, or my employees with A RE55 ���7,7 e, wages as�heir so�e compensation,will do the work ond � n, - � L�ifqstl�`- � �� �x the structure is not in�ended or offered for sale(Senion w�r• , 7044,Business ond Professions Code). MOV7 7EL ` � I,os awner of fhe pmperty,am exclusively cortroUing CONTRA TOR NO. ��,• •y�.n�'i wRh licensed wn�rocrors to consrrucr the projec�(See- pDORe55 � • + • a�',O O� tion 70A4,Business and Professions Code). REOUIRED , TOTAl5ET6ACK FROM EXIS7. , CONSTRUCTION�ENDING AGENCY � SEt BaCK YARD HWV PROP.LINE WIDTH !������� 1 hereby offirm thot�here is a construcfion lending ogency fw fRONi . �he performance of the work for which�his permil is isvued P.t. (Sec.3097.Civ.C.�. SiDe � . P.L. Lender's Name � L ' r . cre j � �.—��^5 Lender's Address P.G Fee S Perm�t Fee v,-� - p0 p C�.' • o I certify�hat I have read this applicoiion and sia�e ihat the issuanro Fee O ,ylU1• � above in rn ian is correct.I agree fo[omply wilh pll Cou�ry Invesiiga�io�Fee - J �v �.�• ordin ces an State laws reloting to building construUion, iotoi iee /� �,n�t ro . and ereby authorize pr sentatives of ihis Coumy to enter ��,�D up fhe bove- ed property fo�inspection pu�poses. � r,H . , � - �/'`�"'�/ SEE REYERSE FOR EEPLRMATORY IANGUAGE Signarurc of App' nr o�A9eni Dare - � - �9 � 3� o o a 5. � c o o N o 0 o Clv �,� G) 41 ]' x g o 0 �o �c 5- �? � � o- � �$ ' ;r o n � � � o � v o � �` O I �� I � K � p � O A � � ❑ N -. � � j- 7 �Z x �� ? -F �7 � �C � " �'Q fn. � � � m �' �3 A o o � N W � e � 3„', a� fl ° ti y � Ho� o - o � < co H� � � 3' o � � �m � a G oY o 'o m r; i o Q w o v �p ; 3 Q 'o C �' 7 H v� � n o m 0 O � O v O a � j � � � O n. � A\ 3 � - ti l 0 � � ` . � N N `�' O a a C � � � C � Z. a A � 6 Q O. 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