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
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