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HomeMy WebLinkAbout1701 /oja3/�f/ 4 . WORKERS'COMPENSATION DECLARqTION - .� �� � I hereby affirm that I have a certificme of consen�to s��f APPLICATlON FOR �UILD1�11t�G� PERMIT insure,or a cerlifimte of Workers'Companstion Insurance,or � a cerrified copy thereof(Sec.3800,1a6.C.) COUNTY OP LOS ANGELES BUILDING AND SAfETY - ' PolityNo. � Company � - � � Cenified co is hereb furnished. BUIl01NG. �7/�� C /v�'�R p ❑ PY Y FOR APPLICANT TO FILL IN nooee5s oC G'• � � Certified copy is filed with ihe county 4uilding inspac- BUILDING y . � /��/�, . lion deparimeM. � AboRE55�f�a � ��M � . tOCALITV vy!r�- - Date Applicant � CRY � �I�V ZIP � CROSSST. f7� � � CERTIFICA7f OF EXEMPTION FROM WORKERS' NO.OF BLDGS. n55E550R � - COMPENSATION INSURANCE �� SIZE OF LOT NOW ON LOT MAP BOON PAGE PARCEL (This seclion need no1 be completed if the permil is fo�one � USE ZO MAP hundred dollors(E100)or less.) � iRACT BLpCK lOT NO. � NO. Y TEL. GJ SPECIA y OWNER� f�!' CONDITIONS I certify thot in ihe performance of the work for which this d permit is issued,I shall not employ any person in any manner OISTRIC7 GR$�UP TVPE ' FIRE PROCESSED BY (� so as to b ome su6jett to the Worke s'Compensation Laws. ADORE55 • � //� CONST. � ZOf� O p l�� /+ /f Dale L a A limm /�N y �� Ciiv dir� z�v ��� 3 a PP s ` ARCHiTECi OR TE� STATISTICAL CLASSIFICATION AP7. CONDO. NOTI TO PPLICANT: If, afrer making this Certificute of � � w Exemption, yoV ShoV�d �]e[Ome SubjeCt lo Ihe WOrkers' ENGINEER NO. CLA55 NO. DWELt.UN�TS d H Campensotion provisions of fhe La6or Code,you musf forth- ADDRESS � SEWER MAP � � with comply with such provisions or ihis permil sholl he � deemed revoked. CONTRnCTOR! ;,d w,�od Tnip BK. eG, VALIDATION LICENSED CONTRACTORS DECLARATION i�� � ' I hereby affirm ihal I am licensed unde�provisions of Chapter 9 n�DRE55 �/y1.49d NO � yq�UATI N (commencing with Se[tion 7000)of Division 3 04 ihe Business and ��f��u � ��� �� Professions Code,and my license is in full forca and effect Uiv'�jT NM CLASS Q� s Q� 3987�Z � S�.fT. NO.OF NO OF CHECK LicenseNumber Lic.Class � SIZE STORIES FAMt�lES ONE , Con�ta[lor w��✓�00 w���j'O1e ��Z.L� / DESCRIPTIDN Of WORK ' N -y� NEW $ OA�D I am exempl from ihe licens�ng requirements as I am o -��" litensed architect or a registered professional engineer • ALTER � FlMAL � , octing in my professional capacity (Section 7051, REPAIR � DATE _ . Business ond Professions Code). USE OF fINAI � E%ISTING BLDG. OEMOL � e Li[.or Reg.NO. Da1e APPLICANT ,y� TEL Y OWNER-BUILDERDECLARATION � vRiNT) 'r //J/j • NO.$� �! 11��0/ � i hereby affirm thot I om exempl from fhe Conirocior's License v fL law for the foilowing reason�Sec�ion 7037.5, 8usiness and � p�55�� �I�✓� �± ahL.+� �y/�,�/�� Professions Code): vktxNi ❑ BVILDING 1, as owner of Ihe property, or my employees wilh ADDRESS wages as�heir sole compensation,will do the work and Ihe siructore is not intended or offered for sale(Section ��A��T� 7044,Business and Professions Code). MOVING TEL. . � I,ps awner of the property,am exclusively roNracting CONTRACTOR NO. with licensed coniractors to consirud Ihe projeU(Ser ADDRESS � lion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY �a1�RED YARD HWY 70TAL SETBACK FROM EXIST. SET BACK PROP.tINE WI�TH I hereby offirm Ihat Ihere is a construction lending agency for pgONT . - ihe performance of fhe work for which ihis permil is issued P.L. (Sec.3097,Civ.C.}. SIDE P_L. Lender's Name $ Lender's Address P.0 Fee 8 � Permli Fee _ ' W i cenify that I have reod this applica�ion and state�haf the iss� ce Fee � Qabove information�s correct.I agree to romply with all Coumy imesugano�Fee ordinances and Slate laws relating 10 6uilding conslrudion, � Toial Fee m and hereby auWorize representatives of this County to enrer . . � upon the ab /e-mentioned � riy for inspection purposes. � � /�� a 7`��.�f SEE REVERSE FOR EXPLANA70RY LANGUAGE . � qnorure of�a pp�;�a r Aqem �a�e �� � � � c T = � .� � p � O A r N W a O C. O S n � � � �^ o N m m n m � '° Q „ � Q %° a a 3 a � o • fN fl�� � r � p Q j D'O � � O �.�a.p � �O , j m fG M �4 � O p 6 O„ 00 y i0 � m 00 � r 77 � � T � � ro 9 � 1 q � ��' �� z � C . 3 .� � � � Q N o N v .� • � �Z % c�£ N N a N �> > � ' .� � ' -03 � � � = � m � 4 T 0 a �o = m� I ' . 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