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 .
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