HomeMy WebLinkAbout1588A 1589A . . ....___
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WORKERS'COMPENSATION UECIARATION � " - � � �
I he.�eby a,{firm thal I have a certifim�e of consenf to self APPLICATION FOR .BUILDtNG� PERMIT
insure,or o'�er�i4icate of Workers'Compensaiion Insurance,
or a�certified copy thereof(Sec.3800,Lob.C.) � ��""� � - -�-�-� - � �- ���
_ _. _.__.... .... .._.
COUNTY OF LOS ANGELES BUILDINCe AND SAfETY
Po❑li[y No. Compony BUILDING � i� �
Gertified mpy is hereby fumished. FOR APPLICANT TO FILI IN ADDRESS C .�.CJ
� Certified topy is filed with fhe county building inspec- gUILDING ,� l
iion deporimaM. � � � ADDRE55 - � � ��1.1/�c�
., . .. . . L ... . .. . ...... � .. '� .,'I � . . . .
Do1e Applicant � CITY ,i zIP �OCALITY ��UCZ-L�(.T �
CERTIflCATE OF EXEMPI'fON fROM WORKER$' NO.OF BtDGS. NEARESL.._.___.- . ._. _. . .__.. . -.. .
� � � COMPENSATION INSUf2ANCE� � � S�ZE OF LOT NOW ON LOT CRO55 5T.
(This sec�ion need not ba complefed if�he permit is for one �"`�R
hondred dollprs(j100)or leu.) TRAQ� B�OCK LOT NO. �App gppK p,qGE PqR(FL
L o (sT. ,��. ��ZONE �,P 3 3
� r . }
I cerfify thal in�he performance of�he work for which�this awt�ER N . �� _ �
permil is issued,1 sha�l noi empioy ony person in any manner �/ �! �-SaECIAI � - -� - � �- � -- � �
so as fo 6ecome sobject io the Workers'Compensatiori tows. ADDRE55 p� ,L�L(. V� CON�ITIONS v
j '_ c�rr� U.7 L. T zir m
Dote�Applicanl ��°LL/ 0
i NOTI E TO APPLICANT: 1f;afler making is CeRific6ta of ARCHITECT OR ht� DISTRICT GRouP TYPE FIRE SSED 8Y .�
ENGINEER �� CONy�! � ZpNE �
Exemption, you should become subject to �the Workers' r'� 7 W
i Compensntion provisions of rhe Lobor Code,you musr forth- A�R� �. ��' ✓/ . d
wifh comply with such provisions or this permit sfiall be - y
� deemed re�oked. - )TE�� � _ STATISTICAL CUSSIFiCAT10N AVT. COf�100. Z
. CANTRACTOR NO. . . ..
IICENSED CONTRACiORS DECtARATIOM � � �C p�, _ CLASS NU.��DwEU,UNITS �
1 hereby offirm thaf 1 om licensed under provisioas of Chapier 9 ADDRE55 3� .� �..0 �- S{WER MAP � �
(commancing with Secfion 7000)of Division 3 of the Business and . ���_ �
Professions COde,and my license is in fuli fo¢e ond effM. C7?Y CIASS G�'r � � � VALIOA710N
p C-� Xi.R. NO.OF NO.OF CMECK � � � � � �
LicenseNumbar�-7�33(1 .Lf�,Closs ���J SIZE SiDR1E5 FAMILIES ONE yA�UATION /�/.,./� �
'�IY�IV._... ......._ . . _ . ..
C❑ontractor ' C Oate�- ��IPfION OF WORK - A� ' ; J ► . � -
I am exampt under Sec. s „ � �^ r -
ALTER � q� = .
B.BP.C.for this reoson . i REPAIR � ;
USE pF �, a s �,�
Dafe: E%ISTING&DG. UEMOI ❑ . . '
�- Signoturo APPLICANT TE�. FINAI / G j • "%" `'�,��.
. �.
OWNER-BUILDER DECIARATION ��M �" OATE *- p �
lherebYaff'xmlhaFlamexempF#romtheConir«toisLicense ADDRESS ._..........���.... . FINAL . e . �.�.:��
� f.S
law fOr fhe following reason(Section 7031.5,8usiness ond
Profess�oro Code): . . . .. . . . vae-rm By- , ii._,�,c_r.;i
� I, oa ownar of tha properry, or my employees with nUooeE5�5 � - �
wages os thair sole aompensation,will do ehe work ond , `���� {��������
the shuctura is not intandad or offered for sale(Section ����TM �
7044,8usiness aad P�ofessions Coda). � - naOv�taG TK_ � . '�• ' '' ' � �
� I,as owner of{he propeny,am exdvsively coniratting ��T�'�� �' C .
wifh licensed coMractore to conetrvct the projact{Sec- - . � " '-f����
tion 7044,Buainese and Drofeuions Code�. nDoae55 T
REqUIRED TO7AL SETnACK F20M E%I T. �• ` . ,. , ::�+
CONSTRUCTION IENDING AGfNCY ��-- SET BAIX VARD HWY pppP.LINE WiDTH
I hereby offirm that�here is o constr�aion lending oge�cy for fRONi � " '� '- '<t
�i,�.,::.-t:.,.
fhe performanm of the work For wMth lhis permit is issued P.L � - � �
(Sac.3097,Civ.C.). � SIDE �
g P.L.
= Lander'a Name �7,�- /� IDMq Ref.M ; � ��
$ P.4 Fee S �^-7���v Permit Fee . . . , .-. ...... ... .
- Lender's Address ' �
I terlify thot I have reod this.applicotion.and state that 1he tuoan�e Fee �, LDMA P/C M � - - � - �� .�
� above infarta�ion is corcect.I agree to comply with all Gounty In�es��pi�on Fee �-.
��,g ordinancea and S�ota laws relating to 6uilding consMuclion, Towl Fee �•�`� toMq Pa�m.M �- � � �
and hereby o��horize reprezenratives of this County to ante�
� uppn ihe obova-mentioned property for inspetfion purposes. , .
'a �J�1OT/�j7��� �'-3� �0 S SEF REVERSE FOR EX�LANATORY LANGUAGf
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