HomeMy WebLinkAbout1815A 1961A (10) WORKERS'COMPENSATION DECLARATION � -_...
I hereby affirm that i have a certifimte of consenl to self A P P L I CAT I O�N �FO R B U i L D I N G P E RMIT �
insure,or a certifimte of Workers'Compensation Insorance, _ _
or a certitied copy thereof(Sec.3800,Lab.C.)
,/� COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑CYN�om�nY s��� ��r J . ... _
Certifed copy is he�eby furnished. FOR APPLICANT TO PILL IN ADDRESS � � c<.S
� Certified copy is filed wilh ihe county building inspec- BUILDING �j �
tion deparlmeM. ADDRE55 � .•_ �" ,,,5' LOCALI7Y
�� NEAREST
�ate��Applicant `�.��' CIiV ZIP CRO5557.
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�GS. .a55E550R
COMPENSATION INSURANCE SIZE OF l0T NOW ON'LOT MAP BOOK PAGE PARCEL
(This section need nol 6e completed if the permif is for one USE Z NE MAP � I�5
hundred ao��afs($100)O��es5.) TRACT ` QQ BLOCK' LOT N�. � �� NO. � �1 �
7EL. - ' SPECIAL
I tertif thaf in ihe erformance of the work for which ihis OWNER L NO. �t� ).p" � CONDITIONS -,"-,��
Y P . . DISTRICT GROUP TYPE FIRE PROCESSE�8V
permit is issued,I shall not employ any person in any manner � CONST. ZONE '-�
so as to become sub"ect w the Workers'Com ensarion Laws. .4002ESs ; _
I p -' �rj (.0 �y� :-�
CITY " ZIP, l� `-9
Dafe Applicant S7ATISTICAL ClAS51`ICATION AP7. CONoO. .�
NOTICE TO APPLICANT: If, pfter making this Certifiwte of ARCHiTECT OR TEI. , . /�n,
Exemp}ion, you should be[ome subject to ihe Workers' ENGINEER NO. CLA55 NO.�DWEIL.UNITS "�
:�
Compensa�ion provisions of fhe Labor Code,you must forih- qDDRE55 SEWER MAP � �'
with comply with such provisions or this permit shall be TE� `
deemed revoked. CONTRACTOR NO. �-� gK� �. VALIDATION
LICENSED CONTRACTORS DECLARATION LIC. �
I hereby affirm thaf I am licensed under provisions of Chapier 9 ADDRE55 � i /ir Q G1�-�,� NO. t7 39 VALUATION
(commencing with Section 700D)of DivisiorY 3 of ihe Business and �i�, /� 'r�l �'� �.; F p
Professions Code,and my license is in full force and effect. GTY C1A55�C,,,) 5 }
is Sq.FT._ '� NO.OF NO.OF CHECK , +�.y 5�H�6
Lic0n5E Number 7���� Lic.Class � S�ZE p STORIES FAMILIES ONE
�y NEW � S
CoMracror�G��'"1 (ifTlC.��Date�"� DESCRIP710N OF WORK
AOD �
�I am exempt under Sec. • �
ALTER FINAL �
� DATE y `, �
B.&P.C.for ihis reason REPAIR ' � �z
Date: USE OF DEMOL ❑ FINAL e'e e!J.U v�;
EXISTING BLDG.
Signafure P.PPLICANT TEL. gY �1 �5 r 1 —F!�
OWNER-BUILDER DECLARATION PRINT) /JRf -i NO. ^�'/ '
1 hereby affirm that I am exempt from the Coniractor's License ,,�1
Law for ihe following reason(Section 7031.5, Business and ADDRE55 /�rh'.�r l�d�
Professions Code): v
❑ BUILDING
I, as owner of the property, or my employees with ADDRE55
wages as iheir sole compensation,will do fhe work and �� i 9 6.1 A
ihe siructure is not inrended or offered for sale(Section LOCAUTv
7044,Business and Professions Code). MOVING TEI. 'f"!¢ c �. � c 1
� I,as owner of Ihe property,am exclusively ton}racting COMRACTOR NO. I m "v G
with licensed contractors to<onsiruct the projact(Sec- qDDRESS
tion 7044,Business ond Professions Code). r�^�x
REQUIRED TOTAL SETBAIX FROM E%IST. ° � �C.:�v v c_
CONSTRUCTION LENOING AGENCY SE7 BACK YARD HWV pROP.LINE WI�TH
I hereby affirm that there is a conatruction lending agency for FRONT , �����`G�L
ihe performance of ihe work for which ihis permil is issued P.L.
(Se<.3097,Civ.C.J.. , , ' . SIDE ' - � � � � �
P.L.
$m Lender's Name - �
/
lender's Address P.G Fee$ +�✓'� Perm�ir Fea �� �v
� 1 certify that 1 hove read this application and state�hat the Issoan<e Fee ���
a above information is correct.I agree to comply with all County Investigation Fee
$ ordinances and State lows relaring to building construction, 7otol Fee ��✓�
and hereby authorize representatives of this County to enter
� upon ihe abave-mention propeNy for inspection purposes. � �
^ � �yµ.�� a:�—��f�.'>fJ SEE REVERSE FOR EXPLANATORY LANGUAGE
�IL7I
Signarure of Applimnt or Agen1 Dare �s
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}'Lia�Zi)A�i6.P.�_�,7LtCRNT � INSPECTOR'S 6YOSES - �� r`i��eTo.TJ€�i�'d9Pp D}�'7 e��2A'fI0'ti _
Y�'�"''�`���rs��� . . --,- ..I here5/o$r�m.Shat I cm c err- from t7:,=Cor-raCrcr s
� - . �.„. .- . _..._ _.._ . _-�
� . �cR�atRwd� � r4�� ��,���m���- T---` License :qw tor ihe�tollouving eason. (Sec 7031.5)
- 0'� !''+ �� tiac.��arar..a.e rcjc.,....^,.:s.,ode:F;=yce5yor:or:r.e,�u•�:e'n
���P7n.` -..�c`SaPe�� -�:l'c�. � �e�?s \ ;,zrsi:a;u b ..<. io oo;as!r::C;a.ter,zvranrac;c;ar molisl,
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_ __ � ��� ��-�- Sh-¢�n uz: f -cSI,^.crmx:8^fi. ta yqned st<tcenesvt
. .. ! �7 . . ,- -t< � ��n� d p .:.rar.t.o tlie pro..ss.xx ef zh:Cor.'
• :. � ...�-l',.yL.C/�-C7'+'V. ~ y ira�e�r's d,xcaf:so i,uu�(Cr`:a'J�c:9l r'cnrxmenedaag ecdti;Src'
— � �y � � ---- tin:�'LL'OJ f Di:vaenva 3 r f t'r.c Husia:ess d�sd�Profe;xinns
,�_T�__��� � �� ��(1�__ _ Cc«c(oa�!hat ne rs e.re.:.pi tSerefrnm aitd tl�e`5aszsjnr t�a
/� x:.�� r �r5 �at a� .>f� �n 70 1 S hy
A e�.m!s _ Amyuir�cS pa#c @ecoivad � �� ;y��,� + �. ar�° rs �� s�7..� •;_ chbt'r�at n¢ s�il
4'w" or AFproved �;---- .�-"`.�"=_-_-_____.__ j. t .�-;en �r F a s �ur' �dollur�,��$OQ)�:
�-_-_ _. _ �a _..-- ,
�c __. ,es ow,e .,-:tie propeNy,or ny emplo�ees,w,ih
I Wator Ceriirimr= I� g - --- �� �wayes as their so!m cr.mpensetion,wii!dc the v✓ork,ond
�------ � .n•r.s;vc�iire;s noi-inl�nu�ad or c'�fered ior;ate(Sec.704d'�
'Hea!?h Deporimervt '� - ' _ � - _--_._____—__ ;yis;r:.r;;s u:„-;a'se,°esaror.�Cce:'r i;�a Cr,r.'rac:r�.Lice:^:sc
--�----- :'.cu:Cn:::r.o::j:t;ly to an,cs�rer.g'pr.:pr::t��u:bn'seei'ds
. �, i Fir�rtn�n! . ---.- , ,r�,so.�ar t$vre<;n;a::d;c.�c 8oal.sr%cb i:rcrk,F,i:fssclf nr
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�Greding I �' provevre"idTs �re a:c.t�d:ztssdc.'��nr ayemz';er 's&?s. ij,
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Thr�.with iicenx:�d<o�9;cc:ors to cansrruct;ha�rojec;(.iec.
Soecial inspc_tiori 7.'o;:c„rsinea::.;r�:f_?r;r,`_c=ss;ans Gmde:%'!�_Coal.rctor':
jCenc.}(hheeonr;�)(vVeldir.g)I . . . . .._ r�:rense;,cF:,•Ficz.;;•, r.,ar,^;:,�e,a;'irrrter3�ec��a
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