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HomeMy WebLinkAbout1025A 1026A (5) _ __ 4.„�: .w,.._- --., --.--,-� _ _ _ .. . {nsu�e,or a ce�ti'ta�e ot Worke�s'C ensation Insur self eD C TI.O N, .FO i� BU I LQ I NG P ERMIT � WORKERS'CQMPENSATION DECIARATION I here6y o� fha�aCv��artif%tPe of��en��an<e. . I��) ��.,,.._� .,;;,.. orok@��d o Lab.C.J � � °J ���" � U`Z—�G CQU,NiY QF.L9S.ANGElES BUILDING AND SAFETY PolicyNo. P Y . . . . .... .... auILOING � . � �5�. /' !�. � Certified mpy is hereby furnished. FOR.APPLICANT TO FILL IN nooRess �� � Certified[apy is filed wilh the county building inspec- ADDRE55 �b J 4� �-L5.5 G� C'.� LOCAUTY c�//�fl✓�g �/��� /Y• tion department. _ NEAREST �/'�'� �L /'�/a� �� arr i'� „ 1� ziP _Ross s d /� /<;/�/Z ✓ Dat Appiimnt a5S:S5 j�� NO.OF BiDGS. ,1� C TIFICATE OF EXEMPTION FROM WQRKERS' SiZE OF LOT�• NOW Oiv LOT MAP B OK' ��(Y+'�' PAGE PARCEL COMPENSATION INSURANCE � � 9 USE NE M.�P ) p ,/,/ (This section need no�be completed if ihe permit is for one 7RACT � S t✓ BLOCK �Oi NO. J� �(`��` N0. � (�4 ��Y'r hundred dollars($1001 or less.) . � � TE� SPECIAL � OWNER �LC? '�j., r�o- '•6',?4'l' �'"�•'"t� coNomows � I certify thaf in fhe perfqrmance of Ihe work for which this � DISTRICT GROUP TYPE FIRE PROCESSED BY � permil is issued,�shall not employ any person i�any manner qpDRE55 dZ�-• CONS� ZONE so os to 6ecome su6jed to ihe Workers Compensotion Lows. %� � ' � CIiV ZIP �,� DaYe' Appiicant - �� STAilSTICAL CLASSIFI TION AM. C DO. � NOTICE TO APPLICANi: If, ofrer moking this Certificate of ENG NEERr OR NO. CtA55 NO.�DWELL.UNITS 'u Exemption, you should became subjeU to the.Workers' �" Compensation provislons pf fhe Labor Code,you m�st forth- qDDRE55 SEWER MAP � with comply witb such�provisions or this permit shall he .� . TE� � �7 A T- VALiDATION deemed revoked. CONiRaQOR l�+./v,. / � rt�.� No. S�' �S� gK. �, LICENSED CONTRACTORS DECLARATION .�. uC. r 1 hereby affirm that I om litensed under provisions of Chapter 9 ADDRESS B �t� _ Ji� NOS-r�'"��3 VALUATION :�-� ��'L�� (commencing wilh Sedion 7000)of Divisio0 3 of ihe Business pnd �+ �p L�C. ` $ '�' �-� , v Professions Code,and my license is in full force and effect. CiTY O�ff�4'r C/i. U'155 I , i� o e � a L� ? /� S�Q.FT. N .OF NO.OF CHECK LicenSe Numberfs �� �� Lic.Clau 'J SIZE STORIES FAMIUES ONE $ �4u88 1'1'N* ���G�.Sl�/ Date � � � DESCRIPTION OF WORK NEW � � -- Confractor ADD � ` °`1..£r J�: �I am exempt�nder Sec. !f� � � AITER � FINAL 1'(.('(�-'�J 8.8P.C.for this reason y e-L�l``:3�G� � REPAIR � DATE �-z 3-L��i Date: USE OF p�Ot � FINAI EXIS7ING BLDG. By Si nature APMICANT � TEL. 9 ' PRINT` -�.NO. OWNER-BUILDER DECLARATION f�_,� I hereby affirm ihot I am exempr from ihe Contracror's License AD�R°55 �f) -' Law for the foilowing reoson(Sectlon 7031.5,Business ond �i� ` � ����6�' Professions Codej: E ENi ' � ;, c ry ❑ �BUIIDING � / s� �'`�� � � . I, as owner of the property, or my emp�oyees wiih ADDRE55 �/%C.+� wages as their sole compensation,will do ihe work and �1 i�-� �'��Q(: the strudure is not intended or offered for sale(Section IOCALITY f.l �� 7044,8usiness and Professions Code). MOVING TE�� / �C?������� c�� � QCONTRACTOR NO. /,,,,,..LL� �� e �. .���%':i�: I,as owner of ihe praperiy,om exclusively canfraaing ,�w••- with licensed contractors to construct the project(Seo- :����^� t':rS.!'v"�� Yion 7044,Business and%ofessions Code). ADDRE55 ///���j!(, � REOUIP.ED yqRD HWY 10TAL SETBACK FRGM EXIST '(,�(� CONSTRUCTION LENDING AGENCY Sei eaGx PROP.LWE wl�Tri r� �6�� I hereby affirm that there is a construction lending agency for FeoNi � p �'�''t'°� r � the performance of the work for which this ermit is issued P.�. ��v� O��„../t� (Sec.3097,Civ.C.J. P SIDE �}''�" `�� "� � P.L � � Lender's Name�b//�� G �J � S P.C.�eeS d-�D PermttFee ,J e�� � �%�S� - Lendei s Address � - �„� . ( � I certify ihat I have read this application and state thm the . � . i svance Pee �f1�' i '� � above informptioa is correcL I pgree to comply,with.pll County- . Inves�i9avon Fee,. . � ,(� � . ��� ordinances and Slate.laws relating�tobuilding construtfiori, � To�af Fee ��[7' �� �� � and hereby a�ihorize representatives of this County to eMer _ . � upon ihe above-menhoned property fo inspecfiod purposes. � � � :��.�� � � � �����. � � n �/1�:�������Gt �j. 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