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HomeMy WebLinkAbout1471A 2332A (8) WORKERS'COMPENSATION DECLARATION � I hereby affirm ihat I have a certificate of consent to self qpp`ICATION FOR BUILDING PERMIT insure,or a rertifimte of Workers'[ompensation Insurance, or a certified copy thereof(Sea 3800,Lab.C.) � COUNTY OF LOS ANGELES BUIIDING AND SAFETY PoliryNo.RAFi7L�5�7 Company FAT42is(iI�IT euitoiN;, � Ce�tified copy rs he�e6y.furnished. F6R APPLICANT TO FILL IN nooaess � � Certified copy is filed with�he t ty boil n ' spec- BUILDING 1633 I�erringer Lane ���� fion parim nt. ADDRESS IOLALITV NEAREST Date "� ` Appliconl CITY ZIP CRO5557. RTIFIC E OF EXEMPTI F OM WORKERS' �� NO.OF BlDGS. ASSESSOR � COMPENSATIO INS RANCE - 'SlZE OF l0T NOW ON L07 1 MAP BOOK PAGE PARCEL (This seciion need not be com ed if ihe permit is for one 24046 C USE ZONE MAP hundred dollars($t00)or less.) TrzncT siocK �oT No. � �J� rvo. /D�`.�5�� TEL. SPECIAL � �_ I certify fhat in the performance of th work for which ihis OWNER ` NO. �FTG'�€7 CONDI710N5 ' i4.. permih is issued,I shall not employ ony erson in manner DISTRICT GROUP TYPE fIRE PROCESSED B� � so as ta become subject to ihe Work 'Comp s on Laws. ADDRE55 CONST. ZONE �•� l� �� � � Dote__-��-Applicant `� CITY ZIP STATISTICALCL4551FICATION APT. CONDO. � NOTICE PLC NT: If, afrer aking this Certificate of ARChiiTECTOR TEL- ,.y � ., Exempfion, you should e subject fo ihe Workers' ENGINEER NO. CW55 NO._�DWELL.UNITS_ �! Compensation provisions o the bor Code,you must forth- AODRE55 SEWER MAP ' '�� with comply with such pr " ns or this permit shall be x deemed revoked. COMRACTOR P1L��t`I�vT No. 594-261 gK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. � I hereby offirm ihat I am licensed under provisions of Chapter 9 AD�RESS NO. VALUATION (mmmen[ing with$ection 700D)of Division 3 of ihe Business and ' lIC C'�je��n Professions Code,and my license is in full force ond effxt. CiTV Diamond Ear CLASS �-1 S�-� , 283724 �-� SQ F1. NO OF NO.OF 1 CHECK 1 i 4 7.1 A License NVmber Lic.Closs SIZE STORIES FAMILIES ONE Contracror PTF.P?•TART�7T Date 7��4 DESCRIPTION OF WORK�C! t ,8 7-/i NEW � $ tj o 0 0 •2�j �I am exampi�ndei$ec. ACICIlt1011^ AD� � . � � i 9 1.2 5 ALTER � FINAL �^� ry a e i �1 L G`J ti B.&P.C.for ihis eason � GrlC,>T iPt�n,r� REPAiR DATE S I J q pP1e:T use oF � �v� 0 2� 0^8 4 /� EXISTING BIDG. DEMOL ❑ ��N��"� ��: Signature U APPLICANT i TEL. - ER-BU l.DER DECLARATION PR�NT ''��Il NO. , - ► �� + I hereby off' at I om exempt from fhe Contractar's License Law for 4 lawing reason(Section 7031.5,Busingss ond �+�DRE55 Professi ns de): PRE ENT � �' � - _ ❑ BUILDING �_i J J,G�', I, as owner o4 the property, or my employees with AD�RE55 wages as their sole compensation,will do the work and `o� T rj o u s c e j the siruct�re is not intended or offered for sale(Section 7044,Business ond Professions Code). MOVING tEL. � ( ��'',�.�.�U � I,as owne�of ihe properry,om exdusively mntrading CONTRAQOR NO. � with litensed tonlrattore to tonstruct the projea(Sec- .. ..-,:;;2i tion 7044,Business and Professions Code). /+ookE55 � REQUIRED TOTAL SETBACK fROM EKIST. C.�).G G`H L� CONSTRUCTION LENDING AGENCY �ET gq�K YARO HWV PROp.��NE WiDTH � I hereby affirm ihat there is a mnstrudion lending agency for FROM � ihe performance of fhe work for which this permit is issued p.L. (Sec.3097,Civ.C.). SIDE - P.l. Lender's Name / �/ / . $ P.C.Fee$ /�I' � J Permir Fee ��J+ � Lender's Address � I certify that I have read this appiicaiion and state that the Issu ce Fee C..S� above inf rmation is mrrect.I agree to comply with all Counry InvesHgorion Fee � ordinan and Sfate laws relating to building construciion, 7orol Fee o7,�,�"�.�C dnd by aufho'z prasentalives of this Coonty fo enter m u n t e abo�e- oned property for inspeclion purposes. � "- — -- ' � ---`� � � - � - a 7�R�R(F SEE REVERSE FOR E7(PLANATORY LANGUAGE � 9gno�ure of Applimnt or Agane Do�e ' �s _ �_.�_,___�_�___-__ � �,�._�. . ;. .� '-�'� ��.�._� pla:��c e6��Yv � � is�-�s: ���,.�3 � � �rE�rv � e����. �ci,��a '�,otv . - . .:� �v � �- �6..+...�-.+..�,•.a;�w.ii�e.r.r.=.�+=..e�-.,m � ��,�� � I. F c�rl a�Mi t arn srey�l{r re� he Con7��cor's gm; - . P£p�Q���, j -- iiie 3.. fp� thc.to o�s ng recso. (S 7���1 51 rA99;ar¢s! ' --..=e _ _____ ,?ee s e �` . � .r 33 0 �.r u i b �n.� s c 1 �'Yin. -.D^�rw � . 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