HomeMy WebLinkAbout0707A 0786A WORKERS'COMPENSATION DECLARATION � . �I
insureborafclertifiwtelafWorkerseCompen�lonlnsurancesalf ,�pPLICATION FOR BUILDI�NG PERMIT LS
a certified mpy thereof(Sec.3800,lab.C.) ' COUNTY OF LOS ANGELES BUIL�ING AND SAPETY
PolicyNo. Company
❑ BUILDING � �
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AD�RESS l .� .f/
❑ Certified copy is filed with the county building inspec- gUILDING
, tion deparimenL � � ADDRESS ✓��(j..�/�9r»dx��A/'�` ' iocnSrv �/iP-vrt �.� .
� � - ,� �J NEARES7
Date Applicpnt CITY,_,_,// pjp /J.S�/' ZIP CROSS ST. ��9'�Ti' "
CERTIFICATE OF EXf.MPTION FROM WORKERS' NO.OF BLDGS. .a5SE550R
COMPENSATION INSURANCE - SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
� (This section need noi be completed if the permit is for one u5e zoNe MAP
h��d�ed douors(S�ao)or less.� rencr a�ocK �or No No ,.,.
TEL. SPECIAL �}�,,,
I cerlify Ihat in fhe performon<e of Ihe work for which fhis OWNFR ���/f � NO. CONDITIONS �j
ermit is issued,I shall no}em lo an erson in an manner DISTRICT GROUP TYPE FIRE PROCESSED BY tJ
P P Y Y P Y AUDRE55 CONS�"� .ZANE- ��
so as to become subjec�fo the Workers'Compensation Lows. : �
��;� ,i� �'..� /,!/, •k-�-� �
Date /l%Applicanf��'_ / CITY ZIP STATI51'ICALCLASSIFICATION APT. CONDO- �
NOTICE T AP LICAN7� If, after making this Ce tifitate of ENG NEERT OR NO � sj
Exemption, you should betome subjeci fo the Workers' CLA55 NU. .-� .�` DWELL UNITS_ ��
Compensation pravisions of Iho Lnbor Code,you must forfh- i
ifh comply wilh s�ch provisions or this permit shall be �nURESS ; ,� SEWf�R MAP �=
deemed revoked. � TE�� -' ,VAUDATION
CONTRl�CTOR ��,_ NO. I I V )`f�h�� BK. PG,
LICENSED CONTRACTCRS QECLARATIOiJ tIC. � �C'�b,'7� �
I hereby affirm�hat I om Ilcensed under provisinns of Chapter 9 �D�RESS - NO. ypLUATION
(commencing with Section 7000)of Division 3 of�he.8usiness ond LIC. ;�Er % �m 8 �L 3
ProFessions Code,and my license Is in full force and efFect. GTY CLASS � ��,J� �l� .
� SQ FTy/ NO.OF / NO.OF CHECK J 8 9�n�n
LiCense Number Li[.Class SRE/,_7� 510RIE5 ! FAMILIES ONE � V. 1;
Coniractor Date DF.SCRIVTION OF WORK NEW � � m�s s�j��,�5���
+❑ .1 . AOD
I am exempt from the licensing reqoirements as I am a / N r!J/ h' qLTER O FINAL /y �y f �'' ���,
licensed architecf or a regislered profes5ional engineer � DATE /oK �� q
acting in my professional capacity (Secfion 7051, � �
Business and Professions Code). u5e OF /� REPniR
EXISTING6LDG. !"gI� .S�i�«�� DEMOL � FINAL . �
Lic.or Reg.Na. Date APPLICAN7���J ,1 ��y.� „""`� 7EL. BYt--" ry
� OWNER-BUILDERDECLARATION (PRINi)EC[1L�(flY! /�!� /P/ry�V(J N0.7�N7�U`�yaj
I hereby affirm�hat I am exemot from the Con±ractoi s License /
Low for ihe fallowing reason(Section 7031.5, Business and ao0RE55 � ��s.� �C�'�C�v't�i���!�J1. s� �' ��f• �
Professions Code�: PRE ENT
� BUIL�ING _._ ... .___ , �(1�]�(]A
I, as owner of the property, or my employees with A�DRfS$
waya;os Il�iei�aoie compensarion,wiii do ihe work and .
ihe siructure is not intended or offered for sale(Section LOCauiY �.o a r,:a • �
.:7044,Business ond Rofessions Code). - MOVWG TFL �
O'�,I,as owner of the property,am exdusively mniracting CONTRACTOR - No. � • 1 Q 9,5 0
with li<ensed conirocrors to construd Ihe project(Sec- pD�kE55 m'�o � (��'j,���
tion 7044.Business nnd Professions Code). � .
RE(;UIREO T07AL SFT6ACK FROM EXIST_ ��
CONSTRUCTION IFNDING AGENCY 5[T RACK YARD HWY vROP.I.INt WIDT41 � ' � I ��L�"H.�I
I hereby affirm Ihot fhere is a mnsiruction lending agency for FkONI . .
the performance of ihe work for which�hls penni�is lssued p_�
(Sec 3U97,Civ.C.). � Sioe - � �
r.i
Lender's Narne
lendar's Address_ .. _._ P.C,Fr.c S ����'�. u���� Per nii Fea f C���• L���
I cerlify ihat I have read Ihis applicolion and state thot the � issu ce Fee �.:.i �) �
abave informafion is r.orrect.I agree to cornply with all County invest�i9m�ion Fze - a �
ordlnonces and Stale laws rel�ting to building construction, imol Fae �(,� ��7
and herekiy outhorize represenintives of.this County to enter .
upon pbore��rnentioned properly for inspedion purposes. � _
r� . SEE REVERSE i08 EXPLANATORV LANGUAGE �
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