HomeMy WebLinkAbout1725A �
WORKERS'COMPENSATION DECIARATiON �
;�s��ebo�a`�e,,f�a,eo°wokes,'�om'Pe�sa,o���s�:o��a` APPLICATION FOR 8�111LDING PERMIT �
or o certif�ed copy thereof(Seo 3800,lab.C.) � ' COUNTY OF LOS ANGELES... ' . BUILDING AND SAFETY � -
I_ j
P❑olicyNa. 4?6 CompanyS7R��H/ BUIIDING � r
Certiiied copy is hereby furnished. FOR APPLICANT TO FILL IN - aooaess 3'Q ��G/
� Certified capy is filed wilh the taunty building inspeo- ' BUIIDMG �
tion department. � ADDRE55 �' T�n'ldK LOG4LITY�� ^a�V�
q NEAREST
Date Applicanl CITY � � Or Zlv 6 CROSSST. ' �d'�L
CERTIFICATE OF EXEMPTION FROM WORKERS � NO.OF BLDGS. ASSESSOR � �
. . COMPENSATION INSURANCE . SIZE OF LOT NOW ON lOT hwP BOOK PAGE PARCEL
(This section need not 6e campleted if ihe permit is for one � USE ZONE MAP ,
hvndred dollars(E100)or less.) . � TRACT BLOCK LOT NO. � . NO.
...
. C IEL. ' '� .. . SPECIAI . Y
1 certify thal In the performance of the work for which this OWNER � a'G„ ' YNO. CONDRION$ a
. �1 �y.... .. .... . ... .... .. DISTRICT GROUP TYPE FIRE ROCE O
permit i3 i55ued,I Sholl not employ any person in any manner - ADDRESS`� I-��1��'1@� �/' j T. ZONE � � V
eo as to bemme subjecl lo ihe Workers'Compensatian Laws. I�.. .. R . �-a
� — — _ _ . _ tiJ �G-1.�
Date � ApPII[on� - CITY Q Z�P STAi15TICAL CLASSIFICATION APT. C . O
NOTICE TO APPLICANT: If, affer making-lhis Certificata of - � ARCHITER OR . _ TEt. _ ^�''"1 � .� � w
�Ezemption, you should become s�bjee fo the Workers' ENGINEER � NO. QHS$NO.�`DWELL UNI75 �
Compensation provisions of ihe La6or Code,yau must forth- . ADDRE55 - � - -- �-- - SEWER hWP �+
with compiy wilh s�ch provisions or this permil sholl be =
TEL.
deemed revoked. � CONiRACTOR (iJI P- rypS9 C�� � �-BK.'�� �PG, � � VAIIDATION� .
LICENSED CONTRACTORS DECLARATION �J i��. �j,� � ��
I hereby aTfirm tha�I am licensed under provistons of Chap�er 9 ADDRE5537 e� dnr�� NO. ��1 J ypt pTION� (3oJ � �
(mmmencing with Section 7000)of DivisioM1 3 of the Busineu and I- J ��� L ���' C D
.Professions Code,ond my license is in full force and ef(ect. dtt �/"'MM M55� S �� ,�Z 5{�
n�y�', SQ.FT. NO.OF NO.OF CHECK .
license Number ���J Lic.Class� SIZE STORIES FAMILIES ONE
�1,� s . #. . . .23
Contmctor pa�e DESCRIPfION OF WORK C�QM����[kT� N� ❑ �
ADD . 0 I • •2�00
�I am exempl under Sec. � � � . � �
ALTER � FINAL . . •.• •2 S O O= .
U
B.BP.C.for lhis reason � � � � � ' -� � REPAIR DATE ' � . .
Date: USE OF . .. ... DEMOL ❑ ��F�N^�.- .. - - . .�. 0 2 2 4�8 4 .�
� EXISTINCa BIDG. - BY .
$Ignature � APPIICANT TEI. " "' .._ _ ._ . . . . _.
PRINT NO. ..
OWNER•BUILDER DECLARATION � - - . ,
I hereby affirm thet I um exempl from Ihe Conlractor's ticense .
Law for ihe following reason(Section 7031.5,Business ond . /oortE55 � � ��� � � �
Professlons Code): PrtES�NT � - �
❑ BWLDING . .. . .
I, os owner of tha praperty, or my employees w(Ih - ADDRE55 � - -------
wages as their sole tompenwlion,will do the work and �
the str�ct�re is not intended or offered for sale(Secfion ��4L1TY - �-�� � '
7044,Business ond Pro(essions Coda). MOVING TEL .
� I,as owner of the property,am extlusively tontracting NTRACTOR No. .... .. ,,��' I f��
wilh licensed coNractors to conslruct the proiect(Sec- ADDRE55 � � ` � '
tion 7044,Business and Professions Coda). - __._ .,_ _.. � �. . . .
RE�UIRED TOTAL SEiBAIX FROM EXIST.,
CONSTRUCTION IENDING AGENCY� ser encK YARD Hwv PROP.LWE wiorH , � �':
.1 here6y affirm lhat there is a cons�ruclion lending agancy for . FeONT � •� � - � - � � ��-
the performance of the work for whith this permit ii isiued ' P.L� � � � � �
2$CC.3097.CiV.C.J.... . , : SIOE ' . • .' •
. � . .� .. . .�. . .... .'P.L. '..... ._ ,.• . ::_' . . .__..; :-.��. ..�-� _._ .. , . . . . . ...
Lender's Neme � . ��. .. . � � . � .. . . . ;. : . . . . .
/7 _... ._-
�.ts-�7.
Lender's Address � - - - P.C.Fee E L� � � Permit Fee � - .
I tertify that I have read this applicalion and stale that the �- � I:suonce Fee � .
obove information is mrrect.I agrea to comply with oll Coonty Invesrqaron fee �
. ordinonces and Slate laws relming fo building construction, � � � � � ���'' � �� � �-' �� - -
Toral Fee
� �� e rapresantmives of this Counry to enter - .
upo hereb�aurhor',y'.Q ed propeny for inspaction pvrposes. - � - � � -- - � - -� �� ���- --�- - -� � �� � �� �
Y
I . y{- ��� SEE REYERSE FOR EXPLANATORY LANGUAGE _ __ _�_ _ . , . . , ,
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