HomeMy WebLinkAbout1441A 2620A (15) � .
-�'�� � WORKERS'COMPENSAiION�ECLARATION � � Kj �
I hereby aifirm ihat i have o�e,��t��ofe ot consent to self A P P L I CAT I O N �F O R B U I L D I N G� P E RM I T zS
insura,or a certificate of Workers'Compensalion Insuronce, � �
or a cerufied cop rhereo[(gec.3800�,Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
�2�J� lvC� r'/9/P/j7�/p�
^ PQolicyNo. .7 Company BWL�ING �
Certified topy is he�eby furnished. fOR APPLICANT TO FILL IN ADDRESS �� ��� 'V\
trM� Certified copy is filed wiih ihe caunty building inspec- gUiLDING ,� �7 `
�1 tion deparlmeM. ADDRESS � � 7—Y1L. LOGLITY • �J
l DO10 /1pplimn . ' ���� NEAREST
'y G-8y �P /Ssd a nr caoss sT. �
\ CERTIFICATE OF EXEMPTION PROM ORKERS' . NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE.- . � , SIZE OF LOT NOW ON LOT MAP BOOK PAGE. PARLEL
(This section need nm ba completed if tha permit is�for ona- . � � ' � uSEZONe nn.nv o _ . ,
hondred d011on(E�00)or IeSs.) . � � . � . � � TRACT. � BLOCK - . LOT NO. � . � . NO. �J�
� ,t TFL. SPECIAL . }
�cerlify that In the performante of 1he wo�k for whith this� , OwNER � V �� NO. - CONDITIONS � 6
j� Y' L J�J� � DISTRICi GROUP TYPE FIRE PROCESSED BY O
permit Is issued,I shall nof employ nny pe�son fn any monner qDDRESS�T�I 5�����GS�"� ��I CONST. ZONE V
so os to become subjec�to the Workers'Compensofion Lows. ,]p. . . ��„
Dote Applicanr � am � L�I //�� ZIP ST�TISTI�AI CtAS51F 710N� . A� CONDO. . O
NOTICE TO APPLICANT: If, a(ter making ihis Certificate of ARCHirER OR TFI.
ENG�NEER MO. C1A55 NO. DWEIL.UN�TS_ ' W
�Exemption, you should become subject to the Workers' n.
Compensotion provisions of 1he Lobor Code,y0U mu31{O��F1- A�DRE55 ' ' SEWER AAA.P �Z
wi�h comply with soch provistons or this permit sholl be yy� TE�(j'�� �
deemedrevoked. � - � � CONTRAROR �/li NOV� /�� I 'BK• �. VALIDATION�
IICENSEO CONTRACTORS DECLARATION `l iiG
I hereby affirm that I am licensed under provisions o(Chapter 9 nDDRE� !J� NO. VALUAjIQ � �O � �
(commencing with Setlion 7000J of Division 3 of the 8usiness ond �� �i�' �a,� E �� -�—
/ Profeuions Code,and my license is tn full forte and effect. CI N I CLA55 7' V ►
n d ��_ �'�' NO.OF NO.OF CHECK
License Num6er Lic.Class SIZE STORiES FAMILIES ONE
m !� / NEW � S �� GI1.� A
Contraclo!!�//�C ,h�LDate�C2—�� DESCRIPTION OF WORK
J;/�� _ ADD � �. . . #• • • •2 3
\ ❑I am exempt vnder See. ��
AITER � FINAL �� � • �'2�O Q
� B.BP.C.for ihis reason REPAIR DATE \{\� .
Date: . USE OF /�N�f}S�/G � . . o�,o� p FINAL \ � � �P�O�F��
EXIS7ING Bl �
Signature AVRiCArv / TEL z�-, �i � 0 2 0 8-8 4
OWNER•BUILDER DECLARATION . ��N 6 , o.S� /2/I >,�J
I hereby afiirm thol I om eaempt from tha Conirottor's litense ' � . ��•�0��
aooRess
Law for the following reason(Sedion 7031.5,Business and `t �
Professians Code): . pRE N `` n�.v
� �I, as owner of the ro e BUItDING . �v+�
p p rn/, or my employees w�th ADDRE55 `� ^��,�
wa9es as iheirsole compenwlion,will da Ihe work and .
tha strunora is not intended or offered for sale(Secrion ����TY ��` - � �
7044,Business and Professions Code). � MOVING TEL. - I
� I,a5 awne�of Iha property,am ezclusively coniracffng CONTRACTOR NO. �� ��
with litensed contraclors to construc}tha project(Sec- qDORE55 � ��
fion 7044,Business ond Professions Code)._ . , n
REOUIRED YARD HWY TOTAL SETBACK fROM E%IST, �'�6 2 Q!t
� CONSTRUCTION IENDING AGENCY � � sei BnCK pRpP.LINE W�DTH ►
I hereby aff'�rm thm there is m m�stiuction lending ogency for FRONT -� � #� e . � � � � .
the performance af the work for which Ihis pe�mil is issued �v.L �
�Sec.3097,ei�.e.�. � sioe . � I • •3 Q 5 0
, . � � � . P.L.
lenders Nama � (v� . . - • • •J Q 5���
Lender'e Address P�G iee f � Permit Fee vO . ,
. �I certif thar I hava read this a �licalion and stote that the Q O -� O�l.O 6�8�l
Y PP . � bwonro Fea
obove Information iz wrrect.1 agree to comply with a�l Covny Inves�iqmion Fea � • -
ordinances ond Stala laws relating to building tonshvction, � torol F<e ��
ond hereby authoriza representatives of lhis County to emer .
upon the o ove-mentioned property for Inspection purposea � - - � � - -
�� � '_ , SEE REVERSE FOR F7(PLANATORY IANGUAGE _ , .
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