HomeMy WebLinkAbout1818A 1819A (19) I � WORKERS'COMPENSATION DECLARATION ��
. I hereby affirm ihat I have a certifiwte o,consent,0 5a�f � APPLICATION FOR BUILDING PERMIT
insure,or a certificate of Workers'Compensation Insurante,
or a certifed copy thereof(Sec 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolityNo. Company � Ui��T' M� �`3�
� Certified mpy is hereby fu�nished. FOR APPLICANT TO FILL IN gUILDING t q. :� ._ ,�`�L, ,�`
ADDRESS ���
� Certified copy is filed with fhe county�building inspec- BUILDING y .
tion deparfinent. ADDRESS �
ry,r� / LOCALITY y�i(yirv�,C;��:y7�.
Dafe_��,"tl T' A li[ant - CITY Z�P ` NEAREST �"�
PP I a CRO55 ST. c:a�v�cvyrc'
CERTIFICATE OF EXEMPTIO FR M WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON lOT MAP BOOK PAGE PARCEL
(This section need not be completed if ihe permi}is for one USE ZONE MAP
hundred dO�lprs($100)or less.) TRACT eLOIX LOT NO. NO. �L� "'�;
TEL. SPECIAL
I certify ihat in the performance of the work for which this � OwNER � � �'J�+ �'�� CONDI710NS FL.
permit is issued,I shall not employ ony person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY '+.d
-so as to become subject to the Workers'Com ensmion Laws
- ADDRE55 ° �� CONST. ZONE F�
Dafe�• �.� 1"�� A licanf �r� ` .% CI7V � ../ � ZIP �.: G� `'Q � �
PP �� ARCHITEC70R TEL STATISTICALCLASSIFICATION • qp7. CONDD. �%
NOTICE TO-APPIICANT: If, after ing this Certificate of� � ,� ��
FN(.INFFR Ntl �7_
�'el1)NiiUil, yUu SnOUiO OECOTE SIID�ECI IO �i12 WOfkQ�S' - — ����—�
Compensation provisions of the Labor Code,you must for�h- , AODRE55 �IVv - '���
SEWER MAP
with comply with such provisions or ihis permit sholl be `X;
deemed revoked. rEL.�; VALIDATION �
1 COMRAQOR Np. . � _ BK. PG,
LICENSED CONTRACTORS DECLARATION i��
I hereby affirm thm I am licensed under pro�visions of Chapter 9 ; ADDRES � NO. VALUATION � �'1 8 1.H A
(commencing wifh Se[Iion 7000)of Division 3 of fhe Business and �� �_ •� -
Professions Code,and.my license is in full force and effect � QTY C A55 S���j.��' �� � o n J?,.
License Number Lic.Class ' �"FT. NO.OF
NO.OF CHECK , � �L 9 4
� SIZE STORIES FAMIUES ONE � ¢ a��",
CoMfatto� � Date OESCRIPTION OF WORK - � NEW � $ b W v/,9��U
❑I am exempt onder Sec. ,O )"'' • 6qJ Ao� � j c
AITER � FINAL ,�; � 'D� -��
B.&P.C.for fhis reason REPAIR � DATE M1���1��
Date: � USE Of FINAL
� � E%ISTING BLOG. � �EMOL ❑ '/�
Signafure - APPLICANT TEL. J �l BY �y i`. Z�'"���
OWNER-BUILDER DECLARATION PRINi) /�(,� NO. � ' p� �
I here6y cffirm ihat I am ezempt from the Cororactor's License A,n C ,
Law for the following reason(Section 7031.5,Bosiness and ADDRE55 ,� /F� ✓�
Professions Code): NT -
❑ BUILDING q � �� o� �n
I, os owner of ihe property, or my employees wi�h ADDRESS / � ��
wages as their sole compensation,will do the wo�k and , J
ihe structure is not iMended or offered far sale(Section ����TY �' P �m � � o m`�
7044,Business and Professions Code). � MOVING TEL.
� I,as owner of the ro ert am exclusivel contmctin CONTRACTOR NO.
P P Y, Y 9 � a '�t!1,2�j
wifh litensed contracfors ro consirucf fhe project(Seo- qDDRE55
tion 7044,Business�and Professions Code). , �, E �4 y,G cJ�
�REQUIRED TO7AL SETBACK PROM EXIST.
CONSTRUCTION LENDING AGENCY �SET BnCK YARD HWY pgoP.LWE wIDTH , ��U� ,,,8�
I hereby affirm that there is a consiruction lending agency for peONi
�the performance of the work for which this permit is issued � p.L. �
tSec.3097,Civ.C.).. � - � . - , . � . . �SIDE � . .. .. � . .
- � � . - . � � � - P.L. . . . . . . . .
lender's Name - - - �
`� P.C:Fee$ ���.-x (� Permit Fee � a
Lender's Address `.�a E%c ��
i
I ceNify that I have read this applicafion and state ihat the Issuance Fee j 1;,,,�G
� above informafion is<orrect.I agree to comply with all County Inves�igaiion Fee
ordinances and State laws relating to building consirut�ion, To�al Fee .�� - -
� ond hereby authorize representatives of this Co�nty to enfer
a upon th abov mentione propeny for inspection purposes. .
a SEE REVERSE FOR EXPLANATORY LANGUAGE
j n ignature of Applicanr ar Age s'� . ,
�s
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