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HomeMy WebLinkAbout1409A WORKERS'COMPENSAiION DECLARATION . y� insurehorafcertifcateofWorkesrrCompensatonlnsurancet APPLICATION FOR BUILDING PERMIT L� or a certified copy ihereof(Sec/.3800,Lab.C.) , COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NyQ;���s�(�°nr���Js;�i�l1��:n=Jll� � Certified co is hereb fumished. BunDiNG���, J� �_ � S av r FOR APPLICANT TO FILL IN ADDRES$ Y' f,�` Certified copy is filed with ihe county building inspec- gUILDING / �`� .�..� /1�� LJ fwn departmeni. ADDRE55 7'��.� ��t;�i% (Jl -SI .� R/ LOCALITV ��'�� .aLu.i NEAREST Date � ! APPlicant��`+ ���/�%J� CITY�� ' ziP CRO55 SL �'L�'� ERTI ICATE OF E%EMPTION FROM WORKER$' NO.OF B�oGS. ASSESSOR COMPENSA710N IIdSURANCE SIZE OF LOT NOW ON LOT MAP e00K PAGE PARCEL (This section need not be completed if the permit is for one 1�"��'� '7 �:• use ZONE MAP �(� Y,3�/ hund�ed dollars($100)or less.) TRACT r � ib. BiocK �oT rao. ,.9 No. TEL.'_ . t SPECIAL ���I�� � I certify Ihat in ihe performonce of the wbrk for which this OwNER�.� -�1;�'L�itC�i,',xr N --�`��,�j� � "'l CONOITIONS ermif is issued,1 shall nol em lo an erson in anner DISTRICT GROUP TYPE FIRE PROCESSED BV �D P P y Y P ADDRESS� � Z��„S 4;� CONST. ZON J ��� sa as to 6ecome subject lo fhe Workers'Compe wtio Laws. �. f f',(y 6t !� ,J �! .�% ._,�,,i �.,� % � � ! .!i i li� v.l t.�r_�� ;,a Date�S��ApPI�Canf -� . . : CITY� 'll fJ . � ZIP �'`�-' STAiISTICALCU+551FICATION APT. CONDO. �. NOTIG TO APPLICANi: If,.after making is C rtificote�of� ARCHISECTp � tlSEI.� -�,.�� �-. , . � . . Exempfion, �yo� should�become-subject-�to� fhe Workeri� � ENGINEER.. ' '��= NO, -„ , . �CLA55 NO. -���� DWELL.UNiTS_ � Compensafion provisi.ons of the Labor Code,yoo must fonh- qDDRESS � ��� � ��'. � ��ffl{•s� SEWER MAP �; wilh comply with such provisions or this permit shall be �- ` - � TE� w� ", deemed revoked. � � CONTRACTOR�.�..d � 4ydJ'' � N .sj:f `� . BK. PG• VALIDATION '�" �LICENSED CONTRACTORS DECLARATION „ �iC. I hereby affirm that I om licensed under provisions of Chapter 9 ADDRE55' ' a �•'�f r1, .yj'�" NO. � � VALUATION � � (mmmencing with$ection 70W)of Oivision 3 of the Business and ., ���. , .) (P'� � � r $ /�/ r� Professions Code,And my license is in full for<e and effect. CITY �s'� � j �� CLASS /.,�� '��.�f�(...�" , � �(',� 5�.F7+�g7 NO.OF NO.OF ECK License Number'�L��'�j_�Lic.Class �f SIZE J,7�,� STORIES � FAMILIES ONE $ Con�ra[lorryl•L : ��lAS���B" Dafe DESCRIP710NOFWORK /L"° /�� NEW � . ❑I am ezempt under Sec. "� ;e;,y�/p�Z;�.,.� �� Aoo ALTER FINAL 'l B.BP.C.for this reoson REPA�R � DATE ,�,� ' � , USE Of /� FINAL ate: EXISTING BLDG. !j� Y"�L'G`." � .s �EMOL ❑ B (\J� '�- Si nature, ��•�7��f--� '�ri-E��a'�'*�� APPLICANT_ TEL. � ��\c. 9 � WNER-�f�Rf1E DECL"ARATION � PRlnli, {� . NO. ' 7 � r� f. � �� I hereby affirm that I am exempt from the�ontractor's License . _ �.�1''� lnw for the followin g reason(Section 7031.5,Business and . ADDRESS. ' '���� � E.,>` y •`�"' � � �PrOf siOns Code�: � PRESENT ���W I, as owner of the properly, or my employees with ADDRESS � '� woges as iheir sole compensation,will do the work and ���,� � '`--'�-' is noi in�ended or orTered ior sale(Section ��µiii"r 7044,I Bosiness and Professions Code�. � MOVING TEL �' 9 `-� �?r��� ❑ C NTRAC70R NO. 1;as owner of tha p+operty,am exdusively comracting }:F� c e o m '� with licensed wniracrors to construct the project(Sac- qoDRE55 tion 7044,B�siness and Professions Code). � r,F 7��0 REQUIRED TOTAL SETBACK fROM EXIS7. CONSTRUCTION LENDING AGENCY 5E7 BACK �ARD HWv vROP.unlE WiDTH ► I he�eby afFirm 1hm ihere is a construction lending agency for FRONT , � g"�7`�:�''U� ihe performance of fhe work for whith this permi}is issued P.L G G C�"��1 (Sec.3097,Civ.C.j. SioE P.L, lender's Name � Lender's Address P.0 Fee$ Permit Fee S���•���7 . I certify thaf I have�ead ihis application and state�hm the � iss� ce Fee ✓d STC' � above information is carrect.I ogree to comply with all County �mestigation Fee an ordinancea and State laws relating to building construction, Totol Fee �' � and hereby autho,r�' represeMatives of this County to enter upon the above fnenli ned property for inspecfion purposes. � � 7� '� +'�-� � SEE REVERSE FOR E%PLANATORY LANGl1AGE � SignG ure of pplimnt or Agent ote �S . __�..,_,-._.– — . f7-,-...�....��__�_�__. ...__.r___.�..y - 3 ._' ...._.._`.� t ��.._ �.�_�.�.�.�_�__,-Zx�-.�..._.__.:_�._,-�..�;_._—._._" �..._� �3 ` �T+ Q L. � R! T f V1 j �'t �C�p la � � � j V1 ``�7". 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