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HomeMy WebLinkAbout1022A (7) . WORKERS'COMPENSAiION DECLARATION .. . . . ..... .. . - _ I . . �� I�hereby afFirm that I hove a ceniiicare ot mnseni�0 5e�f :. .. . �- APPLICATIQN FOR: BUILDING PERMIT 'insore,o�a certifica�e of Workers'Compenstion Insurante,or , a certifled topy ihereof($et.3800,Lob.C.) . . .. . . . - COUNTY OF LOS ANGELES � � � BUILDING AND SAFETY . � . Policy No. � Compony � BUIIpING � Ceiiified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 � �J� i[I� Iq'� �Y� � Lertitied copy is i�led with the munty boilding inspeo , BUILDING 7 �/,! G'�� � � . /� . , lion deportmenl. . . . ADORE55 -J iZ 3 J ��,�.CJ (J.0 t'-�L tOCAUTY N !L7/Q � � � � ' � � /J NEAREST A /� -Dola Applicont - CITY L7A� ZIP� CROSSST. i! (.� ' CERTIFICATE OF EXEMPTION FROM WORKERS" NO.OF BLDGS. ASSESSOR �- � COMPENSATION INSURANCE � -�- SIZE OF lOT NOW ON LOT O MAP BOOK PAGE PARCEL _ � �This section need not 6e comple�ed if Ihe permif is for one u E ZQ NE Mna � ' hundred dollars(5100)or Ie55.) � _ TRACT�� BLOCK LOT NO. � �� I NO. } nr TEL. ` .y SPECIAL p� � � OWNER V�1 A� / lCL:E NO�7' / I��D CONDITIONS . 1 cer�ify that in 1he performance of the wark for which this.� u permil is issued,I shall no�employ any person in any manner DISTRICT GROUP iYPE FIRE PROCESSED BY. AD�RE55 j� R7'1�Fr �so os to become subject�o ihe Workers'Compensatian Laws. �O � COnl S% ZONE , O �' Oa1e � � Applican� ' � ��TY�� N � Z'P STA715IICALCLASSIfICAIION . - API. CONDO: � V NOTICE TO�APPIICANT: If, aher making this Ceitificate of - � ARCHIiECTOR J EL , �Ezemplion, �you shvuld become suhjed lo Ihe Warkeri ENGWEER / rJ O � CLASS NO.���WEIL.UNITS N Compensation provisions of the Labor Code,yoo musl fonh- � qDDaf55 � �✓ �/. � SEWER MAP . � with comply with such provisions or ihis permil sholl be TE� . � _' deemed revoked. � • - � � fONTRACTOR � � �� � NO. � bK.� PG,� , VALIDATION • LICENSED CONTRACTORS DECLARATION �.., tK. � I hereby al(irm that I am licensed under pro��sions of Chapter 9 � . nD0ae55 NO. VALUATION �.�s � (mmmenting with Seclion 7000)of Division 3 of the Business and uC. �l'MO . �� Q 2�A Professions Code,and my license is in foll force ond effecl. GTY ClASS S W W - . � � � SQ.FT. NO.OF NO.OF CHECK � - licenseNumber LicClo55 � SiZE �� STORIES FAMILIES ONE . ��� �'.�,�23 � . � � _) NEWi 5 . ��.��i8QS0 Con�roclar �ote � DESCRiPTiON OF WORK R • , 7[� Q � , . _ � I am e�empl from Ihe licensing requiremenfs os I om o � r1 AOD �� -licensed archited or o regis�ered professionol engineer , � _ _ . . F� AtTER � �- FINAL �� � �$4 8�� , ' otling in my professionol mpaciy (SeUlon 7051, REPAiR � DATE �2�Jr�8.� . � Business and Professions Code). U5E OF FINAL � - - � � EXISTING BLDG. �� � � � DEMOI ❑ BY . , LiC.Of RCg.N0. DO1B A77lICANT y� �/ .TEL. � ' -� OWNER•BUILDERDECLARATION "� � � 'IPRWTt jYyEI��PN � ' NO. I hereby affirm that I am exempt 6am ihe Conirocror's License � u . [. � . � � Law(or the following reason(Section 7031.5, Business pnd ADDeE55�3 �v�r�,e.� P.�-C(7�u0 _p J,��I✓ Professions Code): � , FRESENT � �` �j� ❑ . : . _.._ BUtLDING___..__._____'_._ _�...__'__....... . ' ._ _ -. ._ � . � _ . . I, as owner af Ihe properly, or my employees with � A�ORESS woges as their sole compensation,wJl do th?work and ,�_A/ � . the strvtture is nm intended or offered for sole(Secrian LOCAUTY - - ���� � �- � - - . , 70d4,Business o�d Professions Code�. � MOVING TEt. E � � � � I,oS owner of the property,om eadusively c0��ro[ting � CONTRACTOR NO..� � � , w�th licensed mntroctors ro constroct�he proleu(Sec- � .. 't�od7044,Busine55 ond P�ofessions COda). . ADORE55 - . . .. . _ . . . RE�UIRED TOTAL SETBACK FROM E%IST. ' CONSTRUCTION LENDING AGENCY SET BnCK vARD Hwv pROP.uNE wiDTH � �I hereby affirm�ha�there is o construction lending ogency for • faOM � ' ' tha performonce of Ihe work for which Ihis permil is issued P.L, � � (SeC.3097.Civ.C.�. . . . SIDE-. - . . - • P.L. Lender's Name . _ � � � , . ., . . . . . � . lender's Addre55 � ' P.C.Fee S �• Permi�Fee I rer�ify that I have read this application and sta�e ihat the �, �esoa�ce Fee � � . obove information is correc�.I agree ro comply,with all County , in.esr�goi'�on Fee-��� � �� � � - - - ordinances and$fote laws reloting�o building conshuction, '� � Toral Fee � ' � � ond hereby outhorize represemmives of rhis County io enter . . _ . _ , . . � upon the obove-meNioned property for inspeclion purpases. � � . � ' �- SEE REVERSE FOR EXPLANATORY LANGUAGE � S�gnoi�re of Appl�can�ar Ageni Do�c � � . 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