HomeMy WebLinkAbout1647A 1685A (15) . .. , . . ,_ _ j.
WORKERS'COMPFNSATION�ECLARAIION -� . . ` _� . `��� ` ��1� ��"''�� � ' � ` � ,�
. I hereby at���m that I have a ceriiFicote oi mnsen�to self � � � APPLICATIC)N FOR B'UILDING PER� " ��
. insure,or a cartiiitote of Workers'Campenstion Insurance,or '� �
�.certified copy thereo((�c��8�9g,lob C.) �- COUNTY OF LOS ANGELES ' BU1LDfPiG AND SAFETY ,�
ot�C N�'39�—�omPar�y m � .0 . CC�J�ar.I.�
a Certifed copy is hereby(urniehed. � � FOR APPLICANT TO FILL IN ADDR SS S. '��
� � Certified cppy is filed With fhe Counfy building inspec- BUiIDING
tiOndepartmenf.� ' � .. ' ' . ADDRE55" �� S JP��NI� A LOCAUTY �
. � � � , . . . � NEAREST . � . .
Date� � ' Applicont - ' � � �� GtY� !/�V >i i12 z�P � CeOSSST.
- � CERTIFICATE OF EXEMPTION fROM WORKERS' � � NO.OF BLOGS. n55E5SOa . - . ,
� � � � COMPENSATION INSURANCE � . SIZE Of LOT � � NOY!ON lOT MAP BDOK PAGE PARCEI
_ (This section�need nat be comple�ed iF fhe permit is for one � USE ZONE �P - /�
TRACT BtOCK LOT NO. � NQ �` ` �
huntlred dollas(5100)or less.) '. � }
7EL. SPEC�AL
I cer�ify thai in�he performance of the work for which this OwNER /Zl�){ l� IZ�C NO. � CONO�TIpNS � � � Q I
permit is issued,1 sfioll nol employ ony person in ony manner I DISiRiCT GROUP TYPE FIRE PR ESSED BY V
so os to become subject to the Workers'Compensalion Laws. ADDRESS , /�f'�l r � CONSi ZON �
�a C el � O O
. Daie � Applimnt � �. - ' CiTY Z�P ' SinTiSiiCntC�n55t .ATION 'APT. CONDO. (�~j
NOTICE TQ APpLICANT: If, afler making this Ce�lificate o( ARCHITECT OR � � . TFL• _ - � �y�
CNGINEER NO. ClASS NO._�„�DWELL UNITS G.
Ezempfion;�yoo shoold�become�subject,to tha Workers' y
�Compensation provisions af the Labor Cade,you must for�h- ADDe[55 sewea nwP � , � Z
wilh cemply with such provisions or Iliis permil sholl be TE� �
deemed revoked. - . CONtanCTOR - NO. BK. PG. VAUUATION •
- �UCENSED CONTRACTORS DECLARATION - � �I�, . . . . �
I he�eby offirm tha�I om licensed under prov�sions ot Chap�er 9 _ ADORESS NO. � VAWATION � , _
(commencing wiih Section 7000)of Division 3 of Ihe Business and . p�. � O�
Professions Code,and my license is in Iull farce ond eiFece . CiTY CLASS G s �E� ��}OO ��1 6 4 7 A
� /�(�� SO.Fi. JO.DF NO.OF CHECK
lice�SeNumber� 79n Z LicCIa55�T'_� S�ZE STORIES FAMILIES ONE ,#• • •'�`�3'
s
Coniroctor L�,�� S� P�^Dafe � � DESCRIPTION OF WORK '}' L A D .� • � � �6�
'�. ,..�
1 om e empt fram the licensing iequirements as 1 om a Q�{�/1,.(,.V x'�
licerlsed arthiteU or o regislered professional engineer _ , _ . ._.. . - . _ . A�1FR. � � FINAL /- � •�• •� .�d fl Q c�
o ctin g in m y p�afesiionol co pocit y (Secfbn 7051. R E a n i R � PATE �/i� , .
' Bosiness and Professions Code). � USE OF . 0 Z 2 3.�$2
� E%ISiING BI�C"i. � - � DEMOI � FINAI ��
By
�Lit.or Reg.No. Dafe APP�I('NNT , iEL . � � �
� ��� - � OWNER-BUIIDER DECIARATION (PR�M)� � . NO. � � ,
I hereby affirm thot I am ezempt from Ihe Coniracfor's License . . ��� �
Law icr the following reasan(Secfion 7031.5, Business and � ADDRESS 7� L� J '� � . . _ .
Profezsions Code): � � FRESEhr - �
_❑ . . . _ BUit�MG . . . . � .. � . '
.'I. as owner af Ihe property,or my emplayees with Ao�RE55
. woges os the�r sole compensorion,will do ihe work ond . � ' �
the struUure is not inlended or offered for sale(Section � �«A��N �
7044,Business and Professions Code). � MOVING � TEL. �' b� .Jr,A
� I,as owner of ihe property,om e.dusively confracting � CONieACTOR NO. -
wilh licensed contractors fo[onstruct Ihe pr0lect(Sec- ADDRE55 #I������� �!�
� tian 70d4,Business-and 7rofessions Code).-� � � � �
CONSTRUCTION LENDING AGENCY REOViRED TOTAL SETBACK FROM E%151. '
SETBACK YARD HWY PROV.IINE WIDiH I���•�2�50
I hereby offirm�hor�herc is a mnsrrucrion tending agenry for -� � rROM � � � - ��
Ihe periormonce of the work for which Ihis permil is issued P,L � ' . .''• �`z Jr,,5 Q'F�
. (Sec.3097,Civ.C.). . . � . SiDE � �� � - � � � �
P.�. �0226-82
lendei s Name . - � � '
Lender's Address - P.C.Fee S � Permtr fee �, � � .
1 cerlify Iha�1 have reod this opplication and stole 1ha1 Ihe � Issuanca Fee d-J � �
obove informa�ion is correct.I ogree�o comply with oll County ., i,,,,esrgouon Fee / � ' � . . �
ordinances and$�ale laws relalinq fo building conshoction, � To�ol Fee �-j, J d �
and hereby ovlhorize representolives of ihis County 10 enter . .
upan t "above�menfione prpperty(or inspecfion purposes. � ,
l�___,1y��s�-.7y��'iZ_ � SEE REVERSE FOR EXPIANATORY LANGUAGE
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