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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 Signor�re ApPticon�or Aqen� /Doie�_µ . �f a a . � - .n Z '= . . � .�,. p• , .o ni �, a "� • yr �^u' �a., o u- 0 � s n. , p � ��, r � � ' w 'o W �D �y.,, C r '�+�r�'v` n�p �t9 ^ � ° 'O. =' ro . O �t NO �.� .�q� �✓� ti-P p Q n. p. m .� (N O O n �� . L C1 D 3 O G . r� `th O �C 0. � �'p _ �7'�" L4 '� � M ��� m � � � r. p � O .cf �� g r • p-O � � m N � ' t �'^• �p S� i:` =��^p tp • '0 ir3 '�n o o� ,K m �� • � . 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