HomeMy WebLinkAbout0489A 0984A (4)WORKERS' COMPENSATION DECLARATION.
-I hereby affirm that I have a certificate of consent to self . APPLICATION FOR BUILDING PER
' insure, or a certificate of Workers' Compenstion Insurance, or
a certified copy thereof (Sec. 3800, Lab. .)
r� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No �e , �q 4.
Company -
Certified copy is hereby furnished. - -
Certified copy is filed with the countybuilding inspec-
tion department f
Date P Applicarit�A�fO�
IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
hundred dollars (5100) or less.) . .
I certify that in the performance of the work for which this
permit is issued. I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date - Applicant
NOTICETO APPLICANT: If, aftermakingthis Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Lobar Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
License Number— O 7- .3 % Lic. Class
Contractor" „sn.t_ cr. ate /
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
.. Business and Professions Code).
Lic. or Reg. No. Date
FOR APPLICANT TO FILL IN
(PRINT) A, [xNO.
ADDRESS
BUILDING
�r L
I"o-r
..
-, Law for the following reason (Section 7031.5, Business and
ADDRESS O f /!
D
►' /
LOCALITY Ir Li
PRESENT
-
I, as owner of the property, or my employees with
NEAREST
CITY
ZIP-
-
CROSS ST.
the structure is not intended or offered for sole (Section
NO. OF BLDGS.
ASSESSOR
7044, Business and Professions Code),
SIZE OF LOT
NOW ON LOT -
MAP BOOK PAGE
PARCEL
- -
with licensed contractors to construct the project (Sec-
USE ZONE
NOPZ-
TRACT O3 BLOCK
LOT NO.
- -
CONSTRUCTION LENDING AGENCY
�tJ
A
r , • TEL.
- -A hereby affirm that there Is a construction lending agency for
C -m
SPECIAL
OWNER r
p
O. J�rO
- '#.
CONDITIONS
..(Sec. 3097, Civ. C.).
SIDE.
-
nn�
DISTRICT GROUP TYPE
CONST.
FIRE PR ESSED BY
ZONE
ADDRESS R-3 i1�
NY
-21 '
CITY
ARCHITECT OR -
ZIP /
TEL.
P.C. Fee S I Permir Fee Q�
STAi15TICAt CLASSIFICATION -
APT. CONDO.
ENGINEER
NO.
�
CLASS NO. "� DWELL. UNITS--
NITS_ADDRESS
I certify that I have read this application and state that the
ADDRESS
12 1 8,j
SEWER MAP
tnvesrgmion Fee
CONTRACTOR
0 H()EL.
NO.
'� /
BK.
' VALIDATION
ADDRESS 04
O
LIC.
NO. d`D9 3
VALUATION
,
/�
CIN C Pl' C d
e CIAss
—
$_ 3 f'
-:5049A 8.
SQ. NO. OF
sU
NO. OF
CHECK
`-
2 3SIZE
�
ONE
DESCRIPTION OF WORK
NEW ❑
S.
I .!18 /« 8 0
C 1
V.!—! -eh s
ADDR . C]
FINAL ,Ll p _
-.• t 8 /1. 8 0 3
i^-,. p
/P
REPAIR ❑
,/
DATE
1.04.-8,1
USE OF
DEMOL ❑
FINAI /// /` -
6
,I
EXISTING BLDG.
APPLICANT
lEl.
By �,_ -��,
y.
CL
O
U
ed
0
U
a
N
v
- -- OWNER -BUILDER DECLARATION-
(PRINT) A, [xNO.
1 hereby affirm that I am exempt from the Contractor's License
�r L
I"o-r
..
-, Law for the following reason (Section 7031.5, Business and
ADDRESS WOl' [ a
Professions Code):
PRESENT
-
I, as owner of the property, or my employees with
BUILOING ..
ADDRESS
wages as their sc!o compensation, will do it work and
the structure is not intended or offered for sole (Section
LOCALITY
7044, Business and Professions Code),
MOVING TEL."
I, as owner of the property, am exclusively contracting
CONTRACTOR NO.
- -
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).-
ADDRESS
- -
CONSTRUCTION LENDING AGENCY
REQUIRED TOTAL SETBACK FROM EXIST.
SET BACK YARD HWY PROP. LINE WIDTH_R0984
A
- -A hereby affirm that there Is a construction lending agency for
FRONT
The performance of the work for which this permit is issued
P.L.
- '#.
..(Sec. 3097, Civ. C.).
SIDE.
-
P. L.
I.-239,50 -
Lender's Name
'
P.C. Fee S I Permir Fee Q�
•'- 2 3 9.5 0
lender's Address
�
I certify that I have read this application and state that the
lssuo ce Fee
n
12 1 8,j
above information is correct. I agree to comply with all County
tnvesrgmion Fee
.1 ,•
- -
ordinances and State laws relating to building construction,
Total Fee
and hereby authorize representatives of this County to enter
t
,
for inspection purposes.
��T.dproperty
--F
SEE REVERSE FOR EXPLANATORY LANGUAGEor
Agent pore
aJ
2
N
v
m
A
O
A
2
2
H
rnT
°�, n g O b r
O .`• <p
a tt .j �.
M n`
°
C h Oy 4 S
O~ l A O• p N n O
b R. O Ob G. Q w, M• N m Q'
N`�•`�••� a•n 0
q�O` Tt'h �.10„'a k C 7'°u
�A•V
3
° b
F a .A. ° o •� c m 4 f Q f
obLgti�N�
pq �n; d m
0.O °.,
Q h A �P ° '° O 0
O
a O• w. hn l '• O ° CCI
C
O
h 3 O
A b •'"
� a' C O�� N j'
:_m
Q '� w O O. 0 0--
i'' G b fi y T
o who �b
°
�? .hH°'
IDm v
o a�Foc°°
ti o° d
�_h `oma fin-3rr
n
° 3 Po O 9
�' ��^• ~ .�'. F K
z c O�'
1e O O
w
L.. a' ra A w O j 10d
• b
O
O• •t C h O gr;
�.
1 O w. r+ " a •C7 f7
W,1,
F
C
'b °
O ir�.....3,� ZZ
A � A n 0° 3
fi, �•, ac'b a °.ate
O _ yr•y
Z. Q �n � �' C Q O �• u O
� ° � °
a
° �_
w fi b w m `'•
iC ° O~ Q O° 3
tyb ti a.� �•h 3
^• p• C` Q n °• A\ _ '�'I
a
�
a R O n� O
•.• ^ q O a �,� p O m t1
4
a A" O a• O h C a r p N m
h
O
O 1 � C .^. O
O C O`• Q n � • ° h !� � H
O n O
� O ti � n �. O• A ; � � . �
h ,�'„ N?
n x A O' N fi i�' v. O a O C• 0 0 "Q O O p
1�1 kA
n n
ti m ewe ti°• a °n �- ` C " n y e ^. o
• PJ �
w��� h h C` �• H
TC,
T
--
;F-:,
o;
°o
°_
0
rs
n.
z
G
w
b
O
-
�
C
►
o
D
o
�n
° n
n
yo'
7
13
C
yp O
4
C
O K
j
L
t
C d
K
O
I{
O.
r
s
i•
CA
-r
I
2
N
v
m
A
O
A
2
2
H
4 OC b O
°�, n g O b r
O .`• <p
a tt .j �.
M n`
°
C h Oy 4 S
O~ l A O• p N n O
b R. O Ob G. Q w, M• N m Q'
N`�•`�••� a•n 0
q�O` Tt'h �.10„'a k C 7'°u
�A•V
3
° b
F a .A. ° o •� c m 4 f Q f
obLgti�N�
pq �n; d m
0.O °.,
Q h A �P ° '° O 0
O
a O• w. hn l '• O ° CCI
C
O
h 3 O
A b •'"
� a' C O�� N j'
:_m
Q '� w O O. 0 0--
i'' G b fi y T
o who �b
°
�? .hH°'
IDm v
o a�Foc°°
ti o° d
�_h `oma fin-3rr
n
° 3 Po O 9
�' ��^• ~ .�'. F K
z c O�'
1e O O
w
L.. a' ra A w O j 10d
• b
O
O• •t C h O gr;
�.
1 O w. r+ " a •C7 f7
W,1,
F
C
'b °
O ir�.....3,� ZZ
A � A n 0° 3
fi, �•, ac'b a °.ate
O _ yr•y
Z. Q �n � �' C Q O �• u O
� ° � °
a
° �_
w fi b w m `'•
iC ° O~ Q O° 3
tyb ti a.� �•h 3
^• p• C` Q n °• A\ _ '�'I
a
�
a R O n� O
•.• ^ q O a �,� p O m t1
4
a A" O a• O h C a r p N m
h
O
O 1 � C .^. O
O C O`• Q n � • ° h !� � H
O n O
� O ti � n �. O• A ; � � . �
h ,�'„ N?
n x A O' N fi i�' v. O a O C• 0 0 "Q O O p
1�1 kA
n n
ti m ewe ti°• a °n �- ` C " n y e ^. o
• PJ �
w��� h h C` �• H