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HomeMy WebLinkAbout1559A 1651A , _ ��- .____., ,WORKERS'COMPENSATION DECLARAiION I � �� I �'� I hereby offirm fhat 1 have o cerlifica�e oi consem ro,e�f. . ; - :. qpp��CATION FOR BUILDING PERMIT � �� � . insure,or a certificaie of Workers'Compenslion Insv�ance,or � .a cenified copy rhereof(Sec.3800,lob.C. � , �. �. "� ' � � �--'COUNTY�OF LOS ANGELES � BUILDING AND SAFETY � PolityN6iwc�liyi q�ny � �.•--� . �- . - - ' . Cerlified co s hereb furnished. ' � BVILDiNG/��s� �I�MoNP � LVP � ❑ PY' Y FOR APPLICANT TO FILL IN aooaess�alv . a Certi{ied copy is(iled wilh Ihe munty 6vilding Mspet- �1 gUILDING l I,p . � �VD• �/ MvNY j�7� lion deparlmenl. , AD�RESS lV IOCAUTY � - Dale � Appliconl ' � � � CITY V I D D�!/ � Ziv� �� CRO55557.� I�V (/�S� U� � CERTIFICATE OF E%EMPTION FROM WORKERS' - � '`� ' �� ��` G 2/lr'7u NO.OF BLDGS. �� ASSESSOR � r� � � COMPENSATION INSURANCE -� 5¢E OF LOTJ :JIiC/✓ NOW ON LOT . MAP BODK PAGE 1 PARCEL �(This 5etlion need not be[ompleled if Ihe permil is for one TRACT �✓ etOCK LOT NO. v . USE ZONE MO.P � 3_ / . hundred dollars(SI00)or less.) . � - - I � I� � NO. �' .3�3 � I . . , /1� TEL �7 ' SPECIAL � : - a �1 certify thot in Ihe performance of the work(or which this, � OWNER C/Li � NO. li"rn CONDITION$ � O I��/� 5T.5U �I Q �ISTRICI GROUP TYPE FIRE PR SED BY V permif is issued,I sholl not employ any persan In ony manner qDDRE55 �O �.n CONSI�TT ZQNE � so as m become subject io the Workers'Compensotion lows. L ,� J a �Date � A licant � Ciiv S N � ZiP Z7OS - O .. PP " STATISTICAt QASSIFICAIION �APT. CONDO. � � NOTICE TO APPIICANT: If, afrer making fhis Certifitote of�- � ENG h� R Zj37�� ' C�n55 n10. �� U i1 DWEII.UNITS W Exemption, you shoold become :ubjeU-to the Warkers' J N . Campensotion provisions of ihe Labor Code,you musl forlh- ADDRE55� � � �• SEWER MAP Z with comply�with s�ch provisions or this permit shall be TE� deemed revoked. . . 1 � � VAIIDATION • - CONTRACTOR G p BK. PG,� � Y LICENSED CONTRACTORS DE PLARATION P � �g2 N.�AT � n10. , I hereb ofiirm that I am licensed under rovisions of Cho ter 9. _ qooRESS � � � � (commencing wi�h Section 7000)of Division 3 of the Businezs and Q�A N6E �IC. VA�O��'DO � �' S�9�a , .Prolessions Gode,ond my license is in full force ond eFfecf. CIiY �`/l i C1A55 S #�� �'�'�•�3 ' .�n.��`� �.. SO.FT.Io'L1 C NO.OF /� NO.OF CHEIX �. , License Number_ L LiC.C�oss� SIZE T✓ STCRIES L... FAMIl1E5 ONE� � -. ' ' T S ;� . . � Qi4�_ Controclo �-�/��/'1I�f 1/Dafa �2 . .. DES i I N F W�K I N� ❑ �. . . � ' _ - ..❑ W1�1�I WNI l.l�Li`�L ADD � •;• • � �,�lOcl I am exemp�from tha licensing requirements os I om a f/ licensed orchilect or a registered professional engineer„_ _ t, �y-� �y 1 Al7ER � FINAL / p �2� (��8 2 . � acting in my profestional copaciry (Sectlon 7051, C! L�/ (�1�4 REPAiR -� DATE � �t0 O•3 � � � BusinessondProfessionsCode). USEOF ����C ��7A�nO�lA�1i1 � FINAL . ' � - ' � � � EXISTINGBLD �.����-V�ty �.1 V DEMOL , B . . . .: . .. ... .. . APPLICANTI\��TH IY"�IYL+1�� N .t Y 9 . . .. Lic.or Reg.No. Dafe . , ., ' OWNER•BUIIDER DECLARATION � � " ' � (PRiNT1 . � 1 hereby afiirm fhof I am exempt irom the Contractor's licensa . ^� (iG/��� Law for the following reasan(Senion 7031.5, 8usiness and ADoeE55�5 1 ��('� � ' - � - - Professions Code): � - � . �et5etii � � - BUILDING � �" I,'os ownei of the proper�y, or my employees wiih - ao�aE55 � � � � � - � � - wo3e,,.,tie,,,�ie.�m�a�,�,;_�,,:,;!ia�,��.•:��k�-d �AUT� � �1 65,:1 A . � ihe srrucfure is not imended or affered for sole(Section ' - - - �� - - - � �- - . 7044,Business and Frofessions Code). MOVING TEL. • �#� '� ��:.� . � I,as owner of rhe properry,am exdusively contrac�ing CONiR,4C70R NO. � . � . � with licensed coniractors�a construct the projeU(Seo qDDRE55 � I • •3 1,5 0 � �ion 7044,Business and Pro(essions Code).�- - - -�� � . . . . . REOUIRED TOTAI SETBACK FROM EXIST. . _ CONSTRUCTION IENDING AGENCY SET BACK Y�+RD HWY PROP.LINE WIDTH � - �'� •3 t 5 0 c.i I hereby affirm Ihal Ihere is a construttion(ending ogency for �- fRONt . � � . � � � - �� �� - � Ihe performonce oi the work for which Ihis permil irissued P.L � •�2'�[j••$.'Z . (Set.3097,Crv.C.): . - . ._ . . _ . .. .. _Sioe ._ � . - P.l. � . . . . . .. . . Lender's Nome �/� � P.C.Fee S� I I'`/"V Permi�Fee � " V ' � � Lender's Addrezs (7 /' � , � • I cerliiy ihot I have read Ihis applicotion and slate fhot the � �ss�ance Fee� . 0•J v � . above informotion is mrreU.I agree to comply wilh oll County , , Invesngorion Fee � . � � .. . _ oidinances and Stale Iaws relaling to 6uilding conslrucfion, ' Total Fee .J� � and hereby authoriz �repr ntatives of ihis Coumy to e ter • , . �`up t e bo �me��one p .rry for inspecfio purp es.-�' �� � _ . - �-� � ' , '' ' ' � �l- � SEE REVERTE FOR E%PIANATORY LANGUAGE � � - � ' ' igna�uro o Ar„canl or Age Do� � � . 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