HomeMy WebLinkAbout1279A 1569A 1682A , WORKERS'COMPENSATION DECLARATION . _ �. . . . ' � � � � - � � � � �� �
1 hereby afiirm thol I have o teNificole of�o�,e�„o,e�f � APPLICATION F�R BUILDING PERMIT ��
. insure,or a certificate of Workers'Compenstion Insuronce,or
o cenified capy thereaf(Sec.3800,lob.G) COUNTY OF LOS ANGELES BUILDING AND SAFETY ����
' Polic'yNo. � COmpany BUiLD1NG C Q
� Cenitied copy is hereby furnished. FOR APPLICANT TO FILL IN ApDRESS J
❑��.Cenified topy is filed with�he county 6oilding inspec- � BU0.owG (�1 '{
�ion deparlmenL _ ADDRE55 J�• ti �V ��+��TY
�I � � ' � � � � � NEAREST
Dale � ApplicaN � - � ❑TY -V� , ZIP CROSSST. �`1�-t--'ti�-
� � CERT�FICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS.� , nSSESSOR �
� � COMPENSA710N WSURANCE 512E Of LOS NOW ON LO� MAP BOOK VAGE PARCEL
�This sectiori need nat be compleled if the permil is for one �z USE ZONE OP \ � �
hundred dollors 5100 or less. . . TRAQ � J BtOCK� l0T NO. �—
I � � . •TEL. �Z �Y�/� SPEC�AL , �
a
� 1 certify thal in the performance of ihe work for which ihis OwNER (`' } NO. � '' � CONDITIONS � Q
Brmil is issued,I shall nol em lo an erson in an manne� M ` U�S7RiC1 GROUP IYPE FiRE PROCESSED BY . V
P P Y Y P Y ADORE55 �S� V�I�AC C„ ��1� CONST. ZONE �.
so as to bemme su6jec�to the er'Compensa�ion Laws. (�1� G1� �1 `� �� p
�Oate'^��` �Appiiton�� . . . CITY �--C" � . ZIP (Z C� F"
ARCHITfCT OR `�� TE� �i STATISTICAL C1A551FICAiION APT. CONDp. W
NOTICE TO�APPUCANT: If, ofler ing 1hi5 Ce��iii[o1a o� ENGINEER L E w��+ NO. �O p � CLASSNO. OWELL UNITS ' � '
Exemprion, yov should become su ject lo the Workers' �7 1 f�
,Compensalian pro��sions oi ihe tobor Code,yo�m�st forih- qDDRE55 � N 1D �1�• IIV SEWER MnP T
with tomply wi�h such provisions or this permil shall 6e ` �0. '.
deemed revoked. � � � CONTRACTOR J p�J�, - BK. PG, VAII�ATION
� � . LICENSED CONTRACTORS DECLARATION . LiC. . ,
I hereby aHi�m thot 1 om licensed under provieions of Chopter 9 ADDRE55 . NO. VAWATION ,
(commencing with Sedion 7000)oi Drvision 3 of ihe Business and ���• . S � � . ��2 7.Q� '
� Professions Code,ond my license is in full Force and effecL CITV Qn55�
- ' ' � ' $Q.Fi NO.OF NO.OF CF1KK �� . ' �
�'litense Num6er -Lic.Class SIZE � S70RIE5 FAMIlIES ONE . #.��• • •2.3 �
Controctor � Date � DESCRIPTION OF WORK NEW ❑ 5 � /� �G � .'I •��O Q O O _
ADD
� �I om exempt from the Iicensing requirements as I om a • ' J�i"T �--� L?E1���7 i � . _ _• • � �Q�Q c=i
. licemed archi�eU or a regis�ered professional engineer (� �-.�.D� ALTER ,� FINAL n�
, oUing in my pro{essional mpocity (Setlion 7051, y(i'`4�Ls.�a � �L�i � REPAIR � DATE �.j �� . 0 1 ' 5�$.� _
' � B�siness and Prolessions Code). use OF FINAI � � �
� E%67iNG9L G.1� S� Y' DEMOL ❑ B �
Lic.or Reg.No. Da�e . APPUU+Ni, � TEI.G` y , .
� -�� OWNER-BUILDER DECLARATION ' «RiNt� U �NO. 7 O
I hereby affirm that I om exemp�from�he Contractor's ticense �a,� � � � .
...low for the following reazon(SeUion 7031.5,Business and ADDRE55 � U'-1
Profess�oos Code): . . vaeser+r �1 5 6 9 A
❑ au�ioiN� . .
I, os owner o1 Ihe property, or my employees wifh ADDRE55
wages as Iheir sole compensarion,will do�he wark and . , . , . �� ��•��•�3—.
' tfie s!rutlure is nm intended o�oHered for sole(Seciion ����TY � � �
7044,Business and Professions Code). rnOviNG � � TEL I • •�l Q 8 Q
I,os owner of the property,am exclusively roMroUing �ONTRACTOR NO. -: _
wifh licensed contractors to mnsiroct the p/oject(Sec• qD�RE55 � � ,�j�,�4 a 8 O c� ,
� � �ion 704a,Businezs and Professions Code). � - � ' . . �
REUUIRED TOTAL SETBAIX FROM ex�sT. . . � � 0 21 6-�82
- CONSTRUCTION IENDING AGENCY � Sei BnCK YP.RD HWY PROP.LINE WIDiH � ' , ' � � '
� I hereby offirm ihal there is a construction lending agency for Fk�N, � . �1 6 B 2 A ��
ihe perFormonce of the wa�k for which this permit is issued P.l. �
. (Set.3097.Civ.C.). . SIDE .. . . . ' � #� � � � � 1 .
P.L � . ' . , . .
Lendei s Name • [ ',�I - _'.• � 8�rJ 0
P.C.Fee S O � � Permii Fee ��r' U V - '
Lender's Address �/ p � Q' � � �
I certify thm I hove�ead this applimrion and s�o�e ihot the .f- . cf D�0� issuanre Fee O•S� �.�� 8�l.5�� _
,� obove in(ormotion is mrrect.I agree lo comply with oll Counry� in�esi�ga��an Fee �� - � p� ' � � " � �2 2 b—8 L � .
ordinonres and Siole lows relo�ing to building tonShuUion, ' Toiol Fee J ��d - -
he�eby autharize epresen�alives of this Counry to enter . .. . .. . . .
�� -p n the a6ove- e �i ned openy for inspe�ction,�pu�rpos�es.� �
, � /^/L.,.�X) - SEE REVERSE fOR EXPlANA70RY IANGUAGE � ' - � ' '
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