HomeMy WebLinkAbout1280A 1568A 1681A . WORKERS'COMPENSATION DECLARATION .. . . . - �
.,I hereby oifirm rhat I have a certifitoie oi�o�$e��,o 5e�f . � . � �APPLIC�ATION FOR BUILDING PERMIT
insure,or o terti(imte af Workers'Compenslion Insurance,or �
,a certlfied copy thereof(Sec.3800,Lab.C.) . � . COUNTY OF LOS ANGELES � BUILDING AND SAFETY ��Q�
Policy No. � Company - �
BUILDING ty C O�
� CeNiF�ed copy ts hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �1
_❑ Cer�ified topy is filed wilh Ihe tounty 6uilding inspeo BUILDING lrT �\tA� �
lion deparfineM. ADDRESS ���� � �'� ::� �% LOCAUTY �
Date - A licant CITY � c,]Q 4�I.yL '-,� NEAREST � n_
pp ZIP CROSS ST. V\
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. ASSESSOR
� COMPENSATION INSURANCE - SIZE OF LOT NOW ON l0T MAP BOOK - PAGE CARCEL
(This section need not be completed if iha permit is for one q u5E zONE rowP
hundred dollors(E100)or less.) - . . TRaCT J d�� e�OCK iOr No. b'( nlo. - �`�, _
an- /,� L. .. C„^ SPECIAL r
OWNER�„M(X: LU(y '`\ CON�ITIONS a
. I terlify thot in the performanca ai ih�e work for which this �
� permit is issued,I sholl nol employ any person in any manner # DiSTRiCT GROUP TYPE FIRE PROCESSED BY V
A�DRE55 � L V � Q � CONST. ZONE
�so as to became subjeU to_the Wo ers'Compen tion Laws. _` G \Q � � O
'DaIeS�Appli[anf ` CITY !v E ZIP ��IS STAiISTICAtQAS51VICAiION APT. CONDO. V
ARCHITECT 'y, 7El
'NOTICE TO�APPIICANT: If, aHer making his Certificale oi �- - � - �
� �Exemption,�you shauld become su6ject the Warke�s' ENGwEFR �LG�� NO. �d'� CLASS NO. � DWELL.UNITS � tL
.Compensation provisions oI�he Labor Code,�you musi forth- � N'F'� �,�—�,� . y
wi�h comply with svch provisions or.th�s permit shoil be A��RE55 � SEWER MAP �
deemed revoked. , � � � .�'j TE�' . - BK. 'pG, � VALIOATION .
� � ' � ` GONTRACTOR- NO.
-� -IICENSED CONTRACTORS DECLARATION - '` ���, ; I
I hereby affirm�hot I am licensed under provisionz of Chapter 9� � . aDDRE55 . v[�i- . NO.� VALVATION
(commencing wilh Section 7000)of Division 3 of Ihe Business ond ��� .
Prafessions Code,and my license is in full force and effed. . . CITY � CLn55. 5 1�p�� �� 2�;�A
� SO.F �7 C NO.OF NO.OF CHECK - • '
License Number Lic.Closs SiZE L_G- STORIES FAMItiES ONE �����• •2.3
E .
DESCRIPTION OF WORK •�•
� Con}racfor � Date � � NEW ❑ .�� 3'3�,• �. $5,(�Q
� I am exempf from the licensing req�iremenfs as I am o � . A�D � , � �'�8 S 6��
licensed archileU or a registered professional engineer . .. � ,,( AITER � �FINAL/- tJ d .. . .. . �. , �
acting in my professional capotity (Seuion 7051, �d Vai REPniR � �ATE ���/` �� . ���� J��'a�2
• Businesz and Professions Code). . use OF ~ � �
' � � EXISTING BLDG. � - � DEMOL ❑ BY A� I/f��
lic.or Reg.No. Date APP�KqNI L TEl Q L� . �
' � `� OWNER-BUILDER DECLARATION � WRiNT1 w� ' NO. I�Ip -
I hereby affirm that I am exempt from the ContraUor's License C �� � �� S G H A �
Law for the foMowing reoson(Section 7031.5, 6�siness and ADDRESS � /S` U.
ProfeSsion4 Code): -' „_- ' ' � PRESENi
#. .;. .23
, ❑ . . : . BUILOING .. . -. ._ . - . . . . .
I, os owner of�lhe property, or my employees with ADDRE55
woges as Iheir sole tompensation,will do Ihe work ond . . � ' � • •(��`L Q �
- ' the shucture is not intended ar ofiered(or saie(Section �aA�iT� ' � - � - -- ' . ' -�
� 7044,Business and Professions Code). MOVING � TEL. • � �(��2��
I,as owner of�he properiy,am exclusively conlracfing CONTRnCTOR NO.
with litensed coniractors fo con5lr�ct Ihe p�ojecf(Sec- qDDRE55 0 2� 6�8'2
tion 7044,Business ond Professions Code). �
REOl11RE0 TOTAI SETBAIX FROM EXIST. '
CONSTRUCTION LEN�ING AGENCY SET BACK YARD HWY pROP.LINE WIDTH ' �
- I hereby affirm tha��hero is a consnucr�on lending agency fo� - � FaoNT �� 6 a� A
the performance of�he work for which this permi�is issued � p.t. ' �
, (Set.3097,�Civ_C.). . . - . � . SiDE � � - � -- � � �
P.t. #;�.�j�:•�•;� �
lender's Nome �' r )O/ �J �
lender's Addreis - P.C.Fee 5 a � Permii Fee (Q(/ l'u � • 1.9_4 5 0
I certify Ihal I hove�ead this application and state thoi�he `}' h. 'Q Iss�ance Fee �� ' •�• 1 9 4 5 0 c=.i
above informafion is correcf.I ogree lo comply with all County__ ., i�vesiga�ion fee - A � - �
or inonces and State laws relofing to building consiruction, Totol Fee" J��J V � �2 2 6�8 2
a hereby outhorize represenlatives of Ihis Ca�nly to enter , � . .
�-p n ihe abov -m ioned property for inspection purposes. � �� . . �
- � ��r-�L - SEE REVERSE FOR EXPtANATORY LANGUAGE • '
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