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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 • ' ign .i Applicont or Agm� Dote , , �� ;-'! n S o a 3 " �' Ce N o o ,.o ��' =.,,� . G1 � �? x �- z -� � ° O o ° Q _c � � - �•o�.. ma `� o m m o 0 `�� � � � =? .� 3 W�� �o �t ' :,�,- .:o �� � � o o � o o �• o r� q�0 I . '.v -c m W t�- o�o . 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