HomeMy WebLinkAbout1281A 1571A 1680A WORKERS'COMPENSATION DECLARATION .... - - � � - . � �
I hereby a(firm that I have a certificote of consent ro ge�� APPLICATION FOR BUILDING� PERMIT
insure,,ar a certificaie of Workers'Compenstion Insuronce,or ,
o cerrified copy ihereot�Sec.3800,�ab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ��-\(��
PoBcy No.� -' Compony
BUILDING
.� _Cerrified copy ia hereby fumished. FOR APPLICANT TO FILL IN � ADDRESS ry � \ ..
� Certified copy is filed wilh fhe mvnty building inspeo- BUII�iNG �j-� (� . ,
tion deporfinenY . - ADDRESS �Ll� `�l�bJ�� ���. LpCALITY n'C�CSt�
� � � � f NEARE57 (��
Da1e �� � � Applicont - ' � CITV� {-� ZIP i � CROSS ST. � �!\��.i`�� �
�� 'CERTIFICATE OF E%EMPTION FROM WORKER$' � NO.OF BLDGS. nS5ES50R .
� � �COMPENSATION INSURANCE SItE OF LOT. NOW ON LOT MAP BOOK PAGE PARCEL
- (This settion�need not be compleied if the permit is for one USE ZONE htna -� �
hundred dollars(5100)o�less.J . . TRACT� �� BLOCK lOT NO. 0""I NO. 1�3- }
' 7[� C TEL. Z'� l� SPECIAL y
OWNER V A t� Ib fi ' �S � CON�ITIONS �
I certify ihal in the performonce of the work-for which Ihis � Q
permit is issued,I shall not emplo ny pef5on in an manner ` 1� '�(� �ISTRICT GROUP TYPE FIRE PROCESSE�BY V .
so os to become sobject to the W en'Comp ns h n Lo s. ADDRE55 ( Z 1 L� �.V J. `O � CONST. 20NF �� O
�/1 �( �� GIiY ,y1��1��4 ZIP /Z�'J F
Date�L�Applitan ' � r STATISTICALCtASSIfICATION � � APT. CONDO. �J
� NOTICE TO APPLICANT: If;after mokin �hi Certificote ol ARCHI7ECT OR TEL'/J��(O� �y
Ezemption, you should become subje the�Workeri' ENGINEER � r NO�I CtA55 NO. DWEII.UNITS_ 6.
Compensalian provisions oi the Labo.Gode,you must forlh- ADGRESS � SEwE2 MAP Z '
wiih comply.with such provisions or Ihis pe�mit sholl be '- .
deemed revoked.. � . � � � ��E�• _ BK, p�, VALIUATION
' CONTRACTOR � O. � �
LICENSED CONTRACTORS DECLARATION - � ' �i�. .
I hereby aifirm ihal I am licensed under provkions of Chapler 9 aDORE55 _ NO.�- VALUATION
(commencing wi�h Seciion 7000)of Division 3 of the Business and. LIC, . � � �'� Z$,� A ' .
_ Professions Code,and my license is in full force ond e�feU. CiTY � � CLA55 S�\ O�d .
� " 50.F NO.OF NO.OF CHECK -" �r� � �.�2 3
li[ense Num6er ' � Li[.Class SIZE O STORIES FAMI�IES ONE � /� ' � � . ,
DESCRIPTION OF WORK NEW ❑ E� 3/ /� , �� � ���,6 O
Contraclor . .. ' � Dote .. �. . . .
� �� I om eaempt from,the licensing requirements as I am a r^��-r'�� �� .�•�v. A�D � � � • • •61,6 p c.=.i-.
licensed crchitect or a regisfered professional engineer , , . , ALTER � FINAL - -� � �
� , acfing in my pro(essional capacity (Seclion 7D51, REVAIR � DATE ��� Q.�.�5--8,'Z
Business and Professions Code). USEOc BY Al�t�-�I�`� -
' � � � E%ISTING BLDG. � � � � � � DEMOL ❑ �•�,'_
Lic.or Reg.Na. . . .. '. . . Dote AVPLiCANT C TE4 . � . . . .
�� �- OWNER-BWIDERDECLARATION� -� � - � PRMT .,w1� �.NO. � �- ' .
I hereby affirm that I om exempf(rom the ConiroUor's License ,S� I f���I' ' � - ' �� �
Low for the following reosOn(Section 7031.5,Business and AD�RESS L -
Professions Code): . , �� HaeSErvi � - .
�157,1A �
BUILDING .�
� I, os owner of fhe�praperty, or�my employees with � � ADDRE55 � tt•�• • •2 J �
woges os thnir sole comp=nsa!icn,will do Ihe work and � , � �
� the strocrore is not imended or offered for sale(Section � �- ��A��TY � � I ••6 2 4.0 . � �
� 7044,8usiness and Professions Code). MOVING TEI. . . � �
CONTRACTOR NO. 0=
-I,as owner of the property,om ezdusively mmracfing !��• •6 2 4 0
with licensed conrraclors b mnstruct tha project(Set- qDDRE55
- - tion 7044,Business and Professions Code).- -- - - �2� 6_$2 -
REOUIRED iOTAL SETBACK FROM E%15T. � � • � ��
CONSTRUCTION LENDING AGENCY SET 9ACK YARD HWY PROP.IINE WID1H � � � ' �'
� I hereby offirm�hat rhere is a tonstruction lending agenty for � FkON� A
ihe performance of�he work for which ihis permii is iswed o.L �1 6 8 0 A -
(Sec.3097.Civ.C.). .. . .sioe . � .. . . . . . .
P.l. #��:�:• • •��
lendei s Name 1
' P.C.Fee S lp1�� Permir Fee J� � . � �;��.b�5 Q �
Lender's Add�ess . o . �
�I ceriiiy�hat I hbve read�his applica�ion and sio�e thm the � (r�',�� issoonce Fee � D•�O ' ' • 1 6 3.5 0 c=a� �
; obove informoiian is correcf.I agree ro comply with oll Coumy . _ in�es��garo�fee . - . ��� �
ordinontes and Stale laws relating fo building conslruttion, To+ol fee /G 3. ..r�� j �0 2 2 b.-$`2 �
a here6y authorize represenlatives oi this County to enter � � 1
u n the obove entioned properry for inspecfion purposes.- � . , ` \ �
c 2-Zb-�'Z , ` � -
SEE REVERSE FOR E%PLANATORY LANGUAGE �
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