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HomeMy WebLinkAbout1281A 1571A 1680A (6) 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 � a�q of Appl�can�or Agen� � Doie �� m-n r r m -n v+ -n 'o r tn „'u � G� ?± 'S �. o C _ nx o o , o ino� o o nv �� � m o �o � c �' T f° 3 , v �- �T'O ` � � �' � ^ m � � � o � I - 'j � 7 � � fD C1. O._' 7: fl r n O. fD � 1.�'1. 7'. fD S ; . O �� I�� O ;G ' O� n-� �D �O . `� tl: � n 1 m• f7` � �-7 � � .7 v � O !i� p � N � Z x � ._ " 17 7 O 7 a (1 7 . 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