HomeMy WebLinkAbout1282A 1570A 1679A (6) WORKERS'CDMPENSATION DECLARATION ... . _ . . ' �
I hereby affirm ihot I hove a ce�tifimte o��e�,e�,�o se�f . . - - APPLICATION FOR BUILDING PERMIT.
-insure,o�o terlifi[ale o(Workers'Compenslion Insurance,or
a ceni(ied copy ehereof(Sec.3800,Lab.C.) . COUNTY OF LO$ANGELES BUILDING AND SAFETY �`Qa
PolicyNo. Company �y
�. Ces�iiied copy is hereby fumished FOR APPLICANT TO FILL I Q noosEss 154 ,LS�M[� OJ�
�� Certiiied copy is filed wi�h fhe coun�y building inspec- BU4�iNG � -
tion department. ADDRESS �� O�C�!+QU LOCALITV
� �- � �1 NEAREST
Da�e�� Applicani �' CITY l7 ZIP � CROSSST,� S '�!� -
� ���CERTIFICATE OF EXEMPTION FROM WORKERS' ' ' � NO.OF e�DGS. ASSESSOR �
�' -� � - COMPENSATION INSURANCE ' � SIZE OF LOT . NOW ON LOT MAP BOOK �� PAGE PARCEL
' (This seclion need not be completed if�he permit is for one 2 USE ZOrve /�wa - . 1^�
hundred dollars(5�001 or less.)• • � ittACi d.7 BLOCK LOT NO. �'� NO. �5 d.�,� � S �
� /�. TEL. SPECIAL a
OWNE IC� (�b NO. SI" � CONDITION$
I�cerliiy thot in Ihe performance of Ihe work for which this - �
�ISTRI�T GROUP TYPE FIRE PROCESSED BY
�permit is issued,I shall not employ pny person in y monner qDDRE55 � ���0 . CONST. ZONE V
so as l0 6ecome sub�ect lo fhe W ers'Comp ion L ws. ) �O � C
Da�eZ~2� �Applicanf ' ��TY � � Z�P L`��� SfAiISTICALCLA IFICATIDN 1 ` APT.�'CONDp. - �O
. NOTICE TO APP�ICANi: If, ofrer makin i is eriiflca�e of aRCHITECT OR � - Te�. .
E.emption, yo�-should became subjecf the Workeii ENGiNEER NO. CfA55 NO. DWELL.UNITS_ CW,
-Compensolion piovisions of Ihe labor Code,you must forlh• - qD�RF55 � � (�1 t/ SEWE2 MAF Z
�with camply wiih zuch provisions or fhis permit shall be �
deemedrevoked. . . � - � CONTRACTOrt P�j� � - - BK. PG, VALIDATION ,
.LICENSED CONTRACTOR$�ECIARATION � � liC.
I hereby off�rm ihai I am litensed under provisions oi Chap�er 9 . ADDRE55 . NO. VALUATION ' �� 2��2{� �
(commencing with Seaion 7000)of Division 3 of the Business and �i�. \� �O� . � � ' '
Professions Code,ond my license is in full force and ef(ecL� fITY � - � ' CtA55 5 �•��.�••.2 3
' SQ.FT/�� NO.OF � NO.Of CHECK � • .g 5 b 0 �I
License Number Lia Class 5¢E ✓ STORIES FAMILIES ONE. � �
�ESCRIPTION OF WORK s '�
Canimctor Dare NEw ❑ z(�� (�Z� .'. .8 S 6 0 c=+
� I�am ezempl irom fhe licensing requiremenfs as I am a �' "7 '��j.�N� ADD � . � '
licensed architect or a regislered professional engineer . ., , ., ALTER � FINAL � . Q,�,� 5�-$2 �
acting In my prvfessionol capociy (Secfion 7051, S� �, REPAiR � DATE I. G � � �
� Boslness and Professlons Coda). USE OF _ ^ 2 r ll� � - �
E%ISTING BLDG. •V r V O W r- DEMOL ❑ By A� �1 .
LiC.or Reg.No. -DatB APPLICANT �' TEL �' . � - - .
` -- - OWNER-BUILDER DECLARATION- � - - �(PRWT1 N . � O � / ,
I hereby affirm that I am e.emp�from the Contracmr's License � .C. . . � . .
. Low for�he following reoson($eUion 7031.5,Business and ADORESS 11 �
�� s�,oa
ProFessions Code): - FaE en,i � � ��
, O . . ' . . . , BUILDING, . . . . . .. ,•
-I, as owner of fhe properfy, or my employees wi�h nDDRE55 '�� � '�TJ
wooes as thxir sole compenso!ipn,will do tha work ond
� �� �tha shuUure fs nol IMended or offered for sole(Section � ��A��TY � � � �.•��5��,�2 Q
7044,Business and Professions Code�. MOVING TEL. '
. ❑ CONTRACTOR - NO.. . , � •:� �5�;2:O
I,as owner of the property,om exclusively confrocting c_,
wi�h licensed contraUors b mnstrutl tha project(Sec- aDDRE55
- �tion 70a4,Business and Protessions Code). -�- � � � � - (]2�(7�$,2
REOUIRED TOTAL SETBACK FROM E%IST. � '
CONSTRUCTION LENDING AGENCY SET BnIX YARD HWY PROP.LINE WiDTH � � � - � � �
� I hereby affirm tho�there is a mnstruciion lending agency for - FROM � '
the performance of�he work for which�his permii is issued �a.t. � � � �� 6 7 9 A
�.. (Sec.3097.Civ.C.I. . . . SIDE . .. . . . . . . . _ ,
P.L.
.. Lender'SName ..._ . (7 \ . . . . #i�:���'�.�.� ,
� P.C.Fee S OS. V Permt�Fee Uf/ � ���..��_�q,5 p
iender's Address 6 ! . �
I certify fhol I have read this applicolion and slale ihat the ��• .yO Issuon<e Fee d'J� ••�1 7 9 5 0�
, obove informotion is correcf.I agree fo wmply wi�h all CouMy Inves�igoron Fee � � � � - ��� � / � q �
ord�nances and State laws relo�ing to bvilding[onsl�u[fion, Tobl Fee� 'I•J U � O p 2 G"'$2
and hereby auihorize represematives of this Coonly to enter - . �
� up n ihe above� entioned property for inspection purposes. ,
� � �8z. -- � � SEE REVERSE FOR EXPIANATORY LANCUAGE - ' �
'� $ig r of Applicani,, 9en1 . Dote �. . . ��'�
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