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HomeMy WebLinkAbout1398A 1868A . WORKERS'COMPENSATION DECLARATION ___.. . �� � � � � � - � � � I hereby affirm �hat I hava a cerlificate eE�o�ze�,�e 5e�f , . APPLICATION �FOR BUILDING��-PERMIT � insure,ora certifimte of Workers'Compenslion Insurance,or . o cerrified copy tbereoi(Sec.3800,Lab.C..� COUNTY OF LOS ANGELES � BUILDING AND SAFETY PolicyNo. Company � Cer�ified copy is here6y fumished. � � FOR APPLICANT TO FILL IN ^� noosess d � �� L�� � ,� Cenified copy ii filed wiib the county building inspec- BU4D�N6 ^ /�� � �tion deparlment: ' ADDRE55 � d}J f�� LOCAIITY /7'/" f NEAREST Date Applican�� � CiTY� �S� � ZiP fG�S CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' . NO.OF BLDGS. � n55E550R � �- COMPENSATION INSURANCE � SIZE OF LOT . � NOW ON LOT MAP BOOK PAGE PARCEL �(This setllon need no�be completed if the permi�is for one� 1 USE ZONE nnnP _ ��� � hundred dollors($100)or less.) . iRnCi OLOCK� LOF NO. �` � ,„ 5�an� } v d I'certiiy ihot in the performonce of 1he work for which this OWNFR '� � � � CONDITIONS � 0 permil is i55ued,1 shall not employ any per5on in any monner DISTRICT GROUP TYPE � FIRE PROCESSED BY (J � ' so as ro bemme su6ject to the W ers'Com n afion Laws. - ADDeESS (' �' , ,/O CONSS�j Z,SpI� �7,f /� O ,, /� CITY T • ZIP • .J !�i' F Dale Z APplicant I STATISTICAI IFICATION APT. CONDp. V `NOTIC TO APPUCANT: If; ofter moki 1 '-Cerli(icafe o ` ARCHITECT � TEt. ��'1� � . , W Ezempfion, you Should become subj0cf �o ihe Wo�kers' ENGiNEEti � V NO. CLASS NO._y�_DWELL.UNITS � 0. r� N Compensalion provisions of the Labor Code,you must forih- . qDotie55 �y�-% ry SEWER MAP `- � with comply ith such provisions o� ihis permit shall be n ' deemed revoked. � �� . CONiRACTOR yys �.� BK. vG, VALIDATION�. � � LICENSED GONTRACTORS DECLARATION- � . LiC. . � � � I hereby atfirm thot I am litensed under p�ovisions oi Chapler 9. __ ADDRESS .NO. VAIUATION . ���.3 9.8 A' „(commencing wilh Section 7000)of Division 3 oi the Business and - ��� / Professi4ns Code,ond my license is in full forte ond effect CiTY CLn55 . - a �S t�7� � � � � - , � - � , SQ.FT. NO.OF NO.OF - CHECK � � "#� ���I�2`3 License IJ�umber Lic.Closs SIZE STORIES FAMILIES ONE � ' N� s � . .gQ80 �ConVoUor � � - Dafe DESCRIPTION OF WORK ADD . ❑❑ . . . . •,� �$Q 8�� � � I am exempt irom the licensing requirements os I om a � ! � licensed archi�ett or o registered p�o�essionol en9ineer. . . .. , AITER ❑ . DA EL �[l ��'^ 0 2�� �8 2 � � etting fn my professionol capadfy �Section 7051, REPAB � � � " � Bosiness ond Pro(essions CodeJ. � use OF • / - FINAL E%IS71NG BI�G. - � DEMOI ❑ BY Y��� . Lic.or Reg,No. Dole' APPIICANT TEL - � - � � � OWNER•6UILDER DECLARATION � PRWT � NO. G � I hereby aifirm that I am exempt from the Contrac�or's License C`- . . � � - . • �Lew for the following reason($ection 7031.5,Businesr ond ' aDDRE55 � � .�►�1. , � � Professions Code): FRE ENr BUILDING - � �I, as-owner�oi�he prooerty, or my employees with AODRESS � R� 8 b,S�A� woges os iheir sole compensorion,will do ihe wo�k and � � - �� tha structure is not imended or offered for sale(Settion ���`��TY ' � #� •��'• •�� ' . 70aa,Business ond Professions Code). MOvwG . TEL . CONTRACTOR NO. � I,os owner of fhe properiy,om ezclusively comrocting � .� •�1 p 9,5 0 . wilh licensed contratlors to tonslruU Ihe projett(Sec- qDDRE55 - tion 704d,Business and Professlons Code). � ' . . � � " •,� � Q 9,Jr Q� �REOUIRFD TOTAI SETBACK FROM E%IST. ' CONSTRUCTION LENDING AGENCY SEl BACK YARD HWY pp�P.�INE WiDTH , � I hereby offirm�hot�here is a construction lending agency(or . FRONi . O���7—H Z ihe perfo�monce of the work for which this permil is issued P.L . . � �� . (Sec.3097.Civ.C.). .- . �. SiDE . . . . - . ' . . . - . P.L lender's Nome � - � � � ' P.C.Fee S �. � Permit Fee 1 . Lender's Address . .. . I certify tha�I hove read�his opplitaiion ond state ihat ihe � ' , issoonce Fee . �� . - above informalian is mrrecl.I ogree to comply wiih oll Coun�y Invesiigo�ion Fee -� �� - � � � �o dinancez and Stare laws rela�ing io building construciion, To�al Fee ��r. sb . � d hereby a�i ori e represenlatives of this Cou ty to enier � - on the abov -me iLon �property for inspeUi n pu ozes. . � -- C -3 . - � SEE REVERSE iOR E%PtANATORY LANGUAGE _ -, ' � n r�re oF A limn ,. ,_. � ole . . ' � - 7s 2 0 o .. _ `- _ . " ,� ,� o•'. � G� m ,� A ' � , N 7 �c�o 0 0- � S � 9 Q ,d � 'O O ' '•n'v �p, d1 P .p :: T' . . O p Q. ^•p ; .�.0• n � O" n Oc • . , ` �.O�. O �. O'� p . �0 p . -� (17, t9 .�. iD p_ y � � � i-7 4•*o � A . ' . ' 0 n O � � Q� a� �A. ? � � m � O j' 6'. 'y � � � 0= 9 m ' � .� � � O Q�.� a, O O �s7 � -G.n,,. . _ . � • 't O a a c� 3 , o i�'� �o ,Z� -'o . . Q . r .,, ci Z s ,fl m, 1 0 ... � �� °i S �o � �• � o ' �-� ;.-,i . o � N o\ ^..2 x o f � - �. a ~ a M m � y � o R°a � � o_ -� o . 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