HomeMy WebLinkAbout1398A 1868A (7) . 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 _ -, ' �
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