HomeMy WebLinkAbout1475A 2312A , WORKERS'COMPENSATION DECLARATION �
I hereby affirm [ha�1 have a certifimte of consent to self qppLlCAI"fON FOR BUILDING PERMIT
insure,or o certificote of Workers Compenstion Insurpnce,or
o cerrif�ied coqy thereof c5ec.3800,La6.C.1 COUN7Y OF LOS ANGELES SUILDING AND SAFETY
� POIIcyNo. 2.(e'Z� Company Fht�AA��_T
Certifled co is hereb furnished. . BUILDING �
� PY� Y FOR APPLICANT TO FILL IN A�DRE55 E7"�'�'1 r��� .�-�,u-�-�G � 'L
(� Cenified copy Is filed wnh th ccu ing inspec- BW;oIN T-�6`��,�. ..1-� �(1�' ^ A
��{ !lon deporiment. ADDRES �„+�y�` '� . ��.�x+� LOCALITY /,,,r�r<...,t_.--+--l+ci•� ,�J�1-�C.��
/'� i �7..,�,�p NEA2E5T f
Date .� `y Appl'i�ont � CiTV l � �SA"'Q�ZIP CRC555T. /�N -�`-+-��� ¢+`�u.���^-zJ
CERiIFICATE OF EXEMPTIO FR M WORKERS' � NO.OF BLDGS ASSE550R
COMPENSATION IN ANCE SiZE OF LOT uow On LOT MAP BOOK PAGE nRCE�
(This sectlon need nof 6e completed if ihe permit is for one � USE ZONE �^A/+P /�� �c��
TRAC7 �}) 9LOIX LOT.vO h'O.
hundred dollors($100)or less.j ;-
owNeR p ��.��N`o '3 �3 �/A� coN�iiiaNs �`/'��D�/�S� a
I cerli4y�hat in the per{arman<e of t'ne work For which�his OISTRICT GROVP TVPE FIRE PROCESSED BY �
permll is issued,I shall nol employ any person in any manner 7��.+�� � CONST. ZONE �
A�DRESS��lJ ..` ..4. .µ �
so as to 6emme subjea fo the Workers'Compensmion Laws. �,r� �
l .s-' /'� `"
Dafe Applicant ��ir � � � Z P ����J STA'ISTICAL CLASSIfICATION APT. CONDO, �
NOTICE TO APPLICANT: If, aFter making ihis Certificale of HRCNi?ECT O 7EL q.., � �
Exemption, you should become subject ic th= Workers' ENG�N=ER � � 7 l�3� CiAS5N0 v`-� DWELL UNiTS� y
Compensotion provisions of the Labor Code,you musl forth- qDDRE55 SEWER MAP � Z
with comply wiih such provisions or this permit shall be
deemed revoked. �G ^� ��q TE4""' VALIDATION
CONTRACTOR""'�'t�%� ' 3�, j BK. PG,
LICENSED CONTRACTORS�ECLARATION � tlC
here6y affirm that I am licensed under provisions of Chap,er 9 qD�RE55 � �.v0�' . � VALUATION
(commenung valth Section 70D0;�of Division 3 of the Business and J _�� ` �� �7•��i
Professions Code,and my license is in iull io�ce and effecL CITV . � CLA55 _ S !�, ��
sa �T. � no oF �o o= cHece �° " � •2 3
License Number ��� �ic.Class� SIZE STORiES FAMiLIES ONE S + p °V��C
COnirpCfOr����.'� ��- Dote • � �`L. DeSCRIPTION OF N`JOR�K ` 1EW e V _
� I om exempl from the Ilcensing requirements as I am a {��� 1„��„ P'� � ��+V u
licensed architect or a registered pra4essionol engineer A,'ER ❑ FINAL ,o �i p 2,C 4—8 2
pcting in my professienal capaciiy (Section 7051, R'PA,R � OATE G �,?i �
Business and Pro4esslans Code). USE OF
EXISTING BLDG. DEiJ�O'. � FINAL
Li<.or Reg.No. Date na�uCavT yy BY
OWNER-BUI��ER DECLARATION iPRi�T'� � ' �ti"
I hereby affirm fhot I om ezempt from the Contracicr's License �e�'} ��r�4�`
Law far ihe foilowing reason (Section 7031.5, 6vsiness and AJORESS r 1�5
ProfessionsCode!: cRe n�� �- � -
❑ . - dUIL�ING
I, os owner of the property, or my emplcyees wilh AD72E55
wages as!heir sole compensatlon,will do�he work and
the struc�ure is not intended or cffered fcr sale iSec'ion� ���"��iY z 2 3 1.2 P�
7D44,Business and Professions Code1. n�Ov�NG TEt. , .
� 1,os owner cf ihe property,am exdusively confracting CONTRAC?OR ho, �m e e m s �
wi�h licensed controctors ro consvocr the prejeci(Sec- qoo2e55
� tion 7044 Buslness and Professions Cade). �'e x%9,��
REG�UIRED TO-A�SETBA.{F�O,U EkIST
CONSTRUCTION IENDING AGENCY SEt anCK °A�o N•.vv RCF.�,r�� wiorH
I hereby afiirm thot fhere Is a construcnon lending agency:or �Rp�T ° e k 7 4,5 G%
the per{o�mance of ihe v;ork for which ihis perm�.t Is issueG =�
(Sec.3097.Clv.C1. SIDE ����2�`��
PL
Lender's Name �'��1"��'t�-�C��� v ¢ .
Lender's Address�`-`�IrJ.�`"�'(! +1�'� �7� P���.Fee S ��F'-d�� n��Fee . ��
I certify thm I have read ihls appiiwrion ond state rhot�he isso
above informatlon is correct.I�gree to comply w�ith oll Coun�y �esi�qa���o�Fee � �/ �
� crdinances and Stote laws relating'a builoing wnstructien, rc�al re �,J�
and here6y authorize reoresentotives oF�his Cou�ry ro en�er
upcn!he abo� - nYio�ed prcperty fo•InspecHon purposes. : . . � " '��"� - �- ���"� � '- � � , � - � ,
�( .�+_ .�a SEE REVERSE FOR E%PLANATORV LANGUAGE •
'ignqNre of Appl.co� c4<'.� ����3� '
�.�,____-_____._�-__�.....__.��_„�.�e.._. ,�.. ��.._..�....,_.�......._..�..._.�_..���_..�� ,�r r.
s ��ar�s ro�,��zie�,�aa ' l�dSFECTaR'S F€{DiES ct�: ��-��aa.�t��rcc�aArao�
d-.--.-.<-�...�-.,-.-.-..�.s.-.-- .�,e.--.,.,��--�.-_..�:.. _ __ ..� ._ .__ ._ __ . _ ��-� I hereby affvm?hai I am e:cemp!f•em the Contmctor's
i � - Litense Law for ihe following reoson Sec 7031.5'
�c; � .��.QB�rna�° - � 1
( �. � �"���'�J'�� T.. � Susir.ne,ard?rn,�ssiors Coda:;ry c,';y�r er.un:_y'w1 icT:
Ra�� I'�eke �1o.�Z�:.`.s � :s9uires a fiermit tc tnY.sfYucc,a'ke;impro:%e,demo!ish,
�j—'�---- or rspair er.ro;trrecaure,rrdnr to iu issuae:ce,s.'ac regzlres
�� `�~�~��y ��` >Gf G�7�SLP�RSC#for saaco parn:rozt to ji!e¢sJgaed s;.a.¢n:evtE
, �—�-- , ." , _. , . . ihat be is:r�ar,s�d pursuant aa tfia provissons of:be Cox-
� � � � tractr,r'sd,icense:aw(Cha„�Eer9J(rommesar'a�uiEbSer-
� . --� -- . , t.'ox 7QG0/nf Divisiott 3 of tbe B:uin.ess and Profnssfans
� I CndaJ nr tl ct he ia exene[�t toc-refrom and tbe 8asi.s for tfie
�..,.-a..m.,,�...�„_._.-.,.-p-�_-J�.. - �� cl?eged arcrnptioz.Any violrstion f Secatnr. 7Q31.5 hy
�u�� � 4��'�.'`�'� � a3.�;3m�aivcd � � an��appJicarx;jora yarrnftsuEjeces tbea[ylicana ao a civif
9 �PP'mvai: ar G�egac�-aav�
,i � .Yas f R9a� ` ._ ,. . : _ . . . .. per.a?ey f xat mer�ft.sctt!'vc hundrad tinllars(SjpO/•1:
_] I,cs o.vner of the�roperty,er my�mployees wiih
V!ater Ccrtif mt2 � � . - . _ - , woges cs ihe�r sole compensai'on,w II do the work,and
.�.-,_�.�______��__.�.� � � � " `.� ' -� the shuc�ure's not i�iended or offered for sale(Sec 7054)
���• � - . . Aerss.seu a;ad Prc essiors Code:"I'be Contractor's Litersse
lieni)n Dc-partmant � � j . : .�
�_._....._.-_.___.._.__.—_' � I . •. � .�a:v sloes r.et ay��•F�'t4 6�41G.24P Of pr'oj�erty wha FaE(ds
or Im cv�ss tfi�renn.erd wl o dces such auesfi Frans�d o,�
i F�re ClepartmenT I � . , . . , .. `.` t" f
I _�_�__.._._�_.._-._-_.__"" .
�� rf✓rnugh b:s r,u�n emplrsyce;, ,nmvided Ed�at sucb i»s-
i G��eci,�,� �I ! . . , . Qrnx�cr.:enes are no; intcnded or ofjered for saTr. !j,
f� J�_�.,._:__„� � ' ' , however,dfiabu>!d.'rgnri�rpmveimen>uso�wiib£nnne
���'—��� m�`� � � �-�`'�- eo«o srom. de::on, tba owneribu.ilder u�dll bave Ene
3 GeoloSicci i . .� , �""i 1' .f S'
..V.__._._.,,__�._...�_�y.._�...�,�._._.�_. — . , - _ _ br�rdsx rrf15rovi.ng¢.5at ho diu'xot hulld or zxaprav�e far•
F�desvicn ProPecfie�� ` i tne pu:pose ojc.±¢/. .
ce)��Cc�opy) � � { � -t L' I,ascvmcroiiheproperty,am�xdusrvelycon7rao-
J__T_.._—_� tirig with licensed contractors ro consiruct the project(Sec.
Soeao�Inso�a;ion � � 7044)Bxsiness er.c Prnfessioxs G'ode:2'he Cos+!ractor's
�Co�e.)('�hasonri•j(�A��Iding}I� I _ � ` 6��s or rrr.,h�f es��3 e�e�n f and:y,o�osf'��f�z•�b
�
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Lut Crc inupe � � - , Qro`jects u;ith u conSractorf.c/licensed,�iursuant to the
I ' � - C�xtrartnr's L£cense Law;.
pa:�:ir.g f� � I �_� ❑ i em exempt under5ec. ,B.&A.C.foHhis
�� i I ,
reoson
- '— ". � Dete... .. Qwnae,.,,_,_„s_....,,,
R����ovaia , 7B;m � �r.s�.sa:'ror's�ijr;F;4rc . . . .
! � .�4;��� ' . . ��� MSPSCTCR'S PJOTES
ria��r:o,._____F � _.,—,_._{_.... _�_... .�.�.,.�
�Se9bcck F.Yprds) � j_ �
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�Poundetic� . _
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jF�am.e
iEncrgy!nsulaPior:, -.__� �`y� � �
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Ir;ouse Number-- ^—� -
Corre�t&Posfed �f__
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