HomeMy WebLinkAbout1476A 2313A (8) ' " ��WORKERS'�COMPENSATION DECLARATION �
� he�ebY aff��m �ha�� hove a certiffm�e af�o�se�„a se�. APPLICATION FOR BUILDING PERMIT
ins�re,or o certifimfe of Workers'Compenslion Insurance,or _
a cerY�ied<opy ihereof(Sec.3800,Lab.C.1
,, COUNTY OF LOS ANGELES BUILDING AND SAFETY
� PolicyNo._�_Company �1i�P'7,E.'G�.T �
� Ce�tified mpy is he�eby furnished. ' FOR,4PPLICANT TO FILL IN Bu��o�N�,Y�/"� �g�/�`� f -��m�•iG .�tt✓',6�'-
ADDRE55 G��'�~ �
� Certlfied mpy is filed with rhe munty bullding Inspec- e�ilolNG .�`t� > ,p
tion deparfinent. ADCRE55 (�,,,ay+-� LOCA�!TV ��k-r-�c..ey�s�cs �CL�-�-�
NEAREST
oare � `�." aPpi�<o�f arv �1 �J zio cRoss sr /�r P.c> �`�'�°e-<
CERTIFlCATE OF EXEMPTIO�OM WDRKERS' n'O.OF BL�GS. ASSes50R - f
• COMPENSATION INSURANCE S12E OF�.6�'" NOW GN LOT r�nAP BOOK PAGE PARC L
(This secfion need not be completed i{ihe permil is fer one C �^y USE ZONE N✓+P J� � �
. hundred dollars(5100)or less.i iRqCT ,'� BtocK LOT NO. �f NO. � '>' -�T� �
I certify that in the perfcrmance of the work for which this O`NNER V1V" }JO ��. "��� CON�TIONS �.-�a��/'C;� �
ermlt is issued,I shall not em I an �� �yp �^V� DISTRICT GROUP TYPE FIRE PROCESSED BY y
p p oy y person in any manner / � CONST. ZONE
: sa as to bemme subject to the Workers'Ccmpensation Laws /+DDRE55 �.�T'`�1�51� \�`�\ f� � ,� �
� Date Applicant CIN�� �f � ZIP �� S?ATISTICAL CLASSIFICATION �-� AP?. CONDO. �
ARCHITECT O 1E
NOTICE TO APPIICANT: If, af�er mok�ng thls Certificate cf ENGiNEEa lP Pi��'�ZJ CLnSS�O.�owEu,uNiTS_ �
Exemptian, you shculd became subject tc the Workers' /��} �J �
l.Compensa'ion provisions o4 the Labor Code,you must forih- qppRE55 � � ' '...Fi"•' i\ SEWER MAP �
""� w�dh wmply with such provlsions ar this permit shall be �"
e�.�. E` VALIDATION
�deemed revoked. CO 7RA TOR •�CY p �3« BK, PG.
� LICENSED CONTRACTORS DECLARATION �,c.
I hereby affirm thot I am licensed under provislons of Chopter 9 A�DRE55 .�j � N ���� VALUATION �]� ['�,(��
(commencing�mith Section 70001 oi Division 3 of the Business and , �iC. �
.� Professions Code,and my license Is in full force and e�fect. q?v C . -' J�,. CLa55� � ,� ��/"��
- '�'p e o e o`Z�
� ,{ SC7.FT. NO.OF ,�C.OF CuECK
. License Number `��`Q����� Lia Class � SIZE STOR�ES FAMRIES ONE � ` E o R Q��
Ps.., DESCRIPT�ON O�WORK NEW
� �
, Contrqctor("'�Gi'Ll�1'�1 [�,1�-Date � ❑ e. � ��;�,v��
� I am exempl from the licensing reqvlremeMs as i am a {�`� ADD
��`� a�rea FINA ��.
licensed archlteci or a regisfered professionol engineer ❑ r� �L. U"��
.�.�+� DATE
pcting in my professional capacify (Seclion 7051, }i„/ RF.PA�,R � b
Buslness and Professions CadeJ. USE O� DEMOL F�N'�' j
x. � E%IS?ING BLDG. ❑ By �,5.
�Lic,or Reg.No._ Dpte APPLICANT T L c�, ,
OWNER-BUILDER DECLARATION iPRINi` -1�3ti
I herehy affirm thal I om exempt from ihe Conrracrar's Llcense `
Law for ihe following reason(Section 7031.5, Business and AJDRE55 I � �
Professions Code): , PRESENT � �
, ❑ B;,iILDING
I, as owner o4 the property, or myaemployees with ADDRE55
- wages as their scle compensarion,will do the work and
• ihe struc;ure is nct intended or cffered for sale!Sec'ion LOCA�iiv
7044,Business pnd Professions Ccde;. MOVING T'cL =L 3 1.3 A
- � I,as owner of fhe property,am exclusively confrocting COhTRACTOR NO
with�iicensed ron!roclors to construct the project iSec �m m e�m •.�
�. tion 7044,Basiness ond Professions Ccdel. ADJRESS
� tONSTRUCTION LENDING AGENCY REOUIRE� TO7AL SET3ACK FROM 'X!ST. � ° I O�J,v.�O �
SET BACK YARD HdJV PpOP.L'NE `N DiH
� I hereby aifirm Yna•there is o cons'ruction iending agency for FRONT � i' 2
the performance of the v.ork*or which inis perm�t is Issued p L ° i :9,5 0� .
;se<.so9�,c�.c;. s�e e G,2 3—�2
Lender'sName �'V��.F'�-�-� F�7'� �� PL
_ �e�der s nddress��='��ti� ��`� P c Fze 5 ({• �C� Pa�m��«a c ;
I certifv that I have read t^is�appllcofion ana stote that tne Iss., ceFee •.S +`
� a6ave information is cc�reU,I a9ree to ccmply w;�h all Ccumy tr.��esngai�o�,Fec �
� ordinances ond State Icws relo��,ng!o building<onrruction, ioral Fee (; �.S � .
end hereby authorize representahves cf ttiis County to en•er �,.''
� upon he abov "nticned oroper'y tor Inspechon purooses. - � ' � -v
i 1 j ^�^ ��� SEE REVERSE FOR EXPLANATORV LANGUAGE
� ignol�re o�apFl c�n• r Agerf Da*e `'a''s
I
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�,.:, _. _
_._.._..�.�....,_ � ..'"`FlkWS i�J.xeP3'liC.�IdFaT..,..�_.=•.,A9i..}..T��, - iiuSPEC6,�'S N3YES 6'U�NE4t-AEJ.'{Li3ER BECLARfsTIORr
...--...��.m.-_+... .a,w�'��� .- . -- . . . ... . . _ !hereoy affirm ihai!am exempt from the Coniractor's
, '^~� 4-,`-:��_„ti� � ����� � , Literse Law for ihe following reason. (Sec. 7031.5)
� �Pz=N6='" � �u.iress ar.d Pr�f ssions Cods:t3tty ccty ar co:�mry whicF.
�
`'PSa�. r�4s ��Sda. ���e � rcgrslres a¢errnet to car,struct,6d1er,lmfiro&e,dsrraolrso,
� —�---�` or repuiraxy atructur�,frior to its iss•�aKca,also xequiras
i f � I � � tFie apf�dicnna foAsutFi f eranlE Lo fdJz a sigseed sdatemsnd
� ---} . , , . .h4t hs l�licer.sed prsrsuaxt ta tbe prouisrosts nj tfie Cox-
i I T � I � � tr¢csor's License Gaw(Chapeer 9/(mmmrancing w>tfi Sec-
�-----�-�---�- �---�-- , . � ti�n 7QOOJ of�J+vision 3 oJ Phe Business and Frofessions
� � Co1ef or!1 aS 5e is axean[it therefrons and tbe basfsfnr tbe
�_...s�..�,.�....n... - �.._..�.A.�._,._....a.+ � c:l:s;,e�exemption.A:sy vdolatiost cf Settior 7031.5 Gy
�E � �o�u3r^d i �.,.., ,+ � . , any:aph?rcasszjorap�rmltsubjectstFieajrpld:amt6oacivi/
�PG'pgF�`,i' ��"� � �'7�'�y�"'ye y ^ al.�o nct annre t,5¢x ELE IJf/i!!LY¢fLlIOIIdYS S5G0.:
( � Yec Tfa � Gs 8a�srauad . h_.a S f f ( �/
`== -�.L—. —� ' � . � . . � - L: I,as owner af ihe property,or my employees with
�4Ve,er t. ificele _� j` - ♦_ , - wages cs fneir sole compen=_ation,will do the work,ond
�� �
L __1 � . � �- . � . � - tLe struc!ure is r.o9 in`ended or o4Fered for sa!e{Sac.7044?
��1rh Dsaortment ' . . � _ . 9v.s:�roess assdFmfessio?�s Cc+�c:T7ia Conh.actnr'sLieeease
_3'__—__�-- .�—� ' Z.av,�stoe�net aji,(rl��to at;awnes'of jir�per-ty�vbo buslds
�`' or irrpro�es ESer�ean,¢:d wFa doss s:icb varh 1.<frn_=!o�•
rc Qeper ment 1 ` �---�I . � . . , " .f
��' . I. �. � . . - . - tbraugh bis cwn emptoyeos,pmv�3ed tFiat sucb im-
�Grading ! � . . . ... _ , -: , - proe�eme.;Ss ere sor intendel or nfj red far syln. Tf,
,l�ou�eE�er,tbs busldes±g or rar.,.^.:ovemext rs sadd waYhin ona
-�ologict�! . . � . year�d rone�letion, tbr ov;mer-b:�ifdsr wii?Fi¢va dAe
����_ ' Fur�deaz�f provs�:,g thut be d(d.rot budlsl or fs?a¢�rove jo.'
� ���.._...__���__....,' ..�.'____..�.��.
fF^oesfricn Protection i - �— ebe purpose n�`solaJ.
�'�ance;(Ccnopyj � I i -' - rJ I,os owner of the property,am exdusively controc-
_ ��_,�S fing wi!h licensed coniractOrs to tonsiroct She project(Sec.
i � � 7044)$usissess an�Professions Ccde:T'be Caxtra<toe's
�Spacial,E�spectlen j
(Cenc.){�i^,nscnry){;Nel�'in9)( i . :,icsnse Z.ere�daes�e:�s c;fJ�lt'tn en ou��rer o}`prof�crt��tt•1•o
I ____ $uilds er irx}7re::es thereen,and wha cn:n£ructs f.r sudi
Lo?Draineae � . • "—` ��projects u�ith o ce�rtractor(s/l:cexsed fsursuand Co tbe
Cnntrcctor's Lrc�nse Law/.
�Parkin: - �������� , , . . � i �
�_�� � _ `_� . C� I am axempt under Sec. ,B.&P.C.for ihis
! � reason -- �
� i ��
I pafe (Jwner
1��..� .t� �L..,,..a...-,�.�,......a. _
� .�;�a�avcYs � ET:tfm � las;-i��3ur'=�4�:�:i::^c� �.e..pa.._..-A..,..e�,.--..--m.-.•.-.�
, : i = J IP9£?ECiCR'S IV�J'ei5� _
Localion— j —�— —� ~ '
���__
�(Se!back&`!crds) j ��__._ .
.oundation�
����--- Er�..�_._ �—
�Fram��` '��
�l � t'�.?..r
j Energy Insu!a'ien I' E
I . - . _ ,� J !.�.-. .
�La?h/Drywcli—� � �
�Inierior '__'___� � , � .
�x,�,;�� j _:�,�,.;
�,1—��se n,�mbzr-- -
;c�,��.r s��s,ee -- - -----�-
Fine1— '
�Enfer on Froni�� ��J� _ .
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