HomeMy WebLinkAbout1553A 1757A WORKERS'COMPENSA710N DE�LARATION ��+g
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I hereby offirm ihof I have a ceriificafe of consem to self ' �pPLICA�'lO�Ne FO�RL �I�I�LDING- PE�I�MIT �
insure,or a certificate of Workers'Compensation Insuronce,
or a ce�tified)c�opv thereot(Sea 3s ab.c.) �pUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic�o- - `�' � � �mpan �G� BUiLOING
� Cert'�ed copy is here6y fumished. FOR APPLICANT TO FIIL IN aooeess c�.s � . ���f"ft
Certified copy is filed with the munty boilding inspec- BUILDING f�•J -� , �� �r
tion dep iment. � ADDRE55 6�JV� ��C. , LOCALITY F�C=�L/
) "O� NEAREST
Date J J `� qppliwnt ` � CITV ( �.0 ✓ ZIp CROSS ST. -e��%����
ERTI ICATE OF EXEMPTION FROM WORKERS' NO.OF BL S. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOw ON LOT nnAP a00K PAGE PaRCEL
(This section need nof be[omplefed i4 fhe permit is for one USE ZONE MAF
hundred dollars($100)or less.) TRACT BLOCK �o,No. No. /.1 3 —�'�.S'
� �e TEL. SPECIAL .?
OWNER {J� �� NO. Lr"� CONDITIONS +�-
I certify that in the performance of the work for which this � �
permif is issued,I sholl not employ any person in any manner �y' DISTRICT GROUP TYPE FIRE PROCESSED BV �
ADDRE55 f� } �� b` �� CONST. ZONE
so as to become su6ject to ihe Workers'Compensation Laws. _ � •� � �
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Dafe Applicanl CITV Z�P STATISTICALCLASSIFIG4TION A . CON�O. ?`
NOTICE TO APPLICANT: If, after making ihis Certificate of /+RCHI7ECT OR TEL.
Exempfion, yo� sho�id become subject fo ih0 Workers' ENGMEER NO. CLA55 NO. �� DWELL.UNITS �
Compensalion provisions of the Labor Code,you must forth- qDORESS S@WER MAP �
with comply with such provisions or this permif shall be ,, „_,
deemed revoked. CONTRAQOR � -� 4'� NO.� BK. PG. VALIDATION
UCENSED CONTRACTORS DECLARATION / LIC. -
I hereby afflrm ihat I am licensed under provisions of Chapter 9 ADDRE55/c � NO. - �✓ VALUATION,.��
(tommencing with Section 7000)of Division 3 of ihe Business and q LIC. �// "� < I �F J A
Professions Code,and my license is in full force and effect. Ciiv .� aa5 .� $ �.�`-
$Q.FT f.� . NO.OF NO.OF CHECK �� �. p ��3
License Num6er�%77�� Lic.Class�� SIZE LU ! SiOR1E5 FAMILIES ONE
Coniracfo �Fl��6'�� Date � � DESCRIPTION OF WORK °-F- ^ NEW ❑ $ � � �2�a O
❑I am exempt under Sec. '� -�' ,� .��1Q�,y""' ADD � / e n e j 5,�G�
ALTER Q pA E`�/ �J�� O L, I S�H�L
� „�„ ❑
8.&P.C.for this reason � = REppiR
USE OF DEMOL � �G
��tB' EXISTING BL ❑ B NA�i-�(, _ —
Signature
APPLICAM � TE. Y /���
NER-BUILDER DECLARATION PRINT '}�~ N e'-. '
I hereby affirm that l am exempt from the Coniwctor's License t (+"4 � • -� �
Law for ihe f011Owing reason(Se[tion 7031.5,BUsiness and ADDRE55 O• ��C'� � �
Professions Cade): PRESENT
❑ eUIL�ING
I, as owner of ihe property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
ihe sirutture is not intended or offered for sale(Seciion I.00AUT�' � k �` �F'
7044,Business and Professions Code). MOVING iE�. ,
� I,as owner of fhe property,am exclusively conirocfing �ONTRACTOR NO. '4,-n e _ o �
with licensed[ontractors to consiruGt the projec}(Seo qDDRE55 � r ���'/j
lion 7044,Business and Professians Code). • " `
CONSTRUCTION LENDING AGENCY REQUIRED TOTAL SETBAIX FROM EXIS7 ,� , ;,,__
SETBACK YARD HWV PROP.LINE WIDTH � . _,c: i .^, �
I hereby affirm ihai there is a construcfion lending agency for FRONT
the performance f the work for which�his permit is issued P.L. � �C G��'"�4��y
�SeC.3097,CiV.C.). � , " . SIDE ' - .
P.L.
Lender's Name � � . /
� Lender's Address P.0 Fee S C�j vermit Fee �4•• �'�
I certify that I have read this application and state thot the Issu ce Fee �G�•.S��r
x above information is wrrect I agree to mmply with all County invesiigo��on Fee „�-
'� ordinances and State Idws relating to building construction, Toral Fee %•. `l S
and hareb u�horize representatives of this County to enter
o upon fhe �ve-mentioned property for inspection purposes.
[
��7.�,i,/ _ SEE REVERSE FOR EXPIANATORY LANGUAGE
ignature o Applicant or Agenr pohe �s
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,- . . .. • �'e•;-;iJYY..i'31[i%isc,C3"AT_tt.:f'ION
� P6A�5 Yty APr�LiCANT . . . . -. .... IP SPEL7'flR'S Plq'fE5 r �-� � '
---_ �. �._ ... . . ....�.---�-------_-�----:-u-+..."�..�.»,..-.�•-...,�,+-_.. , I I+.arouy a9tir;r,t;ioi I am exempt from Phe Con��ratlor's
�Tc: Rea4uPnvd I � -- — �-ice�se Law for h To�lo ng rarson (Sec 7031.5)
j I NpprQvsd �{.SN� 4 a r� st.ex i. C ft�):e:i�6�COf{92Ey L'IJ%(H
!�+to,s - 9?�se - 4dc. --�ara I .�-.r - . �t. �r.sdr�� �tjv.c�,,;�P�•:�,den�,or'ish,
L..��z��._...W�c_.
i � -------�- c . � v✓..�rvc>TMo�f, to�� sx+ar,cc,esor��^gu€ras
I /b ahr7 unt f>'s•+r.b;ern t o !�¢ss;essev'sto-ternenx
i�-- I � .^i�.. ��� � . — -- .- - <J-..t.�C�...C_:i"sC'a'?h:tY.;?.':.3 t�O.k.n hTO:�iSi[i9i5�Jf th.�L'an
� _ I ___. traciorx t,ares�se i,_•.;r;G'i•cih:er J%/cavs�m.esuc#g�s�%ti Sec-
�----. . - - - ;:o:�7:')U(,J r��D:r.+:4r,n 3�y`:�e i?xu;•�;ess and Pre:esrnns
� _�c'sJ o>:i¢t he i.c oweni�t tberefrons�and tbe 5c�isfos thn
�_,.��-�.... ..-t,...�.L�-.a.. . --_____--_______'_ , , ,e:cem�hi� ...A.'sEc x.�%t1aJ ns:of Je.i:on 7v3I5 Sy
i _.^.�.,.. . ��a;yuirss.'._ €3a4srRaaeeivmd . . _-- . ` '«,.^decsr..:sorr:;;er;wzEs:sf:�qa:s:hsanfil'easattoaex'vil
f � wy�rovatlsT or A�pravod rrec':;'o.`;,o.<:ra�c€i�uW J�i,•c:�urdrec�1c1?:>rs(�SSOOf.I:
Yes._�h.e '�____ �.. � . .
- i.' I as o c e�.Snc proacr,y,or my employees v�ilf�
������?-� Yo vnll da ihe worl:,and
I W' 4c e 1 s.`d.� I - .. .. -. _�._ _-.. _ p.
�_ _�_ _� - � � "' ' �� 'ie �<s s .e` F.c�c.d .o � cd for sale(Scc 7C4�'
� ;> -> C,,er�:
Vieo!9h�epertr,�enP I . ---..-.. _ _-._ - _— ., . ., : r� �.zss� __ .,�r a_.er'.s.'.s.,ensc
� +.�v.•anc.:no:..y�f,.5 to en oa�,r.�•ar j:reperh�uTin Guilds
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Firc:De�orman> � . -_.___-__'._ . -____ oe r:r.p�ores tn>-ror,;uixd a�i:�dces srecfi u•o:;i�bim.relf nr
I- � -_--_ _-_- 'L•;-nu�fers.s o�cy; a:r,��do'yU.'pr;nidcd sya.Tsrecb inr-
Grcdiny I . . _ . x):o:•.�,. L .._ nnt :::_..�eri n, oj e.�ar.l jc s¢:e, Ij,
I<_.____ _......__...--..-___.--_,.�1-.�—._.__. . _.__ ' ill;�'Ci':Y.P.J^.,J!:[�.'�4t!�n.'eY�.I.."f.�Jf?':: f D ti E4':FJ 1 :9;
Geel�::i�cl � I-`__ . . . — ::zl: j cR:�aoics s� � �� ar`µ .,,�1�1 � fhc
, ��____...— __; � - ' . . - ha.r�,.>;._�`,*-" i . � i l .S a�,r.. r•r.
..I . , - e 7.u- c f � _ s:;:
,7edestrian Pro'ec'en ' 1 � � -
I(=e�ce��( c o ;�) k • - _ . I e r .m e cl s.e;�contrac
I �I ` � I�ry�-i�� � �c .ar <o to c rsi u z h pro�.:cr�Sec
'Speciol �sp c oa � i . I . _. . -_ � ryQ? �. F .. eons c,rd �f n Con�ructnr':
i'Con�J!Ma cn�y`l(V'/s�e ig: � , , 1 c s L�� ✓,�pt -� u r< ..l$��>crt;:e.�l��;
. _�—�_.____ . �� � .Y_ __ _ � I� � , � '.r ad. ,� d v : .tr....(a for sv�J
Lo9 6.a r.c��, � . . -. .. .. , - �,-1 a.... .. , . ..�crl3,�r::er.ni > t:nn
. � �,..._.c�...si,::,sz'... ,
Farking - . -. . . --_ . . -_._ i . . _
____�._,_,._�..—.� I nm exe�ricl under Sac_______.3.F°.C.icr tF.ls
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� - , r:;oso�i__.________._-__._--.--__ '
�_ _ --i � , .. ._. .' ,'. . . „ . _ , _ G�i''_��__ _��t.0.4�„ ,�
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; ��cgTop;>is � 5�ea4o I Iws%��t4esbS4gne4�rw�- ._. .
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Energy Insulatiun . �., . . . �' . �
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�nterior � I �
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Nouse�ur}ber . � � - , . .- _._ ,. _ . _._,
Correct&?os'z:l � , __ '_ __ _ � . . �
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