HomeMy WebLinkAbout1408A 3788A WORKERS'COMPENSAT�ON DEGLARATION . ' � � � � " f�
I hereby offirm thot�have a certifitotPa oF�o�5e�,}o S��f - - �-� APPLICATION FOR �BUILDING PERMIT . �;
insure,or a certificare of Workeri Com ensotion Insurance,
or a rertified copy rhereof�Sec.3800,lab.C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company �
❑ FOR APPLICANT TO FILL IN BUILDING �
Certified copy is herehy(urntshed. AD�RESS � f-ea fi�,f
� Cerlified copy fs flled with the tounty building Inspec- gURDiNG n�y �2
tlon deparlmen�. ADDRESS O>-/N �Y�-�j/�2GvOdd
Date Applitant CITVf///°r ONA �'�/�- ZiF ��7�5 IOCAIITY 1 �
CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF BlDGS. /_ NFP.REST
� � COMPENSATION INSURANCE S�ZE OF lOT MOW ON LOT CROSS ST. ��� - � � "
(This settian need not ba tompleted if the pe�mil is for one . P ASSESSOR
hundred dollo�s(SI00)or less.) . TRAR (, BtOCK LOi NO. T� MnV BOdC PAGE PaRCEL
TEL.
OWNER 27 v�'S Nod'6a'ZO�� USE ZONE �+P
I certify rhat in the perfarmance of the work(or whith this p�r A� �_r NO• ��- }
permi�is issued,I shall not emplay any parson in any manner ADDRESS p 7/ �7•FEs�T//�R���� '/� � ONDITIONS �
so a�to beeome subject�o Ihe Workers'Compenspiioa1qws. r7�� ^� p r� O
9 7 /�ia�� `i,I� pTYL.N/�}�ON� I��� ZIP /I7�`S V
Date Appllcant �
NOTICE TO APPLICANT: If, ofler moking thls Cerlificole of ARCHITECTOR TEL. OISTRICT GROUP TY7E FIRE DROCESSEDBY �
Ezemptian, you should become sub�ect to the Workers' ENGINEER �• C�ONST. ZONE � V
Compensation provieions of the labor Code,you musf forth• qDDRESS �0 �^� �0' W
with comply wilh such provisions or Ihis permil shall ba . TEL. STATISTICAt QASSIFICATIO APT. CONDO. U7
deemed revoked. CONTRACTOR NO. Z Z
LICENSED CONTRACTORS DECLARATION . . . . ���. MSS N0. ' DWEIt.UNt75
I here6y affirm Ihot I om licensed under provisions of Chap�er 9 ADDRESS NO. ��R�p
(commencing with Section 7000)of Division 3 of the 8usines�and ���,
Professtons Code,and my licensa is in f�ll forte ond eHect. CITV - - � ' C�nSS eK � .. . � VpLIDATION -- -
SQ.FT. NO.OF . NO.OF CHECK
license Num6er � Lic.Class ' SIZE S70RIE5 - FIIMIUES ONE �
. . T l' VALUAT N ��
Conlratl0f � � Dole DESCRIF O F WpRK �{ v N� ❑ = QO
ADD
�I am exempf under Sec. A��R O , �:1 Q(�$�
B.BP.C.for Ihis reason REPAIR � s � • •4 g,fj��
DOte; USE OF DEMOL ❑ �9,tl 9-8 7
_ EXISTING BLDG.
Si nCture APPLICANT p ,f� TEL. /
9 OWNER•BUILDER DEQARATION rRiNT 'JE/li� fVA� NO. O�F¢�QI _ DATE��:.u'�(� �
I hereby oifirm�hot I am e�empt from the Controctoi s License � �V �
Low(or the fallawing reason(Section 7031.5, Business and Ao�RE55 FINAL - �
Pro essions Coda): - - � p2E N -By f_ ` �
1, as owner of the ro er y P Y BUILDING * �
p p ry, or m em lo ees with ADDRESS -
`�.��`1 . �d 1
wages as�heir sole compensation,will do rhe work and ' �_ ;�(� �•
�he shuctura fs not Intended or olfered for sale(Section ����TM � ��� � ��k� .
7044,Business and Profeislons Coda). � - MOVING . TEI.
QCONTRACTOR NO.
1,as owner of the properly,am azclusively contrattfng �3 7 B 8 A
with B[ensed COnlraclors fo[onslruCf the pro�ecl($eC- � qODRE55 - � - �• • • • �
tion 70d4,9�siness and Prafessians Code). _,_ , , . . . � ' •
REOUIRED YARD HWY i0iAl5ETBACK i - , - � � e i�8,O O
- - CONSTRUCTION LFNDING AGENCY� � � SET BACK PROP.LINE WIDTH
I hereby offirm that there is a construction lending agency for faONT . T 1 2�Q���
the periormanta of tha work for which this permit is issued v.L. ,
(Sec.3097,Civ.C.). SIDE
P.l.
lender's Name � � j�--Z S 7
,� IDMA ReL M
lender's Address - - - v.G Pee S Permil Pee
I certify that I have reod this app�ication and stote that the _ iu�a��e Fee •� LDMA P/C 1t �
above fnfo�mafion is torretl.I ogree lo comply wilh all County Inves�igation fee / -1 T
ordinances and Sfale lawa reloling fo building conslruction. Tofal Fsa 'E��I V v LDMA Perm.N
ond hereby a�thorize e:enta�ives af this Co�nty fo enter
upo e o e•m io e prope�fy for Inspectlon purposes.
��� SEE REVERSE FOR EXPLANATORY LANGUAGE
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