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 S�qnorure oF Applican�o�Agen� pole . . . . =�� o o ° ° ' o c ° o c� � c n� �y m' -�1; -� " -� -� i� . .- -� - - o 0 T O � C S .T � 3. c $ �o I , ir. � � � 7 � C . � � fl �= � � m �� � � - � �� � � - 1�i � �= ry.� � ' � .9 7 1 � �2 x �� N y � q 7 -I O n .p C n , . � O y A O� � �� ¢i , � ' i tQ+ G'�7 i t Zj � � � _ 9 � � � �n C". 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