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HomeMy WebLinkAbout1105A (5) � WORKERS'COMPENSATION DECIARATION �q� eborofcertifcatleofWorkes''CompensationSlnsumnca' APPLICATION� FQR BUII.DtNG -PERMIT �s i � i cerrifiad mpy ihereaf(Set.3800 1a6.C.) GOUNTY OF LOS ANGELES . BUILDING AND SAFETY Icy N�o�Company L LOl11 . . . . r Cerrified copy�s hereby fumished. FOR APPLICANT TO FILL IN - nooa ss 4� . � Certified topy is filed with fhe couMy bvilding(nspec• BUIIDING 1 � � , fiondeporimenl. J ADDRESS Q� r�J� 7��C.� - LOCALITY- � � te����U/L�,3 Applican �L( CI7Y I / � Ll " G}� Zip CROSS SL� � � - �' CERT" IFICATE OF EXEMPTION FROM W �K � NO.OF Bl�GS. ASSESSOR � COMPENSATION INSURANCE � SrzE OF LOT NOW ON LOT ' MnP BOOK rAGE PArtCEt � iis senion nead noi ba comple�ed if rhe permit is for one n/ uSEZONE M/.P ��G�.s �r . indrod dollars(j100)or less.� TRACi � /7 ' BtOCK LOT NO, � �� . NO. ✓� .�s � ' ' TEL." ���/ . SPECIAL } � :erti/y Ihat in the performence of tha work for whicb fhis �WNER . �L �l7�YG�� NO. F�� CONDITIONS � �. � �rmit is is:ued,I sholl not employ any person in any monner q - p- --��--�-•���� �� DiSTRItt GROUV TYPE FIRE PRRR���ESSED BY � �os fo become subjacl to�he Workers'Compensalion lows. A�D2ES5 �.-G' `�J'��U�.G.. � CONST.� ZONE � V CITV� � /y7t//� J I ]t0 . . . APPIi[ant ' �'r_ Ziv.. .. . .... ..... STATI TI�I QA�IUTION . APT. CONDO. .O OiICE TO APPLICANT: If, afrer making �his Cenifica�e of � ARCHI7ECf OR TEt. cemption, yo� should bacome subjecf fo the Workers' ENGiNEER NO. C�pS$Np._..p�.�_DWEIL UNI75_ i �, ompenso�ion provisions of tha Labor Coda,you most forih- . ADDRE55 - -- - �-� - SEWER MAP v' � �itb comply with such provisions or this permif shall 6e r � � � •'- - BamBCI fBVOkeCJ. � - . , CONTRACTOR �� /'��'� �� NO.� ��7 BK:�� ��+, � V.�LIDATION � LICENSED CONTRACTORS DECIARATION � / �C.,.,� hereby aHirm thal I om licensed under provisions of Chapier 9 ADDRE55 ISD� �n) • //�-//7 ND. -�Qn� --VAlUAT10N . � � � ' ', ;nmmencing wi�h Setlion 7000)oF Divisio�3 of ihe Bosineu and ��C q , � lofessions Coda,and my license is in full iorce and affecL GiY l��i� n7/ Cta55 L�Z/ S �Ja �a � . � j � SO.FT. - NO.OF NO.OF CHECK � .icansa Number�36l�� . .lic Class ���4 SIZE STORIES FAMIUES . . ONE � S � � . � � • DESCRIPTION OF WOFK NEW � .onifa[lon � � / �ale 'J AD�- � �I am exempf d ec. / 7F� c✓ ` 1�� G AtTER ❑ FINAL �/ r�er.. . �.� � Q 5 A DATE ��Co� �1 #� �� ��� � B.8P.C.for fhis reoson � � �� � - --� � � REPAIR ' ! use oF � /� t • •3 6 7 5 � � - Date: . EXIS7ING BLDG. . DEMOL. ❑ gr 1 ��/ . . • • .3(�7 rj U - APMICANi TEL. � '� � Signature � � VRINT NO. - �- � � �-� ' I . �OWNER•BUILDER DECL4RAilON � ' . O��2 O"H U� �� I hereby affirm that 1 am eaempt from the Contraaor's Licanse � law for the following reason(5ection 7031.5,Business and � ADDRE55 - � � � � � ; Professions Code): . � .. -�. � � . . .. , a � BUILDING �. . . . . . I, os owner of tha properiy, or my employees with� ADDRE55 � - � ------ ---- . ( '� , viages as fiair sole compensation,will do tha work ond ���rv , ; , . tha siructure is not intended or offered for sale(Saction �"-"- � - � -i� � �1 � � � � ' 7044,Bvsiness ond Professions Code). � MOVING TEL - . � - � � I,as owner of 7ha property,am exclusively coNracting CONTRACiOR NO. � � ' � � . . . _ , � with licensad coNractors fo consiruct�he projact(Sec- qDDRE55 � � tion 7044,Bosinass and Professions Code). � _, _ . _. _ _ . ._. � REQUIREO TOTAL SETBACK FROM EX15T. � CONSiRUCTION LENDING AGENCY 5ET BACK YARD NWY PROP.uN WIOTH ► . � "� . , .. , ' '�':... .� � I hereby ofiirm thot there is a construction lending agency for . peONi ���--� ,� � � - - --� � � '� ' � � - � � the performance of�ha work for which this permil is issued p.t. . . , ($eC.3097,Civ.C.)• - " SIDE i � _ . _ _ . _ . . , _ .. .. . . : � . - � P.l. . . . . . I " Lendar's Nama � . :: : . . _. . . . . . J/.� / ..._._. . ... _ .. ._ _ . i - Lenders Address P.C.Fce 5 Permi�Fae .G(� �7 . � . 1 certify tbat I have�ead fhis applimtion and state Ihot�ha � issuonce Fea 0• S�� . above iniormotion is cortact.1 agree to comply wifh oll County Inrestigalian Fee J � � ��' ordinoncas ond Smte laws relafing fo building constrvdion, � � � - � Totol Fee �G• 7J �: and hereby authoriza represenfalivas of this County to eNer . � .�-. u e above-manfioned property for inspecfion purposez. � � � �- - �� � - - � - � �-� �� �- �� � , - �- � � �� � �� �, � � 1 , �-, SEE REYFRS6 FOR EJ(MANAiORY LANGUAGf �� �� �s� � �- •....; , '�.. � :, ' �'�� ". . ._ .. ... .. . ..'.:' � ' .. . -" � . ' ; .: 5' nr or Agen1 � �� - . ' .�t I . . .. . - . .. . . . _. . .. ... . . . ' ! � ��..�. ; :�: '._'_.. ._ � '.:�.�:,_ ..\. ` , � -• - . . . J �+ � � \:.: ��, \\.'\,� . .:, ...., _ /'f"G�ti �� 1� T'�'� v S ..� . ..,... 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