HomeMy WebLinkAbout1320A 1355A 1353A _. , , ,
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•WORKERS'COMPENSATION DECLARATION � . � � - � � � � � - �
,ora{c1err�iificmelofWorkers'rCompensti�°�=�°a��eso � . APPLICATION FOR BUILDING PERMIT - _����
ti'e y t ere 1(S c.3600,Lob. ) .
ay��Q r���q� COUNTY OF LOS ANGELES BUILDING AND SAFE7Y
icy No. Company �� // �
�' Certi(ied copy is here6y ivmished. FOR APPUCANT TO FIIL IN npoeess 7'� �-�i�zd 2E-.1+`"�
i—1 CerfiFied topy is iiled with Ihe counly building inspeo BUIIDING �
�J �ion deportmen�. nooRE55 ��J' '��QC�✓ � � .�f�1�.5 toCAUTr �f nA+�c.ntt �� �
� DOte. � .Appli[ant CITV fa/�C J R-ZIP '/I7C� NEAREST .
CRO55 5T. �
� - CERTIFICATE OF EXEMPTION FROM WORKERS' / NO.OF BlDGS. /+SSESSOR
� � COMPENSATION WSURANCE StZE OF LOi Ga �I Z-U NOW ON t0T MAP BOOK PAGE GARCEI
(This seclion need not be completed if the permit is fOr o�5e USE ONE MAP ,L
hundred doilors�(SI00)or less.) TRACT��Z�� BIOCK y—f�l�QT NO. �� �f NO. �7—.3 T� r
I�.�/YV �/f�zC�L'�'// Et. `�,. �.-sf SPECIAI . O
� I certify thai in the performance of the work fo�whiSh this - OwNER NO.� �.l Ee�+ ��'� '" CONDITIONS '
ermit is issued,I shall nol em �o an ersOn in on mannef '� DISTRICT GROUP TYPE FIRE PROCESSED BY �J
P P Y Y P Y ADDRE55 �� ��JE� ��s4l�s CONST� ZONE �� �„
so as fo became subjec��o the Workers'Compensalion Laws. , . �O �3 O
DO�e � ' ' qpp�iCanf ' CITV �• Z�P STATISTICALClA551FICAiION APT. CONDO. ~
NOTICE TO APPLICANT: If, oNer making Ihis Cenilicale o� ARCHITEQ OR• TEL. - �
n W
ENGINEER� NO. CL4S5 NO. �`"/ �WELL UNITS . O.
Exemption; you shauld betome s�6jec� to the Workers' in
COmpeniotion prO��5�on3 a11hC LObor Code,y0U mUsl(Drih• - qDDRESS SEWER MAP . �
with comply with such provisions or Ihis permit shall be 1� �
deemedrevaked. . � - � � � - CONTRA ����r�, /F�C'/f N�' �% BK. PG, VAIIQATION
LICENSED CONTRACTORS DECLARATION �///1J� liC.
I hereby affirm thol I am licensed vnder provisions of Chop�er 9 ADD ESS ,s �[rJD� Na.3yi�y� vnwnnor+ � . �1 3 2 0 A
(commenting wiih Secrion 7000)of Division 3 04 the Business and �i�, p . 5 .��ya� !�:`_ �� � � 2 3 '
. Professions Code,and my litense is in full force ond effect. Cliv_�' /�i/f�• C1A55.�J '� % • •:��•
�2q SQ.FT. NO.OF /J� NO.OF CHECK � "
Li<ense Numhe�l���� LiC.C�a15 � SIZE STORIES f FAMILIE$ ONE �.• •5 2�0 0 �
�/;�rnE.�i) C/IEEk��iQS, J� � DESCRIPTION OF WORK NEW ❑ S q��O . . • a �
Contrador Dme �/ .� 'J Z���
�� I om�e•emp�from�he licensing requiremen s as I am a � �f,s� y�r'��j�'��C.� ADD ❑ Q� 2 2�$2
Bcensed archi�ect or a reg�siered professional engineer aLiER FINAL J
o[ting in my professionol mpocily (Section 7051, " REPAIR � � DATE J p���a—
' Business and P�ofessians Code�. use oc - /� R 1 3 5 5 A �
� EXISTING BLDG. � � DEMOL � FINAL .
Lic.or Reg.No. Date � APPIICANT iE�. �I BY ����C«n� . #f,• • •��'z 3
- � OWNER-BUILDER DECLARATION � iPRWT� � - � O" NO. �Y' �' /� /,{ �/ZYC�
I herebq oifirm that I am exempl from the Contractor's license �� J°t I� /`�u�(� �j �.' "��8� �
� _Low for ihe following reoson($ettion 7031.5,Bvsiness ond /DDRESS � � �
ProfessionsCode): - recsErv� �Q4t���t�� inJ�1��L ���J,�/'• •.• •..�80� .
eUnDinlG � ✓�It a l!l1-d9e✓
� �, os owner�of the properly, or�my employees wilh ADDrE55 U��2']�82
•xe^�s c;fhcir so�a mmpensofion,wiil do tne woik ond � , . ' � . � .
the strutlure is not intended or oifered for sole(Section IOCAUTY , �
7044,Business and Pro(essions Code). MOVING . TEL. ,
��-� I,as owner of the property,om exclusively comracling CON7aACTOR NO. -
with licensed canfroctors lo construcl rhe project(Sec- pDDRESS � - ' " �� 3�3 A
. tion 7044,Business and Pro(essions Code). � � . � �,
' REOUIRED TOTAL SETBACK FROM E%IST. . `• � � #,• •�� ���`�
CONSTRUCTION LENDING AGENCY SET BACK �ARD HWV . GROP.LINE WiDiH • . , • �
I he�eby aHirm thal Ihere is o mnstrodion lending agency ior FRpNi ' ��• •7 9 5 0 •
the performonce of ihe work for whith ihis permif is issued P.L. '
(Sec.3097,Civ.C.I. .. . . . . . SiDE.� � - � • • •7 9.5 0�
P.L ,
Lender's Name /�) ' '- � �
� P.G Fee S �� L�' Permi�Fee � v V � �� 2 7.�8•2
Lender's Address � �j j1 . . � � �
I cerlify 1ho1 I hove read Ihii applimtion ond state Ihot iha � �.Q 0 Issuonre Fee U '�0 '
obove information is correcl.I agree fo camply wiih all County _.. . i��es��gonon Fee - /J�7 -� � �
�ordinonces ond Sto�e lows re�ating to bWiding constroction, Toml Fee //•.�B '
and hereby aulhoriza repre5en�atives of this Counly to enfer . . � �� .. .
upon th_obove-mentioned roperty for inspec�ion p(o�rQoses. , � .
//�.����,�i�-+'�•J`,^,��'�1�— SEE RFVERSE FOR E%PIANATORY LANGVAGE � � � � �� � q
i f.� �
Sg�oNre of Appliconr or Agent Dote , �
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