HomeMy WebLinkAbout1668A 1827A WORKERS'COMPENSATION DECLARATION � � �
insureborafcertifca'teofWorkeS''�o�mPe�a,o��°=�,e��af�� �� � APPLICATION�-FOR�BUILDING PERMIT
or�certifle�Smpy thereof(Sec.3800,1a6.C.)
COUNTY OF LOS ANGELES_ . BUILDING AND SAFETY
PDolicyNo. Company � -
Certified copy is hereby(urnished. FOR APPLICANT TO FILL IN ADDRESS �S -e�+s/ .Gt�e�'rd 7•
� Certified topy is filed wilh tha counly 6ullding Inspec- BUILDING G� /� 1 �
lion deporfinent, ADDRESS s}�� d•� [sYX.bE.V �/.'..QbO�i U�. LOCALITY
NEAREST
oore �ppHean� cirr �rA,u�,u0 �q.� zir /%G� cRoss sr. �f/C^�z
CERiIFICATE OF E%EMPTION FROM WORKERS' N0.OF BIDGS. ASSESSOR
COMPENSATION INSURANCE Size oF toi Now onl tOi / rn.4P eoOK PAGE PARCEL
(ihis section need not be completed if tha permit is(or one USE ZONE MAP .
h�ndred dollars(SI00)or less.) � . TRAR 36 . S BLO[K LOT NO. � �/ � NO. /���
TEL. � SPECIAI a
OWNER �4�C'OL(f NO. �G�' .3 � �� CONDITIONS ' '
�fCrtify lhat In Iffa performance of tha work for which this DISTRICT GROUP 1YPE FIRE PRpCE5SE0 BY 0
permit is issued,t shall not employ any person in any monner ADDRE55 ��R/-!E AS A�Or�c CONS. ZONE V
so as to become subjecf to ihe Workers'CompensaHon Laws. �O - p:
«+.rt�
Dale �•��•�`�APPlicam '� ,.[.}Ne� CITY ZIP .�. � . ' STATISTICAL CLASSIFIUTION. . APT. CONDO. � 1
- NOTICE TO APPLICANT: If,•af�er kid this Certificaie of �R TEI.,�ij-3.25- �/J V .
S�S ENGINEE S� . /CIl. G NO. QHSS NO.�_DWEtI.UNITS W
�Exemption, you should betome subjett to fha Workers' o.
Compensatlon provisions of the lobor Code,you musf forth- qDORe55 O �f'.�/--,�/. -- �- � � ��- sewe2 mnP �
with comply with such provisions or this permi� shall be �
deemed revoked. TE�• � BK, - p�, � VAIIDATION .
CONTRACTOR _ NO.
LICENSED CONiRACTORS DECLARATION ' �i�,
I hereby af{irm thot I om litensed�nder provisions of Chapier 9 ADDQESS NO. VALUATION
(commenting with$etlion 7000J oi Divisio�3 of the Busineu and ���, �1 6 G 8 A
Profession�Code,ond my litense is in full force and effect. . CIiY CLA55 S ��/'C�'� '
- - SO.FT. NO.OF NO.OF CHECK � �• • • •2�J
Lfcense Number Lic.Class SIZE STORIES FAMILIE$ ONE
s �,• •2���
Confracfor Data DESCR�PTION OF WOR� _ .J,U«�� AD ❑❑ . •.�.�2 Jr.O O c=i
�1 am exempt under Sec. �a�'_( /CEP/,'/� — Gl5/Nd NE>Mtd AL�R ❑ FINAL �2 2� �$4
B.BP.C.for lhis reason ��C��A S�C��/U" sp/c.S .rf'O/_�T'- REPAIR DATE � . �� I
Data; USE OF . DEMOL � FINAL - — �
. EI(iSTiNG BLDG: � -- � ❑ BY
Signoture APPIICAM TEL 9/1�� '_ _
OWNER-BUILDER DECLARATION �iNT ! i? .f� NO. (, _ J
I hereby affirm that t am e:empt from the ConrracroFs license , �
Law for the following reason(Section 7031.5,Business and ADDRESS - - - � -
Profesetons Coda): . - PeEseNr � � '
QBUR�MG �
I,es owner of�he property, or my employees with ADDRE55
woges as thelr sole compensa�lon,wlll do the�rk and ���TM n^�,,G� � , � �
ihe structure is not intended or oHered for svle Sectlon �
� 7044,8usiness and Professionz Code). MOVING TEI. � �7 c�� �� $2 7 A .
1,as owner of the ro er1 y 9 CONTRAttOR NO. r
P P Y.�amezclusivel comractin �/ #� • �,,• •, I
wirh licensed contracfors to consrrucr the pro�ect(Sec- qDDRESS '
tion 7044,Business and Pra(essions Code). . _ - ' .
RE�UIRED TOTAL SET9ACK FROM EXIST. � • •3 Q 5 0
CONSTRUCTION IENDING AGENCY SET BnCK YARD NWY PROP.IINE WIDTH '
t hereby affirm that there is a consirvction lending agenty for FRONT - - - ---� - , -- � •• • _
Ihe per(ormance of tha work(or which this permil is issued P.t. , , `�a$��
75ee.3097,c�.e.�. . , s�oe . _- --.. . . __...__ . 0 3 01 —8 4 ?
P.L. �
Lender's Name y/ M
P.C.Fee E v( 7, � Permi�Fee O,�JQ
Lender's Address
. ._ _.... .. .._. . . ... . .
1 cartify lhat I have read this opplication and stofe thal Ihe Issuonce Fee '
obove infamation ie eorretl.I ogree to comply with all Co�nry Invesiigatian Fee
ordinonces ond Stata lows reloting to building consrruction, � Toial Fea .�� �
and hereby au�horize representatives ot this County to enter
up^on the abova•mantioned property for inspection purposes. - - - - � - � � � � � � ;
. ��� � ����� �.�.��� `_ SEE NEVFRSE FOR EXPIANATORY IANGUACE '
C/ �g aNre of Applicant or Agent po�e ....... _... . .ms
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