HomeMy WebLinkAbout1176A 1624A (7) �
WORKERS'COMPENSATION DECIARATION _ �
insvre6orot1erlihtaielofWorkeseCompenst�on�lnsuranteSolr � � APPLICATION � FQR BUILDING PERMIT �
a certified mpy ihereof(5 3800,Lab.C.J � ' ' �
Y ����1 Y n��� I - �COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polic N ompan � 4
�. Cer�ified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Q Y�'U"� ��� '� •���'J �'�1i�1�
�(`"y�' Cerlified copy is.filed wiih Ihe counly 6uilding inspec- � BUiIDING O �� ��' Lc���/
�Jg� lion department. ADDRES '/t.e� d� �� IOCALITY � �^^`�
'' _ I�1�7J' PP� .�l� ' ' NEAREST .
Date�n nconr • arr �: ',,.G �zivi ceoss sr. ryr�'+t-�-
� � ' CERTIfICATE OF EXEMPTION FROM WORKERS' '� NO.OF BLDGS. .4SSESSOR
� COMPENSATION INSURANCE . i SiZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEI
(This section need not be mmpleted if the permit is for one � US ZONE rnnP /(
hundred dollars($100)or less.) . . . TRACT BLOCK LOT NO. �'3..6'�NO. �1-3'�'�"� }
. TEI. SPECIAI a
� OWNER NO l� CONDITIONS
I cerlify thai in the performance of the work ior which�his 0
�permil i5 i55ued,I shol�not employ any person in ony manner ' ' DISTRI�T GROUP TYPE FIRE PROCESSED BY ,
AD�RE55 �
so as ro•become subjeU 10 the Worke�'Compenzation Laws. � !O ' CONST. ZOn� �� O
I'%
Da�e �' Appli[ont ��TY Z�P STATIS71CAl CLASSIFICATION APT. CONDO. V
�NOTICE TO�T: If, aNer making �his Cerfifimie of ' AR�HITECTOR . TEL . W
Ezemption, you should became su6jecl lo the Workers' ENGINEER NO. CU155 NO.��WELL.UNITS y
Compensalion p�ovisions of Ihe La6or Code,you must(orth- qDDRE55 �/ SEWER MAP •'-
wilh comply wilh such provisions or Ihis permit shall be • ' '
deemed revoked. , . . TE�' gg, p�, ' VAIIDATION
CONTRACTOR NO.
. UCENSED CONTRACTORS DECIARATION. liC. '
I hereby aifirm tha11 am licensed under provisions of Chopler 9 ADORE55 N4 VALUATION $�•� 7 G A •
(commenting with Settion 7000)of Division 3 of the Business ond ��� , :
"Professionz Code,and my license is in iull force and effect. CiTr Ct.455 S �L�� ��Si��••'�3
50.FT. NO.OF . NO.OF CHECK
�liCente Number Lic.Closs SIZE �/i�� STORIES FAMILIES ONE �.�' � g(i Q
) p� S 1
ControCto� Do1C-y`-�-�-`E�- DESCRI�fION OF WORK NEW o • � � I �4 O U
� I om exemp�from the licensing requiremen�s as I om a J � A�D
licensed architect or a regislered professional engineer ALTER � �FINAL �1 1 2 31.—8 i1
�acting in my professional copacity (Section 7051, REPAIR � DATE � l� �oc,
Business and Professions Code). USE OF � �FINAL
EXISTING BLDG. DEMOL 8
�Lit..3r Reg.No. Dote � APPLICANT iEL. Y
� ��� � � OWNER-BUILDER�ECLARATION � (vRiNi� Np
� I hereby affirm that I am ezempt from�he Coniractor's License `` , . '
Law for Ihe following reason(Seclion 7031.5, 8usiness and � ADDRE55 .
rof sions Code): . � . paES"eN�
BUiLDING - �
" I, as owner of ihe properly, or my employees wirh AD�RE55 '
ages os Ilieir sole compensalion,wiil do Ihr wark and � '
�he structure is no�in�ended or offered for sale�Section LOCnLi�Y � �
7044,8usiness and Froiessions Code). MOVING TE�. . �1 6�2 4 A
� �I,as owner of ihe properly,am exclusively conlrocling �ONTRACTOR NO. '
wilh licensed mnlroclars fo consfruct Ihe project(Sec- qDDRE55 #�'���,• •��
.....- lion 7044,B�siness and Prolessions Code). - � - -
CONSTRUCTION LENDING AGENCY , REauieeo VARD HWV � TOTAI SETBAIX FROM exisi. I;• •3�1,�5 O
SET BACK PROP.LINE WIDTH D n'�7�,���2
- I hereby oHirm�ha�there is a constroc�ion lending ogency for FRONi , � - G L �'
ihe perfo�monce of the work ior which�his permil is issued at. � '
. (5ec.3097.Civ.C.l. - . . .. . . SiDE .. . . - . . . .. "
P.L.
Lender's Name � v ,//� q p � �
� lender's Address P.C.Fee 5 D•`� Pe.mu Fee oC J, ��
, I certify thot I have reod this opplication ond stme that the issua ce fee d�-�0
. above informotion is correct I agree to tomply wi�h oll County Invesbgoiion fee /n � �
��, �oid�nonces ond Sio�e laws Felaiing to building conshuction, To�al Fee ��.J" .
'� ond herfby aothorI'ze epresemaiives oi this County to enter ' . ,
upon Jh obove-m( oned o rly for inspection purposes.
� �,i`! �� 1� '-�J � . � SEE REVERSE FOR EXPLANATORV LANGUAGE .
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