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HomeMy WebLinkAbout1421A � � . 1 ' �_`- .. . "I WORKERS'COMPENSATION�ECLARATION �. �. . -� � - �� insvre6oracerfifitafe'ofwo,ke5e�o'mPe�S�o���;�°o�°eso'� � � � �APPLICATION -FOR BUILDING .PERMIT �� o ceni(ied co her f Se 00,Lob ' COUNTY OF LOS ANGELE$ BUILDING AND SAFETY ��.��i-k5J��9�Y pY Y FOR APPLICANT TO FILL IN ADDRE55 �"D /✓ Certified co is here6 furnished. �i�. ��•�� Ceriified copy is Iiled with the county building inspec- BUitDiNG /� fion deporfinent. � /+DDRE55 IOGLITY �"'n-f+K�l .CU�� NEAREST (� 0 D��-I, � Applicont�� ��TY ZIP � CRO555T. wk ' CERTIFICA7E OF EXEMPTION FROM WORKERS' - NO.OF BlOGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NpW ON lOT MAP BOOK PAGE PARCEL `-�Th(s sec�ion'need nat 6e compleied if ihe permit is(o�one Q use 20Ne MAP /�3,3�" hundred dollors(5700�or less.) ,_ . TRACT[,J BIOCK LOT NO. ,e 3 NO, l �, SPECIAL q I cer�if ihot in ihe erformance�of the work for which ihis owNEe N� �� GC CONDITIONS � ��l.3 7/ Q Y P � �� DISTRICT GROUP TYPE FIRE PROCESSED BY 'perrnil is issued,I sholl nOt employ ony person in any manner ADDRESS �CONSi. ZONE � zo as to become subject ta Ihe Workers'Compensation Laws. !Q O Date - � '� ApplicaM � AIRCHITE�R � � ,ZIP TE�.. STAlISTICALCW551f1 AIION� APT. CONDO. V ' NOTICE TO APPLICANT: If, afler making thiz Cerfificote of'" ENGiNEFR NO. CLA55 NO. �� DWEtI.UNITS 0.. Ezemption, yoU should become subject lo the Workers' '9 J�y-- ., Compensarion provisions of the Labor Code,you must forlh- qDDRE55 L/ N7 N with tomply wiih such provisions or Ihis pBrmi� 511011 be ' SEWER MAP ? deemed revoked. , ; TE�' BK. p�. VAIIDATION -� CONTRACfOR NO. � �LICENSED CONTRAC10R5 DECIARATION (iC. - � --- � � � I hereby aifirm�hor I om licensed under provisions of Chapter 9 _._._.. ADORE55 .. �� N VAIUATION (mmmencing wilh Set�ion 7000)o(Division 3 oi the Business and � tIC. S �/),�r - �� 4 Z� A � Prafessions Code,and my Ilcense is in full force and eflect. . CITV C1A55 �G"G' . � � �.Q� 50.fT. `O.OF NO.OF CHECK #• • • •Z 3 Li[enSeNumber�,- )v�LiC.ClasS� . SIZE STORIFS FAMIllES ONE . � � � ./y��/�}r,,�� _..,/�I�'�, DESCRIGTION OF WORK /G NEW S I,• •� S LL O CanlraUof_,F.�r:yrJ.r�—_Dare_rr� , � � I am e.empt from the licensing requiremenfs as Ipm o � ' � ADD �.• •� �"4�� licensed arthifetl or a regis�ered professionol engineer , , , ALTER � FINAL�. _ ,� aUing in my professionol capocify (Section 7051, Q REPAiR � �ATE 0 2���$2 Bosiness and Professions Code). u5E OF .� FlNAL -�- � �� Ex15TING BIDG. �N'�� g , lit.o�R2g.No. Dote APPIICANT TEL. Y � ' � � � OWNER-8I11LDER DECLARATION' � � ' � vRwi) NO _ I hereby offi�m thm I om exempf irom the Confractor's license v/J] � � � ' low for fhe following reason($ec�ian 7031.5,Business ond �" ADDRE55 �v rolessions Code); � � . FRESEN _ . .._ . . - . .. .. .. .. BUILDING__.. . . .... __. .. ... ._.'. '__ 1, as owner of Ihe properfy, or my employees wilh ADDRE55 �� woaes as their solr mmpPn<n�ion,will do!he we•k ond the structure is no�imended or offered for sole(Senion�'- �aAL�iv ^� � 7044,Businezs and Professions Code). MOVwG TeL. .`„Y , ❑ - CONTFACTOR NO. • � 1,os owner ol the propeny,am ezclusively�comroding" � I/�. with licensed[onfrotlors lo conslrucf the prolect(Sec- pDDRf55 � �/�� - �� � - � tion 7044,Business and Professions Code). � - � ' REOUIRED TOTAL SETBACK FROM E%IST. (j� ' CONSTRUCTION LENDING AGENCY SET BnCK VARD tiwV PROP.IINE WIDTH , I hereby affirm tha�the�e is a tonslrvction lending agency for �� fkONi � the performonce of the work for which this permil is issued P.l. � (Sec.3097,Civ.C.). .. � � SioE � - P.L. � Lender's Name � p ' lender's Address P.C.Fee S � O. Perm�i Fee � I cerlify�ha�I have read this opplitation ond sta�e that ihe � Iss�once Fee o6ove informotion is correcl.I agree ro compiy wilh oll County_ . in�esrgoron fee ordinances and Slate laws relo�ing to building constroc�ion, To�al Fee ' ond hereby authorize representatives of this Coun�y ta enter . . . . . �u the ob e'entia e praperly for inspeUion purpbses. . � . - � � � -F� ' SEE REVERSE FOR EXPLANATORY LANGUaGE . �� 3nat�re o1 App��cani or Agenl Doie . ... . . . . . . . . 2 0 ` � `o � �+ W � � ' ` G� � m � � O �c�o p ac Q Q m � Q. • r' n'0. 7"m O O O � '�. �O m . . 4 ���' �7 n,-i �^. � .O O � � �,- �a L�a'� .1; °. �io ,3 m M 9 o �m �`� t 3 N� ���o � � v� p �� � o p�� �o o . 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