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 .
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