HomeMy WebLinkAbout1789A 2181A (10) I ,� WORKERS'�COMPENSATION DECLARATION , , � . � . . � ��
•I hereby o(firm thot.l have a tertificate oF consent fo=e�F .�.. .APPLICATION FOR BUILDING- PERMIT�
, insure,or o certificote of Workers'Compenslion Insurance,or �
a.cgr�f�q�cop'y+hereot(Sec.3soo,�/ob}.�C.')e N • COUNTY OF LOS ANGELES BUILDING AND SAFETY S�t�d .
Ooi�Ynl�o`����.2r'LCompanYr—�l����// \
Q PY y FOR APPLICANT TO FILL IN AD�RESS �p
. i � Certiiied co is hereb Iumi4hed.
'. � Certified copy.is filed with�he coun�y build�ng inipec- BUIL�ING ��" -
' tion deporlment.�� � � � � � ADDRE55 � C�C1C/� � LOCAUTY � - .
�f � NEAREST
Dote �S Applicanl���i1J�.� � �ITY /L UP � CROSSST. Q.SK�
� � ERT ICATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. ASSESSOR � �
� � � COMPENSA710N INSURANCE � � � SIZE OF LOT NOW ON LOT. MAP BOOK PAGE PARCEL
� (This seEtion need not be complered if�the permi�is for one - u5e zONE MAP �l\ ^7
TRACT BIOCK LOT NO. � NO. l
� hundred doilars(SI00)or less.)- � : � � }
. � TEL � SPECIAI ' p� ,
OWNER NO. ) CONDITIONS
I cerlify that in the periormance of the work for which this � �
,permif is iss�ed,I shall not employ ony person in any mannei DISTRICT GROUP TYPE FIRE PROCESSED BY
so�os to become subjeU lo fhe Workers'Compensolion Laws. A�DRE55 O �' `O COt�.� ZONE �``µ'vv�. IK
�..�/ � .Y� O
. 'Dd10- ' Appli[an} ' � CITY �Y� Z�P � 57q7�5TICAlCLA551FICATION ' � APT. CON�O. V
�NOTICE 70 APPLICANT: If, after moking'this Certificete oi� ` aRCHITECTOR �iEl. 7i�V ^n . . iy .
'Exemption; you'shoold become sobjecf to the Workeis' ENG�NEER /Q/,� � CLASSNO.�DWEILUNITS d
N
� Compensolion provisions of Ihe Labor Code,you must forlh-�� � qDDRE55 e � SEwER MnP � . Z
wilh tomply wiih wch provisions or this permil shoil be �
deemed revoked.� . . TE�. ' eK. pG� VALIDATION � . .
- . � CONTRACTOR NO.SS 7'��� .
� � � -�LICENSED CONTRACTORS DECLARATION UC. .. . . . . .. - !
I herehy affirm ihat 1 om licensed onder provisions of Chopler 9 .. A�DRE55 NO.a}`T sd VALUATION � �
(commencing with Section 7000)of Division 3 of the Business and � • ��� • �� .?� 7 a�9 A•
Professions Code,and my license is in(uil force ond eflect CiiY ' CLn55 - 5�� �� .. , � ' �
' ' � SQ.FT. NO.OF - NO.OF ' CHECK �',• •��'�'Z.3
�Ccenie�Number —�Q�jI�'�OLIc.Closs� SIZE � S10RiF5 FAMIUES ONE . -
, . . __ . NEW � S . . .'�"3 8&8 0,.
� COnifaCtor �� ��0 �!; Date �- �ESCRIPTION OF WORK �. , ,
� I am e�empt from the litensing reqoiremen^� � - . �-. - AD� � . . ' • •�J$�$Q c=a
- licensed archi�ett or a regislered professionol engineer.,, . . . _ . .,,. . _ . . . . . alTEa � FINAL 5 'f �a � � �0 3 0 9-8 2
. ociing in my professional capacity (Setlion 7051, REPAIR � DATE _ .
Business and Professions Code). USE OF ' � �
� � EXISTING BLDG.G L GIO Q 1' DEMOL � e�NAL � ,
Lic.ar Reg.No: Date APPLICANT iEl. � ���� ��
• - -� OWNER-BUILDER DECLARATION� ��� � PRwT) -� NO.. S
I hereby affirm that I am exempt from�he Conirotlor's License D - . . . . . . . . . ..
, Law for,tha follawing reason(Section 7O31.S,BuSin055 Ond "�' F+DDRE55 i5 E� � - •
� PrafessionsCode):� �� ,aE EM - �
. ❑ . . . _ . BUILDING p � y5" ' �
I, os owner of ihe property, or my employees with��� noDRE55
. woges as their sole compensation,will da the work and i�A�iT�. � .
� ��� ��he srructure is not intended or of(ered for sale(Settion�'� � � � � . .
, - 7044,Business ond Professions Code�. � MOVING TEL. � �
. ❑ � CONTRACTOR. NO. . � � •
I,as owner of the property;am exclusively mntracting �2� 8.'.� {�
with licensed conlractors to mnstroct the projetl�Sec-. AODRESS � �
• . ..tion 7044,Business and Professions Code). -� - � � � ' � #',��• • .�.;�
REOUIRED TOTAL SETBACK FROM E%IST. ' ' '
CONSTRUCTION IENDING AGENCY SET BACK YAR� HWY PROP.LINE WIDTH � ��I i�4 9 Q.5,0
�� I hereby affirm that there is a construction lending agency for�� ��� pRONi � � � � . ��'
the periormonce oi Ihe work for which this permit is issued P.L. � ' � � � .�''�4 9�.5 =
(Sec.3097.Civ.C.�.. . . .. . . . _ . _.SiDE -. . . ., . ... ... . .. Q cr�
v.t.
lender's Name � . . p I /� .. . , .. . O 4.� 2�8 2
Lender's Address v.C.Fee S 3 p� Pe.m��Fee Vp Q" �. " . "
I cerlify Ihat I have read this applica�ion and s�ate that ihe Issuo�ce Fee ,J '
_ above informorion is correct.1 agree to mmply with all County mvesrganon Fee .. � � - � � �
ordinances and Sa�e laws relating to building consr�uctian, To�al Fea � Q � �
and here6y authorize represenlatives of this Counly 10 enler , .., , . , , ., ,. , ,
�` opon Ihe above-mentioned propeiry for inspedion purposes. - � . � � . . .
� r��j'j���Q�q„�� J%�'�/D_2� � SEE REVERSE FOR FXPIANATORY LANGUAGE� . " � �
c'c��0=
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