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HomeMy WebLinkAbout1590A WORKERS'COMPENSATION DECU1RAilON � � I hereby aff��m,�o�,�o�e a�e�,�f��a�B of�o�,e�,,o se�f � APPLICATION FOR BUILDING PERMIT insvre,or a ce�iificote of Warkers'Compensotion Insurance, or a certified topy theieof Sec.3900,Lab.C.) . ' j r���7 �i� d COUNTY OF LOS ANGELES BUILDING AND SAFETY i P❑ol�ity Nor��-sb'�ompanyl,!�?W10 BUII�ING Certified copy is hereby furn�shed. FOR APPLICANT TO FILL IN A�oeess 2 tv�d �TO �Certi(ied copy is filed with the coonty building inspec- BunoiNG � fion deparfmant. ADDRESS 1�°�l0 iocaun � � , NEAREST . � Date Applicant � �ITY 1.nW0 21P � CROSS 5T. � � CERTIFICATE OF EXEMPTION FROM VJORKERS' � NO.OF 8t�G5, ASSESSOR ' {OMPENSATION INSURANCE . $RE OF l0T . NOW ON l0T MAP BOOK PAGE PARCEL (This settion need not be tompleted if tha permil fa for one � . USE 20NE nnnP �/ _ h�ndred dollars(5100)or less.) � itinCT atoCK LOT NO. NO. ' � � � - TEL SPECIAL S�� d I certify that In the performance of tha work for which this �NFR No. CONDITIONS � �� '� 7� permit is Issued,I shall nol employ ony person in any manner DISTRICT GROUP 7YPE , FIRE PROCESSED BY u zo as to becoma subject to fhe Worken'Compansqlion laws. ADDRESS � GONST. t ZONE ,� �,-, � Date � Applieant � ��TM � � Z�P STATISTICAL ClASSIFICATION APT. C N00. . o NOTICE TO APPLICANT: If, after making this Cenificate of ARCHITECTOR TEI. . �Z � w �Exempfion, you should 6ecome subject lo the Workers' ENGINEER NO. QASS NO. �WELL.UNITS a Compensation provisions of the Lobor Coda,you IRU51 fOf�F1- ADDRE55 � � SEWER MAP N with compty with such provisions�or this permit shall be �, ' ? deemed revoked. . �r /`�1�Of✓ NO. � - VALIDATION � � � CONTRARDR � gK• ��� LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm thar I am lieemed under provisions of Chople�9 ADORE55 `� 1� Yfi1l� N0.�6.��� VALVAT�ON � � � (mmmencing with Section 7000)of Division 3 of the Business and ���• ��� S �(O�p� Profeuions Coda,and my license is in fuil forte and effect. Cltt 1 [�ASS � � - , �f ' ,n ' ' ' ' / � SQ.FT. NO.OF NO.OF CHECK . . . Licensc Numher '�-»� Lic.Class e��5- SIZE Z STORIES FAMIUES ONE � ��(� � DESCRIPTION Of WORK JFjjtQYl'E__ NEW ❑ S . - Coniractor_�1T(1ni�.Y�/Pr�..Dote � , . � � � SI /� ADD � �t S2OA �I am exempt under Set. � lc.kl i� ` AITER � FINAL � '#• • • • •.� .. . B.BP.C.for thts reason � �. /�c-t✓ J!bM. � REPAIR � DATE � '�p • � � USE OF FINA � • �4 9.2 5��� Dafe: DEMOL BY �• � �4 9.2 5� . EXISTING BLDG. ❑ $ignatVre . APRIfANT TEI. � . OWNER-BUILDER DFQARATION PRiM NO. I here6y affirm that�am exemp�from the Conrmc�or's License 0 7.2 2—8 5 . Law for the following reason(Section 7031.5,Business and ADDRE55 -� � � � � � � Professions Code): � - PR a � � � - BUILDING . � , I, m owner of the property, or my employeee with AD�rtE55 woges os their sole compensauon,will do the work ond �' � . . the structure is not in�endad or ofterad for so�e(Setlion . t���Tr - �. �.. 7044,Business and Professions Code). � MOViNG TEL. . . � I,as owner of the property,am exd sively eonfratling C NTRACTOR � NO. , . with litensed comractors to constru tha projecf(Sec• ADDeESS tion 7044,Basinesn and Professions oda). . . . , _, REDUIRED iOTAL SETBACK FROM EXIST. � CONSTRUCTION LENDING AGENCY SET BnCK YARD HwY pRpp,uNE WioTH � � � I hereby affirm that�here is a construction lending agency for �FRONi � �- � tha performance of�the work for which this permit is issved p.�. . . �Set.3097.Civ.C.). � SIDE . - . . . . P.L lender's Nama �7� Lender's Address V.C.Fee f Permit Fee ��• /Vl � . . I certify that I have read this opplication and slate ihol Ihe � hsuanm Fee 2v�� � . � 1 above iniormation is correct.t agrea to compiy with all County �nvesrgauon Fae � ordinontes ond State laws reloting to 6uilding construcllon, � To�ol Fee � � 6nd hereb o�lhorize r_ep[esentatives of lhis Couny to enter . �po abov en efied prg erty for inspettion urpases. � � � - � �� �'� � / T��� .i SEE REYERSE FOR EX►LANATORY IANGUAGF p r! , ,,,, pVrrerMorAgent p�te . � �/4 � �� 77'� ..�s 'J�ZZ-•F� _ __ . . . , + � _ _. _ `o� o v Gl G) , _� _�_ .,.Q, ----�-- � ' i � o C)v o m e+ o m o � j i � .;., � 0. p a� I T r .. �O W � �p O � ^ � r T "n Vf � N O ��7r -.O. � �_'. n 1 O 3 Q� ('�� .� � ; � rt+-n (1S r O 7 p O C �»p �i ��� �- �� „�� m � V ,� � .. � � °� T s `� � � n. a o S� • ✓i i� °• � �� �-i � � � �;� ` �. �U � �u ` � � � m Q F� ? �+ ,n .�.� �4�� 5,� p� —� 3 n �. I` ' � 1 Y O, c. 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