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
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