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HomeMy WebLinkAbout1437A 5306A 5307A 6876A (8) �WORKER$'COMPENSATION bECLARATION ` . ',_ -,. __. �., � � I hereby alfirm Iho}I have o certifimte of consenl lo,e�f . . .: -�- �.� qpp��CATION F.OR BUILDING PERMIT insure,or a cerii(icate af Workers'Compenslion Insurance,or o tertified copy Ihereof(Sec.3800,Lob.C.) � ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy_, u1G1 3_�r ��%�'ta►'I �- �.1�K>1 tl' . . Cerlified co n hereb fumished. � � i BWtDiNG O PY Y FOR APPLICANT TO FILL IN - aoozess �3 �O O � .���/_��+�g� �� Certified copy is filed wtlh the�� buil i g i pec- � � � i BUIl01NG Y 'tion deparfinent. � ' � AD�RE55- � - � /� y� f E�G.l�cf�H iocnurv ".�' � Date�. 51�3 Applitant����a�t!k�LN p�l��uQlj CITY ZIP CRO55 bT. G.f � fY�i�- . CERTIFICATE OF EXEMPTION FROM WORKERS' I ru0.OF BLDGS. � n55ES50R � ����COMPENSATION INSURANCE , � � � � SIZE OF LOT Q NOW ON LOT / MAP BOOK VAGE PARCEL / �Thii setlion nead nof ba completed if ihe permit is for one � � ' USE hlE htnP -. /�7 � 3��. , , hundred doilars(5�00)o�less.) . . � I iRACT � BLOCK LOT NO. �j NO. � } TEL. SPECIAL I certify that in the pe�formance of ihe work far which ihis I OwNER . �� NO. ' ��' CON�ITIONS O efmit i5 i55uEd,I shall not em �0 an y r1 �ISTRI�T GROUP TYPE ' FIRE PROCESSED BY � „p p y y person in an manner qDDRE55 � J�� CONST. 20N V ' so os to become�sobject lo Ihe Workers'Compensation Laws. '. �O .�F-- O 'Dafe� � ' � � � � A licanf �' . . . � � I� CITY � • � ZIP C . . � ' _� . . . Pp ARCHRECT R _ / �" .TE�. STATISTICAL QASSIFlCATION APT. CONDO. j � NOTICE TO APPLICANT: If, ofter moking this'Cerlificate of FNGWFER iC['/'1" ��! O. W Exemp�ion,-'you should become su6jeU�to the�Workers' *, , CUs55 NO.�DWELL UNIT$ 0. �) N Compensation provisionf of fha Labor Code,you must forlh- -� qDDRE55 �{� ' y � SEWER MaP Z with tomply with such p�avisions or this permi� sholl be — deemed revoked._, . � . . . ��� �- CONtRACTOR �[ � BK. -FG, � ' VALIDATION � � � LICENSED CONTRACTORS DEGLARATION ' y ' NO �� � y . ... .. . .. ... .. � . I hereby offirm�hat I om�icensed under provisions of Ghapter9� . aDDeE55 '�y +�l�b�sr 7" VAWATION �.� �l��]{{ (commencing with Section 7000J of Division 3 of Ihe B�siness and. �{ � .��� � /'� �� � Professions Code,ond my licensa is in full force and effetL � CIT /� Q L,;,LL_ CLASS 5.��,jp' �� � a��2 j � �' ' '}�� � � SQ.F � NO.OF NO.OF Y CNECK �license N mb Lic Closs�(_ ' SIZE � STORIES FAMIIIES � ONE S �� � •8�6 8�8 0 ��j DESCRIPTION OF WORK = Conlratlor Dafe s�b-� ADD '�� ��� �1� ��.�8 6&8 0� � I om exempt(ro � ensing requirements as I om a . � '� , � - � � licensed arthitact or a registered professional engineer AITER ,� � FINAL J L. L .� . . 0 2 0 3—8 2 � atling in my professional mpacity (Seclion 7051, � � REPAiR � DATE / �j � 8usiness and Professions Code). � USE OF ) / '�Jr�J Q 6 k �� � � EXISTING 9LDG. fr, - - � " DEMOL"❑ � By A� �„//,,�nl./. . . . �� i LL(�C/`� Lic.or Reg.No. ... � Date APRICANT TEI. `(/ — . ��� •.• •2 3 � -�� ��- OWNER-BUILDER DECLARATION � � � � • f��NT � NO.� ' . . I hereby affirm thaf I am e■empt from ihe Comractor's license � � , � ��•2 7 9,2� � .. low for Ihe following reoson(Section 7031.5, Bosiness and ' ADDaE55 / y� • � Professions Code): � � paeSeNi y - • •2�7 2 2 0� I . O � BUIIDING .. . . . .. . . _ ._ • . . . . I, ai owner of the property, or my employees wifh A�ORESS �� n �, woges as iheir sole mmpensatian,will do the work and �OCALITY' � � � �-0�� � µ—��J 1�.� 'I '' the stroctore is nol iNended or offered far sale�Senton - . , , 7044,Business and Prafessions Code). ' nnOwNG � � TEL. ' � � � �5 3 Q 7 q� � �� �1,os owner o(1ha property,om exclusively comracling CONTRACTOR N0. � . ' , . wiih licensed tomratbrs 10 construci the praject(Sec- �. -- � . . � � #• , •2'J —� � �tion 7044,Business and Professions Code). �� � ADDRESS . . REOUIRED TOTAL SETBACK FROM EXIST. � I�• ° • �,E)D CONSTRUCTION IENDING AGENCY � � SEI BACK YARD HWV� PROP.IINE WIDTH ' � I hereby ai(irm iha�there is a mnsiruction lending agency for � pgONi ' � i " • • �,�7�� the performante of the work For which Ihis permit is issued , p.L ' ' .. , Isec.3ov7.eiv.e.>. sioe. . , . 0 1�1 4—8 j � P.l. � Lender's Nama '�� � p' � ,. � /�/ ���.�so a. _ � m LBndEr'S A[J[Jress � � I P.0 Fee S O `�/•�e Permi�Pee � f � ' �`�' � � - � �j(� . O� +� �. . P. W I certify thal I have read this application and state Ihal Ihe I Q� nv Issuanre Fee `O„yD P •O � � � � a _ abo0e information is mrrecl.I ag�ee ta comply with all Counly. , . Invesnqotion Fee � �. . . . � � � f' =� ,. . / ordinantes and Slate laws relating to building canslruction, � /./ '/eO 07 p CS � • P � ond bereby aathorize epresemarives of this Coonty�o ente� Toiol Fee Y• r GJ O O —� p � � ' po the above=menli ed perly for inspeciion purpases. ��� , . � � � �H . � '� a � SEE REVERSE FOR EXPIANATORY LANGVAGE � , S�9�a�vre of Appli�a � . . � � ' y .� _-__ . � ° .. . ' ' . ., ... ...,- ^-t!� "�R m p .m � m� . , - � n,d m Q. o a v s ' 'O p p � .,7 Y, . � (1� . r x,. 'O n a? �O' o �• 17 O c ,, -✓� p � �� . . �m -n N c . �p � .. p `�� ��j� p 3 '�O n O Q '. a a a °� � 6�. y a 3� .,�-o � � W � �+ C�Z a u � o. ao v a , o m coo � « �o ' �,D �N i �v � o . O A,i o A ?no �n ? . . r� � ' -myyy4 x `°-c � - N -< c . ,2 � , o` � IN C A �9 �" � M 7 . � -„ .� ^ o o- z Z O N� o i o m o � m o n: '� a.� � ,°p � o A m, � . '" A c n �, . `�'`'\�' v � � 3 r e ./ i�,"�1 0� . . z Q Q fY .Z.1 � � ` � � .r . ; �'; . 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