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
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