HomeMy WebLinkAbout1438A 5301A 6877A (8) ' �WORKER$'COMPENSATION DECLARATION % , . '' , ' - � ' If
. I hereby aiiirm iho�I have a cenlf�coie of consent to self ;� . . �- APPLICATION FOR BUILDING PERMIT _ LL
insure,or a cerlifico�e of Workers'Compenstion Insuronce,or � ,
a�certified.c�oAy thereof(Set.3800,tab.C.) � n �y, �
volis�.WG13�0.��Pa�y/(f��yw;f'y�_�, I�rjrn.}-(,!, , COUNTY OF LOS ANGELES BUILDING AND SAFETY
�� Certified m is hereb iu�nished. ' ' . BUILDING � (1 �����w•
❑ av Y I FOR APPLICANT TO FILL IN ADORE55�'�G'n � .c�-t�
- _� �Certified copy is filed wilh Ihe county boilding i 5peo- gUILDING . . �,v'� � �
tion deparlment. T7 ' ADDRE55 LOCALITYI GQ-+..-!'x� i
DC !'�E •
frk(t�,: NEAREST. ,e�� ,
Do�e 5/r/�Applican� ��l C1G ��7y . ZIP � CRO55 ST. C��++�-I).�G ��"-��` �
' CERTIFICATE OF EXEMPTION FROM WORKERS' r NO.OF BtDGS. ASSESSOR �
� �� COMPENSATION INSURANCE � � SIZE OF LOT Q " NOW ON LOT � MAP BOOK PAGE PARCEL i
(This settion need no�be compleied if fhe permit is for one � u5E O E MAP
hundred doilars(5100)or less.) . � TRACT BLOCK LOT NO. �� NO. � �I7 "J�f� r
� IEL. SPECIAL � O
I certify ihat in the performance of Ihe work for whith tbi5 ��• OWNER . ' � � NO. ��L CONDITIONS �
permit iS is3ued,I sholl not employ any person in any manner /� DISTRICI GROUP IVPE fIRE PROCESSED BY . V
� so as to be[ome subjepct to 1he Workers'Compensation laws. ADDRESS G CONST. ZONE
�af��Y�I 7Qpd�rednt '. CITY � ZIP C • lO G�� l� . � u
SIAf15TICALCLAS5IFICA710N APT. CONDO.
NOTICE TO APPLICANT: If, ofter moking this Certi(icore of ARCHiiECi e iE�.G�3��'/ . w
-EMemption, you should become subjecf io fhe �Norkers' . , ENGINEER � •�i.�' NO. ) !� QA55 NO. DWELL.UNIT$ N
y �
�Compensation provisions of the labor Code,you mu51 forlh- ', qDDRE55� 1' SEwER rnnv , Z
with comply wilh wth provisions or�Ihis permil shall be . I � . —
.deemed revoked.�,' . . � J� y7 TE�. , VAIIDATION
� COMRACTOK4D AC� a NO 1- Q I eK� �•
LICENSEDCONTRACTORSDECLARATION `- 1 � I n?�!' ' , . - -� •��
I�hereby aifirm that I am licensed under proviaians of Chop�er 9__�� � pppgE55 Yq� NC O��'i VALl1AT10N�j �y � ;"'� �
_(mmmencing wilh$ecfion 7000)of Divis(on 3 of the Business and . /� `�"�J. J� �3� U'�8� � r .
Professions Code,ond my license is.in iull force ond effect. �,,,.__ CiTv QD1 IGhDJ C1a.55 — '"i� ""1+� . . ' � '
� � SQ.FT NO.OF if NO.Of CHECK,� I%• •�" ^f:J
license N�mbe�^ lic.Class� SIZE STORIES 4 FAMILIES �� ONE � � � } � � , ` I
' � y I t{� 5�20
Conlracfor pole�-�-�_ ' DESCRIPTION OF WORK NEW �3 O� � �
� I am ezempt from tha ' ' g requirements os I om a � - A�� . °yj.��5�,�n� r ��
. licensed orchiletl or a registered professionol englneer � AUER � FINAL j y G ,
a c t i n g i n��m Y P�ofeizionol ca pacit y (Secfion 7051. •- - � O DATE �'� ( t/� � 0 2'�:'—�� ,
� � 6usinezs and Professions Code). � � R E P n i R
. U5E OF DEMOL • '
� � - EXISTING BL � r� �� �
Lic.or Reg.No. Date APPIICANT TEL. gY A`�i1ZGl��L� ' :-, j�U ,�, 1 . ,,
--�-�•�' � �� OWNER•BUILDERDECIARATION ' � IPRMTI � 1'S�' � ' NO. (JU� `��1��1 •- �
I hereby offirm�hal I am e�empt from the CoMrattor's Licensa . � y{ . � p �� ,
� �o ;�: 1.
,.�Low for the following reoson(Saction 7031.5,Business ond ADDRE55 W '� . 'i
ProiesstonsCode):- � � � ' • PeEservi � �?�`� . � �. •
� � I, as owner o{the ro ert or m em lo ees with gUnDING � . � s 2�( �,lJ�
P P Y Y P Y AODRE55 � . . � � ' / , ^ ^ - �
,••���•�•�heir sole tomp.nca�ion,w'li de thn work ond � ��t7 =1'f°,'"^� • �^�.;l';�•�'� r
�� �- theitructore is not INended or oifeied for sole(Section IOCAtITV � � - ' � `" " �
7044,Business and Professions Code). � ' MOviNG TE�• � �,
� I,as owner oi the property,om exdusively tontracling' CONtRAC70R - NO. . ��.� 4�����
wilh licensed mntraUoro�o conslruct�he project(Sec• . � . .
��.. tion 7044,Business and Professions Code). �� � , ADDRE55 � . - •
CONSTRUCTION IENDING AGENCY , REDUiRED yqRD HWY TOTAL SETBACK FROM � E%IST. ' , '
SET BAIX PROP.LINE WIDTH . � �; . • _
�I hereby affirm that�here is a mnstruUion lending agency for ' FRON� '' ' . . %-'V�' (, /j; � `
�he performance of the work for which this permi�is issued I P� . �
�Sec.3097,Civ.C.). . ' � sioe � - � . - ' � � ,. ° • ^ _ '-����
. � P.L � � . �. ' . � �
_.Lender's Name � ; 7 � . � . . . ,� ?,%i� !,(��i �
� P.C.Fee S � �S�.}�D Permit Fee � y, �D ' ' �
lender's Address - ' •• �,;';�-�),{'�: _
I certify that�I have read�his opplitation and slate ihot�he , � Q�� � Issuan<e Fee .�� � '
above informalion is correct.I agree 10 comply with oll County i�ven�igmwn Fee� � � � � ����"��/���'" '
. ordinonces and State laws reloring to building constructian, � To+ol Fee ��57• �'T� . � '
ond hereby authorize representa�ives of this Counly�o enter � , . , . �
ihe obove-�ne .ropert far inipec�ion purposes. � . , � � �
�� S SEE REVERSE FOR EXPLANATORY IANGUACE ;
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