HomeMy WebLinkAbout1364A � . WORKERS'COMPENSATION DECLARATION �
1 hereby aff��m �ha� � ho�e a�e�f�f��a,e of�o�se�,,a=e�f APPLICATION FOR BUILDING PERMIT
insure,or a certificate of Workers'Compenstion Insurance,or
a ceriified copy thereof(Sec.3800,��b.C) COUNTY�F LOS ANGELES BUILDING AND SAFETY
PolicyNo. Company �
� Certified mpy is hereby tur��shed. FOR APPLICANT TO FILL IN ADDRESS �.�v�cJ ��--C���
� Certified copy is filed wifh the county building inspeo- ew�DiNG_ ��;� ����_ .
tion depariment. ADDRESS � �(�C�����G._,] LOCALITY
NEARESi '1c�l� _
Date Applicen! CITY � � 71P � CROSSST. � ���1
CERTIFICAiE OF EXEMPi ION FROM WORKERS' NO.OF eL�Gs. A55FSSOR
COMPENSATION INSURANCE SIZE OF LOi NOW ON LOT � MAP BOOK PAGE PARCEL
(This sectian need noi be wmpleted if the permi�is for one USE ZONE MAP _
hundred dollars($l OQj or less.) TRACT BLOCK Lo7 NO. �+ No. �� � � Y
(1,� �('' b� ` TEI ��l� n SPECIAL a
I cerfify that in the performance�of the work tor which ihis OWNER y� �- E. �} yiJ�.1.:`J NO.��'-� �.]� �� �a"�1Q CONDITIONS o
permll is issued,1 shall not empioy any person in any manner t.� UISTRICT GROUP TVOp��— fIRE PROCESSEI7 BY V
so as to 6ecome subjec�to ihe Workers'Compensation Laws. ADDRE55 ��(V�\,�L.- � � � � p�-
0
�ate ApplicanY C�Tv Z�P STATISTICAL CiA551FICATION � APT_ CONDO. V
NOTICE TO APPLICANT� If, after making ihis Certifimte of � AkCHi7EQ0 . � e TEL ^-�� b,` ya
Ezemption, you should become subject fo fhe Workers' ENGINEER � �: 4. , `v NO.�`l���4 CLASS NO. DWELL UNITS� �
Compensalion prcvisions of fhe Labor Code,you must forih- qDDRESS y, SEJJER MAN �
with comply with such provisions or this permit shall be
deemed revoked. ' CGNTRACTOR� NO. 6K. PG, -- VALIDATION
LICENSED CONTRAC70R5 DECLARATION LiC. � �
I hereby affirm rhur I am licensed under provisions of Chapler 9 qDDRE55 NO. VALUATION
(commencing with Sedion 700D)of Div�is on 3 of the 6usiness and LiC � � a z� 3�t 4{�
Professions Coda,ond my license is in fu�l force and effcd. O�y CtA55 $ �
SCZ.FI. NO.Of NO.OF CHECK #� � � �2 3
LicenseNumber Lic.Class SI7F STORIES FAMILIES ONE
Contracior potc �ESCRIPTION Of WOItK
NEW � S � s •CS,Oa
� I am exempt from ihe li[ensing requiremenis as I am a ��� ���y� � �,�1�_ ADD � • o e'��a Q�
licensed architecl or a registered prefessianal engineer AITER � FINAL
octing in my professional mpacify (Section 7051, REPAIR � DATE Q�.2�]�8 Q
Business and Professlons Code). U5E Of
E%ISTING�BLDG. DEMOt � FINAL
� Lic.nr Heg.No. Date ANPLICANT'w�� �p iEL �}� tF� BY �
OWNER-BUILDER DECLARATION IPRiNt)`�� �����5.,1,h�:\] NO.��(.l"s�\�v
I hereby affirm that I am exempf from the Contrpctor's License . ��r f-�� ��� fi . � -
. Lqw for ihe following reason �Secfian 7031.5, Buslness ond ADDRESS �a 4. �
Professions Code): �RESEN� '
� BURDING j>� �
I, as owner of fhe properiy, or my employees w��th ADDRE55 �.V
wages as fheir sole compensation,will do rhe work and . �'��(P� /�3 .
the struciure is not intended or o4fered for sole(Sectioi� LOCAUTV j„
7044,Business and Professions Code). � MOVING 1EL j�
� I,os owner ot the property,am exclusively<oniracfing CONTBACTok NO. /1/•
with litensed contractors to construtl the project(Ser- �
tion 7044,Business pnd Professions Code). �DDHE55 . �
CONSTRUCTION LEN�ING AGEMCY REOUiRED 70TAL SETBACK FeOM txiST. .
SEI BAC:K YARD HWV pROP.I!NE WIDTH .
I hereby offirm that ihere�is a mnsiru�tion lending agency for FeONi
ihe performance of the work for whkh this permit is issued p.�.
ISec.3097,G�.C.). - SioE � ,,
P.l
Lender's Name -
7 (�
Lender's AddrPss P.C.Fee S ��,�� Permif Fee �'��. L}
1 certify ihat I hove read this appllcation and state that ihe issu ce Fee �
- above informalion is ccrrecL I ayree ia comply with oll Couniy Imesiiganon Fee pn r.
ord�inonces nnd Stote lows relaring to building construdion, Total Fee - � d
ond hereby outhorize representatives of ihis County b enter �' .
upon ihe obove-menfloned properry forinspecrion purposes- . -
¢ . - SEE REVERSE FOR EXPLANATORV LANGUAGE �
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