HomeMy WebLinkAbout1305A 1306A (7) WORKERS'COMPENSATION DECIARATION I . �/Yf/g//EU�KV�*-�-� v�C/lj7/I�/I?1 /-C�C�G- I��7 f� �
I hereby offirm tha�1 have a tertifitate of consent to sel(
;�,�,e,oratertifita�eofWorkers'Compensotionlnsurance, �.��� APPLICATION FOR BUILDING PERMIT
or a certified copy thereof(Sea 3800,Lab.C.) � - . � i � -�
� ;y����� �-� COUNTY OF LOS ANGELES . � ••- •BUILDING AND SAFETY
vol' o`:S�L.[co�Pa^v�l�d C'�'"'c'"�`i� . _. . . _ _ - . .. � .
Cer�ified copy is hereby furnished. � FOR APPLICANT TO FILL IN nooeess O 7�� �
� Certified copy is filed with tha coonry building inspec- BUaDiNG �q C� J I 1 .1 .
tion department .. ADDRE55 V �J `EL, ct„ - LOCAUTY� LV� )
, -\ NEAREST
Date 3 �L APPlicant � cltt W LvJu\ zIP � CaOSSsi. � .< I �. �
� C RTI�EXEMPTIO RO WORKERS' NO.OP BtDGS. ASSESSOR .
COMPENSATION I $URA CE SIZE OF LOT NOW ON LOT MAP 800K PAGE PARCEL
(This section need not be compl ed i ha permll is for ona / r� US ZON �P _
hundred dollan(EI00)or less.) TRACT (� BLOGK LOT NO. J � _� NO. � �-3�
- ' TEL � DO SPECIAL . Y
I certify Ihal in Ihe pe�formante of the work ior whtch this . OwNER L g0(� No. ���� CONDITIONS ti
permit is Issued,I shell nof employ any persan in ony manner �� � ^ [�1 r `,- -�-- - �- ----- oi5�eici GROUP Trae ci PRQQQCCCEEE 95eo ev �O
ADDRE55 otO-1 l.- F�1r1 C�-� � /�� C T. /f Z E �% -
so as to become subjeU to the Workers'Compensation laws. . V� . �„
- . . . .. .. - �- �---. ._.._. !� G�V 1 � ' it.tA -
Dote �Applimnl � � ��TM ��L��T ZIP STATIS11CA1M551F1 TION APT. CON00, �
NOTICE 10 APPLICANT: If, ofter making this Cerlifimte of ARCHITEROR TEt. 7 . .U
ENGINEER dC_I��w�+-.S�� - No.�36-OZg� �pu NO.v DWELL UNITS �W
�Eaemption, yo� sho�ld betome e�bjecf to�Ihe Workers' . �y y
Compensmion provisions of the Lobor Code,you most(orth- � qDDaE55 �. 7�J�V RODW��r � GPCA� ' SFWER MAP �
wi�h comply with such provisions or this permit shall be I _
deemed revoked. . - � .. CONiRAROR� �'�'YC.. OZ1.SN0��`�'�3b'-CS3� i--BK.-� �PG, � - � -- VALIDATION �
UCENSED CONTRACTORS DECLARATION . \ , uc. �1 3 0 5 A -
I he�e6y a(firm Ihat l am licensed under provisions of Chapler 9 ADORESS3�l � � MO.���� -'VALUATION �7,.7
(commencing with Section 7000)of Divisio�3 of�he B�siness and ^�-�� �iC. n I ^ �$,••���• •��
Prolessions Code,and my licensa is in foq force and effect. CITY,LtST�"� MS5`�S�J S p/ (�L�• � �
L�-�.n S .-7 �3 SQ.FT. NO.OF NO.OF CHECK , I • •J Z.II� - .
license Number 1 � � r Lic.Class� SIZE STORIES FAMILIES ONE
�,GY`C�.���C�Q(S� ' %���� �ESCRIPTION OF WORK NEw ❑ �s ` ' � ��� �>2•��� `�
Con�roc�or are_r __r„�_ t noo . 0 3 1�3-S 4
�I am ezempt under Set. �W��~�'� �J�� p�TER. � FINAL���+ .
, � . � REPAIR � UATE U--2-� ;-��� �Q[�A .
B.BP.C.for thfs reason - " - -� �
� Date: USEOF ��- � - .. DEMOL ❑ FINAL' ' .�;• • • . •J.
E%ISTINGBLDG. - � �0
APRICANi . .."��'� � �EL �a Y
$ignat�re - � PRINT - uvi��� �1V9S 3�-V,� -
OWNER•8111LDER DECLARATION �I • � H E�G O
I hereb affirm that I am exem 1 from 1ha Controctoi s License C
Law far the following reoson(Setlion 7031.5,Business ond � aDoaE55 �35 O. J ��� � ��yf� • • � � �`�.rl�i�
' PfofESSlOnS COde�: ' PRESENT i _��LJ
❑ - . - BUILDING '�'C !�-i/�/ G� � �-Q�j
I, o s owner o f I he proper ry, or my emp loyees wi t h - A D O R E 5 5
wages os theirsole compansation,will do tha work and " � � P� ,
1ha strudure Is nof intended or offered for sola(Setlion- - ����TY ,�/ =�I�,, � - � � � �
7044,Buslness ond Pro(essions CodaJ. . MWwG 7Et. ��'"``�'`�`� � . �
� I,as owner ot 1he properly,om exclusively cantmcting NTRACTOR NO. . I� . _
wiih Iicensad contracton m consrrucf the praject(Sec- , qooaess � ✓��` � � ' � � �
-fton 7044,Buslnesz and Professions Coda). . .;_ .. _�f� �-/ ^ �- � � ��� ' � �
' RE�UIRED TOTAL SETBAIX FROM E%IST. , �S S�p` _„ ._ ^,
CONSiRUCTION LENDING AGENCY � SET BACK YARD Hwr PROP.uNE WID7H , ,'�' . •�,_�'. -. ,� ; . .
_I hereby affirm thot thera is a tonslruction lending agenq for , -FRONt � - ��` - --- � � � - � �
the performanca of ihe work(or which this permit is issued P.L , �� _ --
�Sec.3097,Civ.C.). � SIDE �� ' . ' � -' \� '
n� P.L .. . .._. _.........._._.... . ' "_ '.�.
lender s Nama � p� ( �
Lender's Address P.C.Fee S �� D 1 Perm��Fee 7��� � . . . , -
. � ...-�- � .� S�. ._. ..... . _ ..
I certify that I hava read this application and stote that the � �� � Issuonm Fee ^ -
obove Information is mrrccf.I agrea lo mmply with all County Invesiiga�ion Fee � � � A� • �� ^'%�•
- ordinances and Sm�e lows relming to building construction, - � toral Fee�
ereby auihor' represenlativea of fhis County to enter _ �-
upon t bove-m n one r rfy for.inspection purposes. � � �- ��� � � � �� �� - � � � '
1
3 ��L b'f SEE REVERSE FOR EXPUNATORY LANCUAGE _ _ -
Sig lure o1 pplicanl or Agent Dore . . - ' �
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