HomeMy WebLinkAbout1066A ,�� � WORKERS'COMPENSATION pECLARATION ' �
� I hereby affirm rhot I have a�e«;��ro,e of�o�5e�„o,e�f �-.,APPLICATION FQR BUILDING PERMIT � �
insure,or a tertificate of Worken'Compensolion Insurante, �
or o certified copy thereof(Sec.3800,teb.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poll[yNO. Compony BVIIDING n �
� Certified mpy is hereby furNshed. FOR APPLICANT TO FILL IN ADDRESS �57� �C W l E�T
� Certified copy is filed with the coumy building inspee- eVaowG / n �
tiondepoftmenf. � ADDRESS � niOCJ � �(f LOCALITY /�l�,
Date Applicanf CI � ��_ /, ZIP � ` 5 NEAREST
� CROSS ST.
' CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGs. n55e55oR �
GOMPENSATION INSURANCE SIZE OF LOT NOW ON l0T I MAP BOpK PAGE PARCEL
(This settlon need nol be tompleted if tha permit is for ane USE Z e �P Q ~'33�
hvnd�ed dollors(E100)or less.) TRAR BIOCK �Oi n10. �� NO.
� � 1 TEL / ,�/ SPECIAL
I cartify that in tha perFormnnce of Ihe work for whith this OWNER 0 11'�I'�N NO.7�y' 6 ' � I,v CONDITIONS f1
permit is issued,I shall nol employ ony person in ony manner • � �{ DISIRICT GROUP TYPE FIRE PROCESSED BY Q _
so as�o become subject lo the Workers'Compe�501ion LawS. /+DDRESS 7� i�G W A �, E % J2• CONSi.�/ ZONE V
f /� -1 r /O .�3 �i 1 �.t� `�e
Dafe� � � Applicant �� �`. ( C S � QTY �� ,A ZIP.-/I /��D STATISTICALClA551FICATION APT. CONDO. O
ARCHI7EC7 OR � � ':.TEL, �
NOTIC TO A PLICANT:.If,�afler making thts Cer iftcale'of � � . � ���' � � q J � � U
ENGNEER�:�. �.� NO. . �CIA55 NO. --�DVJELL.UNITS w
Exemption, you�should become�subject��to-the Workers' � � , . . _ ,, y
Compensation provisions of tha Labor Code;you must forth- � � qppRE55�� � � SEWER MAP N
with tomply wJh soch provisions or�this permil sholl be n 7` � �� n � � p��I/� �p � l
deemedrevoked. - CONTRACTOR r7//�� � �� �K NO.��ys 17'��3 - . BK.- - PG, VALIDATION
IICENSED CONTRACTORS DECLARATION '/ �
I hereby affirm thef I am litensed under provisions of Chopter 9 � ADDRE55 {}" ��'��f� NO. �-(U 7�� VALUAT�ON-
(commencinq wiih Setlio�700D)oi�ivision 3 of tha Bosiness ond th� - LIC. ��G/ E � '7 r p` �
Professions Code,and m license is in(ull torca and effecL CITY� I �f �S CtltSS �ti J � , �
g (� f j 5�.FT. ,/ NO.OF NO.OF CHECK
llcense Nomber � J 7 li[.Closs ` �" � SIZE �6 7� S70RIE5 FAMILIES ONE
� � DESCRIPTION OF WORK N� ❑ � E
�o�,�a�;a�P�,�,� cR��,�,Fs oa« � e � ,
q ADD V�
�1 am exempl under Set. Q ^� L-I¢ 1« ��1� nUt� ALTER � FINAI
B.BP.C.ior this reason � ' � DATE
REPAIR
Dote: u5E OF � DFMOL ❑ FINAL �1 0 6 6 A
EXISTINGBLDG. CS. fAICC B
Signature . ADpIICA � TEL.7 Y �• • • • �.�.
OWNER-BUILDER DECLARATION PRINT � �/C'S No. � �
I hereby affirm thot I om azampt from the CoMracror's License '• /� u � ��• •4 9 2 5
Low for tha following reason(Seclion 7031.5,Business ond 'ADORESS ��K � G�f ll�s �al�' /� •J�1 • ► ��� �
Proiesstons Goda): va Nr � (/� � • • •4 9.2 5 cSr
❑ BUILDING . s'�/ L� �!/
� I, ee owner of tha property,or my employeez with ADORE55 � ` O�,,$`$4
woges as their sole compensation,wil�do tha work and ���TM
- thc strottore is not intended or oitered Ior sale(Section . \ . �
70dd,Business ond Professions Code). MowrlG iEL. \ � �
� I,as owner of the property,am exclusively mntrading , � NTRACTOR NO. '
wi�h licensed contracfors to construct the projecl(Sec- qpDRESS
tion 7044,Buslness and Professions Cada). _ � .
- REQUIRED 70TAl5ETBACK FROM E%IST.
CONSTRl1CTION LENDING AGENCY � SET BnCK YARD- HWY p�p �INE WiDTH � •
I hereby affirm that fhere is a mnsrrucflon lending agency for .FeoNT -
the performance of the work for which Ihis permit is issued v.t. .
�Set.3097,Civ.C.). sioe
.. . P.L . . . .. .
Lender's Name +�' ` 9 .
P.C.Fee E Permit Fea ,j C'r/�
Lender's Address
1 certify Ihat I have reod Ihis opplfcotion and state that tha � �� I�euonce Fee �C• } � � � �
above information Is cortecf.I ogree�o comply with all Counry Imesr�gotion Fee .7 '
ordinances and SIa1e lawz ralaling lo b�ilding mnsfrucfion, Torol Fee �/• '�
and hereby authorize representatives of this Counly fo enter
C upon�ha above•menti ned properry for Inspection urposes. � � � � � �
�I� , � , SFE REVERSE FOR EXPIANATORY LANGIIAGE , .
Sigrwture of Applicant a Agenr � ` Dfite . . ml
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