HomeMy WebLinkAbout0847A 1031A (4) , . �, _ �
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WORKERS'COMPENSATION DECLARATION � �. ._,.�.. .... . .. _ . . . . . . �
I hereby�offirm fhol I have o certiiicate of consent to 5e�f . . . �APPLICATION FOR BUILDING PERMIT
�. insure,or a certificaie of Workers'Compenstion Insorance,or
a certiiied copy thereof(Sec.3800,Lab.C.� i COUNTY OF LOS ANGELES BUILDING AND SAFETY �
P❑olltyNo. � Company . . . i ^.� p' � •
Certffied copy is hereby fumished.' � FOR APPLICANT TO FILL IN ADDRESS�G'C TJ � ' 2
Certified copy is filed with iha�coonty building inspeo- BURDiniG t, (r
.�.'tiOn deporlmenl. � . . .. . . ... ADORESS� 7 7' - G �/ � ���L � ia�uirr ('C��:\ ..�(' ..
Do+e' Applican� � urv�J/�/7CLrr/J IJ�2 - p NEAREST _
ZIP -l I S � CRO55 SL� P
CERTIFICATE OF EXEMPTION FROM WORKERS' � . 5¢E OF lOT 3��,X F�'�G3� NOW ON tOT I_ MAP BOOK - PAGE 7nRCEt
- � � COMPENSATION INSURANCE �
�� (This sec�ion need not be comple�ed if the permit is�for one USe ZONE nnnP r�
h�ndred dollors(5100)or�ess.) _ TRACT ) � BLOCK LOT NO. .�� �' NO. [� �
A n !j 1 TEI. SPECIAI p,
OWNER Je,v'� G (� ,SSCY) N J/ ,SY/ .�� �O CONDITIONS
I certify ihot in the periormance of the work for hich this .0
, perm'tl is issued,I Shall noI empl0y any pBr���jjjSonnnn in ny manner - . DISIRICT GR UP iYPE FIRE PROCESSED BY.
�sv as fo 6ecvme sub'ecf fo fhe Work� � AD�RESS if Q .r EO� ^ 3 CONST. N
I , p sation Lows. �� .��. I� ,L I O
`_ r�
. �Date�2����� Applicanl� �TY Z�P STAt15TICi.lCL4551FICATION A7T. CONDp. ~
AR HITECT OR TEL.
��NOTICE TO APPLICANT: If, ofter making this Certifim�e of "' - � �''�� u
R G,�G NO. W
�Exemption,�you should betome subject to ihe�Workers' 9 CtASS NO..�LDWELL UNITS N
,Compensotion provisions oi ihe labor Code,y ouu mosl torth- �� ADDRE55 SY�d � �-�JA:rarO r .d.'�j��7'ZNa SEwER MAP Z
. with comply with such provisions or.�this�pe�mit shall be TE�.2� —
deemedrevoked. .. . . �-�� CONTRAROR-,��,� Ip �/Lo' t�S.NO.-- �3c� BK. PG, VALIOATION
� IICENSED CONTRACTORS DECLARATION. LIC. n
- �reby offirm Ihot I am licensed under provisiond o{Chopler 9 ADDRESS .). . .,T,F � - .NO.��G /.r' VpLUATION z O�S"G.�'�TA �
(rommencing with Seclion 7000)of Divisian 3 oi the Business and ��� / -
Professions Code,6nd my license is in full forte and effett. CiTY� Wf ,+,0 C(rl� I C�ASS' ;�� E 1 J �00 � . #• �'•.•2��
SO.FT. NO.OF NO.Of CHECK
�LiCenSe Number � $ Lfc.C�a55�� � SIZE STORIES - FAMIIIE$ ONE . '
5 � ^� �4,8,� .
sG��p ��� fr �SiSGGDaieTZ-(c,-�1 . . . ' DESCRIPTIONOF WORK .4 YS �a�) NEW ❑ . . .. e,• � Q(�8 Q�.
� I am eaempt from the licensing reqoiremems as I om a OA171 CN DI�R- eAi�r �rif�t/�l�L AD� r , �
, �licensed orchiiett or a registered professionol en9ineer _ ,. ... nL7ER � � FINAL � '� � � ��—$�
� .. .. _ _. .. . . DATE � RO � .
. acling in my professionol capacily (Seciion 7051, � � � . .�
� � Business and Professions Code). USE OF . RFPAIR _ ,
- � - . � EXIS1iNG BLDG. Ch�. � DEMOL ❑ FINAL
Lit.orRe9.No. Dale APPLICANT ' �TEL. BY �� '�-�� .
� � � OWNER-BUILDERDECLARATION � - �" - �1vewT� /pn S ' Cl, 6�Z� '-NO. /cZ��o� � ,
I herehy oifirm Ihat I am exempt from ihe Contractor's License qDDRE55 •O•� �A -p-��� ✓tJt+.���/{Cr�i-SIP � - � � �-� - �
� Law for the following reason(Sedion 7031.5, Business ond � "�
� Professions Code): � FKiStNi �
. ❑ . � . . ... _ . . .__ BUILOING � ... .... . . . .. .. .. _ _ _ _ '
�I, as owner of the property, ar my employees with � n�DRE55 .
. woges as their sole compensarion,will do the wo�k ond . , � � �
�-- the structvre is not iniended or offered for sale(Section� • locnuTv � � � - � �-� �� �- � �� �� � �- � � - • �
7044,Business ond ProFessio�s Code). � MOVING ' TEL . �
� I,as owner of the property,om exclusively con�rocling -- CONTanCrort No.
wifh licensed tonhadors to constroct the project(Sec- ADDRESS '
� . � fion 7044,Business ond Professions Coda). � �� � � �
FEOUIRED 707At SETBACK FROM ExIST. n
'� � CONSTRUCTION IEN�ING AGENCY SET BACK YARD HWY PROP.IINE WI�TH ' � .� - ' - • z� O��� n
.�I hereby af(irm�ha1 there is a mnsiruction lending agenty for � FeoNT ' � - . � � � - - -` - '
'the performance of Ihe work for which Ihis permit is issued F.L� . � . . ., , #..���'��,��1� �
'(se�.sos�,c�.e.). P oe.. I • 1 3 9.5 0 �
Lender s Nome ,�j . � ' � � � '
Lender's�Address � P.C.Fee S l Q Permil Fee ��• L�+, - � . ' • 1 3 9.5 0� �
I cerlify ihal I hove reod Ihis application and state that the . � In�onre Fee �c9U _�2� 5'�$:� .�
obove inlormotio�l' co rect.I agree to ply with all Counfy_ . , in�esrganon Fee. . . _ . . . . . . � . . . .
ordinances and ate ICws relating to ilding conLruttion, i To�al Fee �3�J��
ond hereby a orize./epresen o ihis Covnty fo enter . -
�pon 1 a6 ve- �lianed p f o inspecfion purpose5. i - _ - .
�� �(1'0 'z_{,J�—8� SEE RFVFRSE FOR EXPLANATORY LANGUAGE . � � ' � � ' �
- Signatore of Appliconl or Agen�� �ate . - � �
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