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HomeMy WebLinkAbout1108A 1148A (5) , �, -- _..._ _.. WORKERS'�COMPENSATION�DECLARATION - - � � �� . � � � e ��, I ncre�i7y�t'iirm tnai i nave a certiricate oi consenf to self ���i ����'�_�i ��� -�������'�/�i� �;(��]�'� � insore,or a certificdte of Workers'Compensation Inswance, L �r , V CR or a cert�Ped copy ihereof(Sec.3800,La6:C.) COUNTY OF LOS ANGELES BU(LDING-AND SAFETY � Policy No Compnny - - � Le trfied copy s here6y fumtshed. FOR APPUCANT TO FILL IN BUILDING ��/ � no�REss (p ❑ Ceri f ed-copy w Filed withthe muniy building inspeo- BUILDWG'% / tion department. ADDRES�7(0� h ; ' Date � APPlimnt� . . .. � " CITY ,`�J�� ZIP�" LOCALITY . � CERTIPICATE OF EXEMPiION-FROM WORKERS' :� 5¢E OF�O ��' � � " �SNow ON t0� N��B. �:. CeO5555i. �� � � � COMPENSATION INSURANCE � - . (This secfiomneed not�be completed if the permit.�is for�one - ` �+.7A�fJ: ASSESSOR - - hondred dollars f$100)or less.) TRACT BLOCK LGT O. $�d �.1+ MAP BOOK PAGE PARCEL ' . . / J .• S . . ,-.. TF ! . USE ZONE MAP / � I certify�that.in ihe performance of the work for wh�icF this � OWNER� "� �� _ - NO. NO. �( —�o� � permit is issued,I shall not employ an person n a manner �� C. ' �1, SPECIAL !o so as to 6ecome subject to ihe rk ' om e s f n Law. ADDRES9- - CONDITIONS � arv�,v Tq.✓�4 G'�Q, ziP 9 L3 35 `'� ��j� �`� � � � � Date.��App(ica �:. G,. . E...'+.� �� NOTICE�7 LI ANT:-`ff, a er makin9 this Certifimte oF ARCHITECT0� C , El..�TEL "� ��DISTRI � GROUP TYPE FIRE PRO SEDBV � ENGINEER (S��l�,/� '�� A8 � `J`10.$ - y ��.� Exemption; you should be o e s�bject to ihe-Workers' -� �{�y,�f�� A.�y, �;� I CONST. _ 70NE Compensation provisions�.of e Lpbor Code,you mosf forth- qDDRE55 �� -���'��T`.�/.+.Wa ��14F/7lV/Q =L,� � � wilh comply��with such-provisions or this��.permit shall be " ' ` deemed revoked. . - '� "��� ��� �� -' STATISiICAi CLASSIfICAT10N APT. CON < r oNrRacroe j�` �1�t7�faxi No. 6 – D / — LICENSED CONTRACTORS DEClARATlON - _ ���r��n9� C:Ass Na.��2_owELL.Uviis � I hereby affirm ihat I am licensed under provis�ons of Chapter 9 ADDRESS NO.pI'(O�DS�-% - (commencinq with Section 7000)of Div'�sion 3 of ihe Business and I���SEWER MAP� �� � � LIC - J-,,;,¢:; ..�_ _. Professions Code,and my license is in full force and effect. � CITY , ' CLASS --- - �- - -'--�� � - VALIDATION- � SQ.fT', 'r � NO.OF NO.OF CHECK ; BK� �'' .. . � . ... License Number Lic.Ciass � SIZE STOkIES / ' FAMILIFS ^� ONF � . :. . . . � _ . . . . . : . � �fALUATION .. DESCRIPTION OP WORK S�/�`, CoNractor Dafe '��� � ADU � +P �y .:�� _�► � .. • . �I am ezempt under Sec. ALTER ❑ z � � Q.��., . B.&P.G for this reason REPAIR ; � DaYe: .. .� USE OF /�� ��B�p td oEnnoi ❑ #' • • •�� � E%ISTING BiDG. � � . s9na�o�e ` aaaucaNr i'/w�»s ot.�w.v.!'r�.r�i. I 9 •9 h b 9 N FINAL � OWNER-BUILDER DECLARATION - - (PRINT) �p ��. NQ �bATE {�r�.`�� � I hereb affirm that I am exem t from the Contractor's license � �� � �� s��� ; Y P 4 G,�b"4 x Law for the following reason(Sectian 7031.5,Business and AD�RESS � C��t �.,i F7NAl /,,,�,9 - - � ' � � Professions Code): ... : . .' �' PRESEN7 , � � . . � --�; By -� -�°.a,°Y��° , = �.. `.k:�.l,� f-'�}�(p ❑ ._ _ �BUILDING , , . - - I, as owner of-the property, or my employees with -ADDRE55" � � . F wages as iheir sole compensption,wili do the work and � - - -�� - - - - � �- �' the siructure is not intended ar offered for sale(Section tOC.4li7Y/,biD4Sr"/� � � - � 7044,Business and Professions Code). - nnoviN� iEi. ��, � �� , �-��_- -�-`.� i �'8--r1 ' CONTRAQOR �.. NO. ^ - . �,as owner of the properiy,am exdusively toniracting . , �. . ' with licensed mniractors fo construct ffie project(Ser qDDRE55 '- --- =��#• o •-s�-1 ' tion 7044,Business and Professions Code). . . . REQUIRE� TOTAL SETBACK F M E � ,�; CONSTRUCTION LENDINGAGENCV � �Tgq�K YARD HWY PROP.LINE WI�TH � - - � ��--��� "� C jl,-�"J ( I hereby affirm ihat there is a construction lending agency for - FRONT . the performance of ihe work for which ihis permii is issued p.�. - � � ,.„ , ��_•_e ' �(�.-L-J��,,, (Sea 3097,Civ.C.). SIDE � . ' - . .. a P.L �2 1 8"'�g._'6� lender's Name � � - �- � � �' / / r� � L�MA Ref.# -� � lender's Address P.C.Fee$ (p Permit fee ! ✓- � � - -- I > �y�, I certify that I have read ihis application and state that the .. Issuance Fee �� �L/ LDMA P/C N ' - a above information is correct.I agree to comply with all County Investigation fee ' - � ordinances and$tate laws relaling to building construction, Total Fee /�- '�� LpMq Perm.# � - - u and here6y authorize re resentatives of ihis Covnty to enter '. � � _ �. m n fhe ove-m ti operty for inspection pur oses. �� - � . a +F� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature�of Appii<anf or Agent -.... �-;� �' .. . . �. . . . �':7 i + 2 0 a .. , , �z ,' - � p Ci1 � 4 m � c�� m o- ° °` a o cD y o v o o � n v� c°o � n � :. 'O � 4 3 �'. C9 -•• ' 4 Ci O n .. .. � F � n Q 7 � � � �� - r . . . T N� � � '� � O-9 � N m N � � cn o m Q � , � 0 0�, o p �. N f � � 6 �,y o O � m o % �mt�+ "� n � n,-n C�o ° 3 �n � a �` � �� �� 3 ° 9 � � � c � 7.p '� � .c p �o '° �D � CD (0 [n N-L 3 N Q N � - ^. � r o � ^ Z � o`c �- °�,�" _ � m �W t� n 3 R°c N n a � y y -.+ -0 3 'o ` a cfl N 9. 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