HomeMy WebLinkAbout1108A 1148A (5) ,
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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
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