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HomeMy WebLinkAbout1112A (5) �� � WORKERS'COMPENSATION DECLARATION � ' APPLICATtON FO� UILDING PERMIT � 1 hereby affirm that I have a certi4icate of consent to self - insure,or a cer?ifimfe af Workers'Compenstion Insurance,or I a certified copy�hereof(sec 3800,�ab.C.) COUNTY Of LOS ANGELES BUILDING AND SAFETY (0 PolicyNo. Company BUILDMG F�� � � Certif�ed copy is he�eby furnished. FOR APPLICANT TO FILL IN no�aess ��1• � /�' � � ��'r ,.�..' <-� � CerLfied copy is f led wrth the county build�ng inspec- BUILDWG % y�� f d - � I �iqJi department .,, � ADDRESS 3 I���r i '�r� �'-�� �Y� �'•�: LOCALITY ��.�•5�i"j�'t" � � . I . (+ .,��, "��_'�'�- ,�.,_:,_ : r . .. NEAREST � :G-'°" i Doie / j+� °'1`.�,-Applicam� ,{!�'«�� +w 1 ;� � d'td%v i ziP � 1 l .`�S� cRoss sT (:?�l ri`i;§ � l.�'�-� 'T�o.:�a.,i 3 . - . C RTIFICATE OF EXEMPTION FROM WORKE� ' . SizE oF�oi?;}C�� � f„�SS No.OF 6toG5. / ASSESSOR � - COMPENSATION INSURANCE � NOW ON LOT t MAP BOOK PAGE PARCEL � '�_(This section need not be wmpleted it the permit is for one _� �.. USE ZONE MAP / J -^7 '�hundfed dollafs'($100)Or Ie35.) TRACi� BLOCK LOT NO. NO. �f /�T ;}� . .�, } } 1 �j TEl SPECIA� g, �'I certify that in Ihe performance of the work for which ihis �wNER �j1.Y�}, 1�.�' y'°"� �-�'� � CONDiiIONs -pe mit is issued,I shall nat employ y person in any manner j A j �ISTRiQ GROUP TYPE FIRE PROCESSED BY � ADDRE55 {.i-�L� ��'�5��y�LF"� §"��"` 4.�I' CONST. ZONE � �so.as to hecome subject to the Workers Compensa{ion ws. 1_ �'j f/.1 .��y �y.y�- �.-.-7- r����' '�_ � C. tf) . . , l �j --.r�` (.. J �Y..- ..i-Hi. E\ r, T ! ( �. %- ' t CITY i.. �9 o1,e'4-'� 7I ���-3� W 'Date! �7 .Appliw�t� �`s'i� � STATISTICAL UASSIFI�ATION APT. CON00. � y,1 �-NOiI E T APPLICANT: if, after making !Fis L.rtificote of AkCHiTEQ OR �EL. � � tNGINEER NO. CLA55 NO.�`-'� DWELL UNITS_ � :£zemption, you should become subjecl io-4he Workers' hfD 'Compensation provisions of the La6ar Code,you must for�h- ADDRF55 S6WER MAP � �with mmply with such provisions ar this permit sholl be �- -deemed revoked � . . � � y M ••T�t"'� y�) VA4IDATION CONTRACTOR ;,s �,��J��Y Y�� e2e'O /i��1 �� �K. PG, UCENSED CONTRACTORS DEC:LAtiRTl97�„� i-7 � LIC '7 r �] ,/ �I he!eby a}tirm thot I om licensed unde provisions of Ch�rpter 9 _ ADDRE55�c�t���a'v k'*�i'"<�# � -��NO� /}✓�✓-�'^' VA�UATION (commenu with Sedlon J000)of Div'son 3 of the Busmess arle� .� "� LIC. . "f � Professi s Code,and my license is in fu�l force and effect. CITY�,,r f;�°��'��� �Y1S'4 {-""q CLASS $ ��� � f .-"' %� . � Sq FTt NO.(7F � NO.Of � CHECK � licen�e Number��`^���, ���-lic.Class �- SIZE ^� �� STORIFS tAM)ILIES ONE 9 ).,. j) .�s� � . �..-s"_„�i-d NeW � $ Conir<actor�'�����rl-t 'j7 q��'�+'T�igefte � �j�` c�� � DESCRIPTIONOF WORK � d 1, y -3 � . � �I'am e emp�from Ih,f cens ng requiremenls as I am a ��i�'1 �` �t�C% �\ Yd� . /���� ��� Ilcerts d or<hiteU or a rey�siered professional engin� . t �—)�- ALTER � FINAL act' g �n�.mY Professonal capociY (Secfion 3f71, ! ��' �f.:��'� � j �"-���� REPAIR � DATE �{..�^`�� . Business and Professions Codel. ✓�^ U5E OF � � }-•'i,�� DEMOL FINA! ."'�'- EXISTING BLDG '�'�L'.r �❑� By . I.ic.or Reg.No. Date . APPL�.CANT -' TEL ("� ��,�: � . OWNER-BUILDER DEQARATION (PRWi) �i�� � �£' �� NO� ��J'j} I, (�� I hereby affirm ihat I am�exempi from fhe Controctor's License `. ADDRESS:at�'' ������2'�-{`���it `�'¢'}�7'� 4� �`✓� �� ; Law for ihe following rcason(Secfio��7031.5, Business qnd Professions Code): paeSeNT '� - ❑ �BUILDING i � _�.�� 7 � !� I, as ownei-of fhe property, or my employees wiih ADURE55 woges as iheir sole compensution,wJl do fhe work ond - „ � � {+ � the structure is not intended or offered for sale(Section �OCai.I�Y . .r}n m i� a�� 7044,Business and Professlnns Code). � MOVING 1E�� � � - � � I,as owner of ihe pwperty,am exdusively contracii�ny CONiRACTUR NO. a -� ���a�.r'n. �� wifh licensod confracfors to consiru[t the project(Sec- ADDRESS � - �:�'�i=��n'� _ tion 7044,Ausiaess and Professions Code). , � � REQUIRED TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY sEi RACK �ARD HwY pg�p.�iNE WIDiH ' $fl,� �`�� I hereby affirm thai there is�a consirudion lending agency for - FRONT . � � the erformance of the wo( tor which fhis ermit is issued p.�. � (SecP 3097,Civ.C.). I� p SIUE 1 � ?,L Lendei s Name .�.� _ " 9 e� / �P_C.Fee$ Permif Fee .?(�r5�' �k Lender's Address t$ � �^[�� � I cenify ihat I have read ihis'applicqtion�nd state ihat tne . � Issua ce Fee '?�7� � �` above information is correc!.I agree to comply with all Caunty .in�oes�igoiion Fee n � t -� � ordinances ond State laws relofing to building canstruction, ic�al Fee �.:1d 7 d-�^' - m and hereby auShorize representatives of this County to entor _ . ._ Wupon ihe 4bove-meniionqt�p o ty fo/r:�nspection purposes. r J���4.., .k, f�,L.��.�, . �¢ �,,� ,� � , ' SEE REVERSE FOR EXPLANASORY LANGUAGE . - '� S�gnat�ra of ApplYconr c�C+genr Daio �s �f' ���s o � � � .�-� � „ � Q � �} �p � O (D � ^,rn p 9 � 5 ,�""' -o o � n� m W o a -�o a m � � .---� n ' 1 �� <q `;�• `° 4 � '.: ',p � �'--.•"' F � 1 �¢ Q 4 Q `n 6 � . -n iro t 9 ¢, �� � a 1 �' � - N O @ n � 3 N Q -c9 3 � � � a � r � � ¢ � � �Q� � �� Q � a� � � -ei C�� n s m � t �'� ' '� � �n_ ��i m, �j � G � � R°' ' � "�,�] Cu � � a � ,r 1 3 O � -L � > 0 q�'. 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