HomeMy WebLinkAbout0537A 0538A (4) w�KKtrts'COMPENSATION DECLARATION � . - ^O� /� '" j� ��� II
I hereby ofFirm that I hove o certi/ica�e of o�,e�„o,e�f. . � � APPLICATIQN FOR BUILDING��PERMIT LS
insure,or a cerri(ico�e of Workers'Compens i�uu �e,or
P�Jlcfj'e�,coDyih�pePfe(�o�Po��ab.C Gt L � COUNTY OF LOS ANGELES BUILDING AND SAFETY� 3,j rf l
ff�'6-/(o/ /
�� `Cerrifled copy is hereby fumished. ' FOR APPLICANT TO FILL IN ADDRESG l.fS%O �
��c.ertiFied copy is filed wi�h the munty�building inspeo- gWLDM ' � y ,
ICJ �ion deporfinenf. . ADDRE D 00 / -� / LOCALITY
NEAR ` 9
Dale � Applicont� � .9 -Zlv � ' CRO (G • S 4�
CERTIFICATE OP EXEMPTION FROM WORKERS' Q NO.OF Biocs. - a55E550a .
� COMPENSATION INSURANCE - , . SiZE OF LOi NOW ON�Oi NJIP BOOK PAGE - PARCEL
� (This section need no�be completed ii IhC permit is(or One ' / �SE ZONE /�nar
hund�ed dollors(SI00�or less.� _. TRa BLOCK LOT NO./ . NO. O�� �
57ECIAL C
I certify.�hoi in the pe�formance of the work(or which this _ I 0 CONDITIONS � �
permir is issved,1 shall nor employ any person in any monner r DiSiaiCi GROuv TYPE fIRE PROCESSED BY l
— . sa az fo become subject to rhe Workers'Campensatian Laws. - k" � �E � f]�CONSi.�/� 2 NE �
. Dale Applimnr ARC 1ECT � ZIP q SiA715TICAt CU+SffIG4TION ` APG CONDO.. l;
NOTICE TO APPUCAN7: If, after making this Certificme o( EN ta � �I [�A55 NO.�1LDwEtt.UwiS
Exerription, you should betome svbject to the Workers' u7
Compenso�ion piov�zions of ihe Lobor Code,you must fonh- � /�A jN U /j'`ct 5ewee nuP -
� with camply�wi�h such provisions or this permit shall be V
� deemed revoked. . . � � g � BK. PG, .� VALIDATION
� - � UCENSED CONiRACTONS DECLARATION ` ���, � .
- 1 hereby affirm that I am licensed under provisions of Ghopler 9 yL/) n � NO. � VALUATION
, (commencing wilh$ection 7000)of Division 3 of 1he Business ond ��� Q
Professions Code,and my license is in full lorce ond Fecl. Cliv �S� — � . � C1A55-- S
,��,',�,�l SQ.Fi NO.OF NO.OF CMECK
� iLnicen,s%Numbe � lic.� �'�'" SIZE STORiES FAMILIES ONE �
/'6lM���G t d 5
C d Dafe DESCRI7TION OF WORK ' NEW ��F a 7 n
� I om evempl from the licensing requi men s os I om a � ADD �
licensed archllect or a regis�ered professianol engineer � �/ AUER � � FINAL t � i=• • '�'2�
� : acting in my prafessionol mpocity (Sec�ion 7051. ( RePAiR � �ATE ��/�/D� . �. 2((�J z a .
Business and Professions Code). USE oF • � �
DEMOI FINAI/�
E%ISTING BLDG. ❑ x
lic.or Reg.No. Dofe APPtiCAnlT 8y (Jf{�l''C(•��� - •�+�Q.rj?��;
-- � OWNER-BUILDER OECIARATION - fvqiNT1 � D Sr� p�q �O�(j
I hereby affirm tha�I om exempl from the Connactor's License ' . - � 0 3 3 1�`Q� �
Low tor.iha following reason l5enion 7031.5,8usiness ond 1+DDRESS � � �
Professions Code): veE iN� , � i � � ��F j£,+n
❑ - � • BUI�DING ' ` �i �
I, os owner ol ihe properly, or my employees wifh ADDRESS
wages as thei�sole mmpensaiion,will do the work and � � . � � � ;;• • • • • �
�he struclu�e i:no�iNended or affered for sale(Sec�ion ' �����TY � ' � � - ..,,f 1 . "
704q,Business and Professions Code). ' MOVING TEL. � � . .�f!�l Q Q 5 n
CONTRACTOR NO.
� 1,os owner of the prope�ty,am eaciusively conlrotling 1 � . .� •�T(��c n�
wi�h licensed conlracrors to constrvct�he prolect(Sec- AD�RESS
- tion 7044,Bosiness and Professions Code). . � � � 0�3� —��
REOUIRED TOTAt SETOACK FROM E%IST. -
CONSTRUC7ION LENDING AGENCY SEi BACK yARD HWY PROP.IINE WIDTH
I hereby o�(irm ihot there is a co�struc�ion lending agency for -� FRONi - . �
Ihe pe�formance of the work for which Ihis permil is issued ' a.�. . . � .
. (Sec.3097,Civ.C.J ,/ � SI�E � - � � ''
'�/ n,,'/ f .lGr G, r.t.
lender's NomP�2 i�"7i �/K��i/�'`+'�/ HS q � .
$ ' //�U� ( / � P.C.Fee$ � Perm�t Fee `� .
Lender's Addresq V (L/���`��(���..ri� . -
W I certify that I hvve read this application and hat the�� � . issua�ce vee �� . � . �
4 above in(ormation is correcf.I agree to comply with Couniy ^ h,resngar�on Fee /,y - � � � �
$ ordinonces ond Slale lows rela�ing fo building c �' , 7oiol Fee �i �
e� y authorizr presenlo�ives of Ihis Cou o e er . � .
� up e bove-me Y ned�roperty for inspeclion pur . .
<' ���'�� � SEE REVERSE FOR E%PLANAiDRY tANGUAGE � � � -
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