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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 � � � - � S�g�oi�re of Appi�<on�o�Agent �o�e . � �s � � ' T m O ' • o O . f!' � '9 ni � � Q D ' . .' N T�p CJ O . � p !19 7 4- � a; O S � . � (n O F � "� ^ O v^ �' � a m �. 'ti= ' . . O T rn � =� G m$ � ;� -''� � o o � 9 _ D r- p � O ,d'. �� �=' 9 . ' O 7i� O ^O � �o p c i � m^� O O O 7' �? � � O- �O 'O . ip` Q'O > > 3 O .ti � ?7 -. C ?' � t0 l9 O x 3 ..fl � v� l9 o O m „ ' '� a O ' ` . 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