HomeMy WebLinkAbout0535A 0536A , � .WORKERS'COMPENSATION DECLA �� ��- - � � ' � � /v � �"�`�` � " � �
I here6y offirm that I have o ceriifitare � ep�. . � APPLIC�ATIQN F4R BUILDING PERMIT �
`�i su or a cert'ficate of Workeri Compens ion I /,La
rtif�c � f f���3�OD, .C.) . ( � COUNTY OF LOS ANGELES BUILDING AND SAFET� 3s`J�j/l
_PO�Y ��� m��Y BUILDINP)
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE99C 0 � J
ertified copy Is iiled with the county building inspec- BViI 1� �
� tio�deponment � � � AD O (S���i1 LOCAUTY -�
� ' � - NEAREST
Date� � Applicont � UTY — 21 CROSS Si. Y � �
� CERTIFICATE OF EXEMPTION FROM WORKERS' A NO.OF BLDG. ASSE550
� � COMPENSATION INSURANCE SIZE OF IOt O NOW ON LOT M-4P BOOK PAGE PARCEI
(This seclion need not 6e complered if tha permit is for one u5E 2oNE �P
hundred dollors(SI00)or less.) - TRACT BIOCK . lOT NO. SP�ECi.4l a
CONDITIONS ' �
I[ertify thot in ihe performance of the wark far which this DISiRICT GROUP TYPE FIRE PROCESSED BY V
, permit is issued,I shall not employ any peison in any manner � ^ �� CONST... i ZONE . . CY.
� so as io become subject to the Workers'Compensalion lows. _ / J // � 0 -
CITY ZIP ��r� ��� (/ � ~
Date Appli[ant , STA115TICAt Cl/A-S�SI�FICATION APT., CONDO. �L
'NOTICE TO APPLICANTi If, afler making �his Certificaie of % H i OR � � ClASS NO..t14�DWElt.UNrtS y
Exemption,.you should become subject to ihe Workers' .
Compensotion provisions ol ifie Labor Code,you must forth- - � SEWER MAP �
wifh comply with soch�provisions or this permi� shall 6e ' . - � �
�deemed revoked. . . T 7 Q - gK, pG, VALIDATION .
' - . LICENSED CONTRACTORS DECIARATION - i � / � / �LiC. � p �
I hereby aFfirm ihat I am licensed under provisions of Chapter 9 � (i'Ltars Gs.. NO d ON . �
(commencing wi�h Settion 7000)of Division 3 af Ihe Business ond LIC. tS-n O '
Professions Code,an y license is in tull iorce and e d. GITY � C- CLASS V!J , . ,
SO.F. NO.OF NO.OF CHECK
� Litens Num LiC� S12F � � STORIES � FAM IES / ONE ' �
Co ro pt Date DESGRIPTION OF WO � N�yy 5
I am exempt from the licensing requiremenfs as I am a � ADD �
6censed orchitec�or o regislered pro(essional engineer . . . .. . _ ALTER .� FINAL _
� vcting in my professional copacily (Section 7051, REPAIR � �ATE � ��'
� Business ond Professions Code). USE OF _ � - DEMOL-� FINAL � .
- - EXISTING BLDG gY � _ '
Lit.or Re9.No. � Date APPLICAM - ���� �� � �0 5 3 5 A
"'� � OWNER�BUIIDER DECLARATION (PR�NT) N �r���•Y Y 2� -
I herehy affirm that I om e.empt frvm the CoNractor's License !s.
. Law for the following reason(Section 7031.5,Business ond AD�R �y�� � � � ;��•2 4 5 2£i
Protessions Code):. � � � Buiiow�G � � � � x
� I, as owner oi the property, or my emplayees with A�DRE55 . . ''2 tt�J,2 R�= .
woges os iheir sole compensa�ion,will do�he wo�k and . _ _ . , � . � . �
� the siructure is not intended or offe�ed for sale(Section iocaurr . , 0 3.3 1 —8 1
� 70a4,Busineis ond Professions Cada). enOviNG � TE�. �
� I,os owner of the property,am eKdusively coMracting coNlaAc,oR � �No.� � , - ��p 5 3.b A
wilh licensed conlraclors to conslruct the project(Sec- qDDRESS ' � � �
tion 7044,Business and P�ofessions Code). � ' � ' �� '',� ' �
RE�UIRED TOiAL SEiBACK FROM EXIST. � '
CONSTRUCTION LENDING AGENCY SEi BACK YARD HWY PROP.LINE W��TH �
- I hereby affirm that there is a mnstruttion lending agenry for� ' fuUN� � � '.� !d 4 6 5 0 - �
ihe erfor onc i�he work for which Ihis ermit is issued P.L - -
(Sec.3097 Ci ). - - - �' SiDE � � ' � - "�Q r!b J{J�
P
P.L.
�d�r's I� L z •
��� P.C.Fee S ✓ / Permi�Fee 8�V 0 a 31'=8�
� _ Lender'sAddr�� ` � y � � .
I certify that I�have read this oPplicotion t t ihe � Issuance Fee
� 'o � � n is correct.I o � e to co . i II �of�ty - Investigo+�o�Fea - - - - � /�, (j -
ordina and State laws r a ng to 6uilding�*pn, Toiol Fee J �� � � -
� a ereby authorize repre raty�s of ihis Counry to Inrer � �
S up 1 �obo -me tion property for inspec�n p pose�.
Y /
� - .- �SEE REVERSE FOR E%PtANATORY LANGUAGE
' �gnolure of Appl�.anl or Agent Do� . ` . . . .. . .,. ..... _ ._ .. . . . . . . _ . ...__. . ��
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