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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� . ` . . . .. . .,. ..... _ ._ .. . . . . . . _ . ...__. . �� ... ....� .. .. . . .. . � • � ? � � . .,o .. � Gl �'• o o � � V� 'a N o p m a ' , . . � � � � O�C� 7 � O G. O . S ^ ' . G 7 n ^ ^ p � y� � c^ �j� . � /f. N 'T� N O 7r O �= � �'. � R � .� �O • ' � 17 r �^ �+ 0 C N p .. � O O Q ». �C 0 � n� 3 ° � o �+ n s o ° �'o ° �'. '��' a • A � o �' a v � o � o m_. a S 3- a.. �o .a � .0 � . � • ^p �N � �O �-. 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