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HomeMy WebLinkAbout1312A � �WORKERS'COMPENSATION DECLARATION � '� �I hereby af(irm thal I have a ce�tifimte of mnsem ro 5e�f . . . ..... . APPLICATIOIV� FOR- BUILDING� PERMIT � � insure,or o certificata of Worken'Compenstion Insumnce,or � . a certified copy thereof(Set.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company - � � � Cerufied copy�s hereby furnished. FOR APPLICANT TO FILL IN ADDRESS � /� �ZNU1L�s � �� �Cerlified copy is filed wilh Ihe county building inspec- BUILDING ' tion�depdrfinenf. - � ' � �—� ADDRE55 _ 1- IOCALIN �� - � � - , . - - ' �` . �� . .. . - ^ . NEAREST . Date'��� - �Applicant � . . .... . . CITY� ..� • � . . . 21P �� � CRO555T. ' . � �- CERTIFICATE OF EXEMPTIDN FROM WORKERS' � NO.OF BlDGS. aS5ES5oR � � - '� COMPENSATION�INSURANCE - . SIZE OF LOT ~ NOW ON l07 C �a- MAP 800K _ PAGE PARCEL '�(This section need not be completed if the permit is for one � 9 USE ZONE N�P /Q P'j 3 7 hundred dallars($100)ar less.) �. . TRACT .j BtOCK LOT NO. J �.f - �, TEI. /� p-� SPECIAI p, � �I certify-thal in ihe performance of the work for which Ihis OWNER l"'�j� � �� NO.�f9 r` r o CONDITIONS � � ', pCrmif i5 issued,I shall no1 employ ony penon in any manner -- � , DISTRICT GROUP TYPE FIRE PR ESSE�BY, V -- ' So Os fo becOme su ject f0 the W r ers' otion Laws. ADDRE55 CONST. Z�IE� ,�` � � l` Cj `�a �o /P3 � /v �la�u- o �Da1e " AppliCan� • ' � CITV , , Z�P STATISTICALCUSSIFICATION � APT. CONDO. {,~,) � NOTICE TO APPLIGA � If, after making t Cerfificate of � - ARCHITECT OR-� � . � - - TEL. - � • . �p Exemp�ion,'you�should betome su6jec1 to Ihe Workers � ENGWEER NO. CLASS NO.�DWELL.UNITS � . � �Compensalion provisions of the Labor Code,you must forth- - qD�RESS � � � � �� SEWER MAP . � � '. with comply�with such provisions or ihis�permit shall be. � deemed revoked.�.� . . . . . ..- . CONTRACTOR ' s TEL.Y(�9 - BK. �. . -... . .VALIDATION�. . �NO. ' � �IICENSE�CONTRACTORS DECLARATION ' - � - I hereby affirm tha�I am licensed vnder provisions of Chapter 9 . ADDeE55 ' ^ �� '• +' � NC. VALUATION � � (tommencing with Section 7000)of Division 3 of fhe Bosiness and ��� 1 y� y ¢� � - Professions Code,ond my license is in full force and ef(ed. _ CITY ' CLa55 It • a t (� /J � . SQ.F�L,, NO.OF NO.OF CHECK �LitenSeNomb r, � � � ^ �L� LiC.ClasS�_ 9ZE p�) STORIES FAMILIES '�' ONE � � . C6ntrocto � ��+ Dote��� t—�`�'� DESCRIMION OF WORK �� ( � N� S ❑ �, . . . . .. .. — . . A�0 � , . . . I am exempl from the Ilcensing requirements as I am a licensed archl�ect or a registered professional engineer _. _ . _ „ .._ . `_ . ,.r- _._, ALiER � � FINAL - . - - �� .���.2�A - octing in my professional capacity [Section 7051, , REPAB � DATE � � � � : . #• • • • •�.� � Business and Professions Code). � � USE OF DEMOL FINAL � - � � EXISTING BIDG. ❑ � Lic.or Reg.No. -- .. . . . .Dote APPUCANT Tei. Bv ' . 'I,• •3 6 7�5 --'�� � - OWNER-BUIIDER DECtARATION � PRiNi) ,, � N� , � I heieby o(firm thot I om exempt from the Cvntractor's License � � , � � - � � . � / ��.� °3 6'7�5� . - _ Law for ihe followMg reason(Sec�ion 7031.5,Business and /+DDaE55� I���. �'Lti 3L'J L � _�/ PfofeS5ion5 COdO�:�. . ' " . PRESENT O.iY 01,3 0�-8-.4 .� ❑ . . .. .. . .. _ . . _ . BUILDING . .. . ���� . �I, os owner�of-the properly, or my�employees with ADDRESS � , n L `f L O� wages as their sole compensmion,will do the work and �- / ; ^ - L i ' � LOCALITY . � (� . .... ._ ._._ . .. _._ . . / . _.. �the structure is not Intended or offered for sole(SeUion - ' � . � � ' � � �� � :7044,8usiness ond Professions Code). � ' � MOVING ' _���- 7EL g� _' � � - ��- I,as owner of the property,am exclusively c6nlratting�" cONTRACTOR NO. - //j � � � - wilh licensed mnlracfors to consfruct the proje[f($ec- qDDRE55 �----'"— � � - ' - tion 7044,Business and Professions Code). � �.� . � � � �� - - �� REOUIRED TOTAL SETBACK fROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK �ARD HWY PROP.lWE WIDTH � � - - -I hereby aifirm ihat there is o conslruction lending ogen[y far� "�-� FRONT - � � -� � �� � � ��� � � � Ihe performance of the work for which this permit is issued P.L � - �„ . � � � � - (Set.3097,Civ.C.L . . .. _ . _ '. 5��E-_. , ... .... . _ . . ._ . _ . _ . . . � . . . . P.L Lender's Name q/ Lender's Add�ess 7,C.Fee E - Permit Fee � d✓•�� . - � •� � I cenity that I have read ihis opplication and state that the .. Issuance Fee �O•✓�Q . ve informatioy,,is corre I ogree to comply with all County in�esrigoiion Fee - - � � �� ' � rdi ces and5tote la�_Js}`relaiing to building construtiion, � �� '� � � nd erebggg au/horize�eq re��s ntatives of this County to enter : _ Taol Fee . - e�vp-mGniio �d� operly for inspectio purposes �./ 1 ' � V SEE REVERSE FOR EXPIANATORY LANGUAGE ` Signa�ure ot.P.PP�m l or Ag . oie � �s � - � z o - _ _ � a � T- ;a 9: . ro � m a • N 'n m (0 O �� � -c o nv W a o a v 3- ' . o 0 0 � o o � �p � � T N � fli0 � �i ^F' J� n0 .Wi^ �� � ' 4 .W ^ �O . r. r' j � 4 C l9 9 _ .. y� .L �Q. ... p � � :« �c3 �l . O �' m.n C1T g Q m � 7 p-' y, ' -1 - > > n� 3 " < � • . A 3 a o •o �� a -o m fl 1� �N T 7� � � � �-� b t0 O� � Q p � 7 3 O 4 , I (-�.� rn t�� D 7 �I t. . , �� 7�- � m �� . N��� . � . 'O j mC � p� � a p � . J7 �-'�. � ' r .n -. A N � . 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