HomeMy WebLinkAbout1312A (7) � �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�' �
�- SEE REVERSE FOR EXPIANATORY LANGUAGE
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