HomeMy WebLinkAbout0991A (5) . ..Y . � ���-' - --"--._ .._ . ....... .... ..'..._.._....._.. ; ._ .:..._._._._...... _ _._. ..._. _......_. _. ..._...._..._.-- -.' . WORKEkS'�COMPENSATIONDECLARATION . . __.. .._.. ..___. ��". . .. , . �� �. .� . .. -.` ',�'. 1' I he�e6 affirm thot I hove o certificata of consent to self . � �• ��5�.e.oracertificoieofWorkers'Compensationlnsuronte, � �APPLICATION-.FOR�:�3UILDING. PERMIT ����- �-� or n certified copy ihereof(Sec.3800,Lab:C.J " �� -- � -"- - --��- -� - --�- - - -- PolicyNo. '� - �Company � _ .+'+!;� ^�;�OUNiY,OF lOS:ANGELE�;:� ! BUILDING AND-SAFETY , . O Cenified-copy is herebyfurnished.•�'� - . �. , ��'e�FOR•APPLICANT�TO�FILL'IN71•` ' ADJRESS� � .(/ � � .Cer�ified copy is filed with th'e county building inspec- i BUIL�ING ' _ � , i tlon deporlmenl. - ' ' ' ; ADDRE55 � � . ., . . . , ., . .. .�. . . . . .. . ... ....... __._ _ . � , Date � - �� • - �Appli�anr... � . .. � CiTY ZIP LOCAtItt ��' ��CERTIFICATEOFEXEh1PTIONFROM WORKERS' � � �; - �--'�� ---��` �� -� i 'NO.OFBtDGS.�-- � - -- NEAREST. _ - . --. •� ;. . SIZE OF LOT NOW ON LOT �r � . ' • �' ' COMPENSATION INSURANCE• � J �� CRO55 5T. _ ' • (This seclion need not be�complafed if tha permil is for one -� � 7RACT' �,S eIOCK � �� LOT NO. �.�I � � /�qp�gppK'�' r -'.� � AAGE� PARCEL hondred dollars(5100)or less.). „ . TE� ' t�gE ���Y�AA222��� � ; � .. . ' . . . � .... . . .. . I OWNER�- _ � - NO.--V �.. r, CD�ITI �Y - . � O I.certify thot in the performance of Ihe viork for which�ihis � r permit is issoed,�shail nol employ any person in ony manner � � � -'� -- ---- -�' - - - � - -- - so tis to become subjett to the Workers'Compensation laws. ' ADDRE55- - - --- t ONS �V . ... ..� ,�� .. , . .. . . �. , . �, .� i , • ' �.�,� i . � .. CITY_. . �.. . ZIP ' J.' ' _. _ "_'___.._._. .. ._... _. .. . .. _ .._.. ... ._ ',O �. Dofe ��' . 'AppIiCOM � ' � � � ARCHITECT O -' 1 TEI. . . •.: NOTICE TO APPUCANT: If, aFter moking thi3 Cerfifical9 of I ENGMEER �" NO. '•� � DISTRICL _G UP TYPE � FIRE SED BY... �.. Exemption, you'should become subject to the Worke�s' . - CONST.`J/ �Z E //�/��,vn .�U Compensotion provisions of the lobor Code,�yoo must forth- qppRE55 ��- " � -- V --- � "%"� �-- y wi�h compiy with svth.p�ovisions or tbis permit.sholl be -.� TEL STATISTiCALQA55 i TION APT. CONDO.- � �Z - � deemed revoked. � �,�.-,•�,�, � • •, � �'�. . COMRACfOR NO. �— . _ .. .. � . .. "' '.. .. LICENSED CONTRACTORS DECLARATION��- •� � �� �-�--�- �� --- �- �- � ---� �iC.- - - - - � �u NO. DWEtI.UNITS I hereby offirm thpt I em licensed under provisions of Chopter 9 ADDRE55 NO. (commencing with Senion 7000J of DiJision 3 of ihe Business ond ._-- l�C:-- . ��R r'�0`P . . ,..•. . �� __._. . . ... . ..'--' - _' - ' ' , Professions Code,and my license is in full force and effect. � C�iv C1n55 -'�-�BK- - � �''---- �- -' - VALIDATION- � � � � ' SQ.FT. NO.OF NO.OF CMECK � . �.. . . -. . .. ' ,, . . , ' '.__. Li[ense Number � � '� � lic.Class� �� � SIZE � STORIES ���� FAMIUES � � � ONE���� , .: ::.�..' - . � , , � , . . .. . ,.. ,. .. � � . VAtUAT10N. � ..� . . ...t . ,� ..� . .•, i.. ...• ....- - DESCRIPTIONOF WORN .__.. . ' ___. ..__.... . • ' . _�. _ r . _ NFW._❑ C❑onlrotlor Dale . ' ADD � s �' , . _ ..___ . ...._. � ._.. . . �..e� I am e:empt under Sec. � � �`_" '-'��"' . : . . ,. _ , . OK � ALTER � _ ,^�p^y �",'� � . ..._._ .' . . �� � B.SP.C.for this reason REPAIR-Q -'-_ � ; - -' - -- _.__. _ ,� . __ ... ... ._ USEOF sL � �� iI-e s • e � -. .._ . . ._. _... _ , ,: - �afe' � EXIS71NG BLDG. DEMOL _.. . ...... ... .. . ' '. __... •� . '...._ APPLICANT TEL.%IV . ' _ ' ';�^ t 'Signclure ' . .. - � ��----� PNINT NO. ' 1 y FINAL � • •�, .. OWNER-BUILDER�ECIARATION ._ .. . . . . .. ��Ai..V:•,,'�• -- .-:_._ . ._. ..._..,_'."' I her�6y affirm that 1 am ecempt from tha Contractor's Litense ADDRE55 Q FINAL ` � "�J� L for the follawing reason(Section 7031.5,Business and � _ '� � ' I 1 � - - . . . . ...' . . . . � �. �. :..: Pf SSian3 CoCIeJ: . .. . ... .. .... _........ ...�. -' - PRESENT _..� y. : G_U C.��!� I,os owner o(ihe property, or my employees wi�h AODRE55 � wages as their sole compensolion,will do fhe work and � �� � � ��� , �� � _ . _._.._..._... .__... tha struct�re is not fntended or offered for sole[SeUion ��'��TY ,��� � � ' ' �- � 7044,-Bustnesz and Rofessions Code).- --- ' ""- MOVING � � -- � " ��- -"" � -TEL--�� �------ -- n - ��� - - --- ----- -� � I,as owner of the property,am ezclusively contratting CONTRACTOR NO. ��/J�p _!�,�� ��� ��' 1 �- -wiih licensed tontractors to construct the projecr(Seo- ' ' �'����-�- - � � ��- ' � --� �' �'� -��" � '".""� j E%1/7ywv _.. _...-. tion 7044,Busine5s ond Professions CodaJ. ADflRESS �Ci�J��L��I�i�✓_ _._-. REqUIRED.. . TOTAL SETBACK FR M. XI T. . . .. __ � "-� - "--'CONSTRURIONLENDING-AGENCY '��� �- - SETenCK �YARD' HWY PROP.LINE wi�TH � 1 here6y affirm that the�e is a conetroction lending ogency for fRONT j � ' ' � -the performance of the work for which this permit is issued ._.. .P.t:.--. .. .- -. .'-' .. _. ... -_-- --.-- -.... � - ' --._. . ..-._,---..�- - ._- - ' _._ . .__. (Sec.3097,Civ.C.). SiDE ,. '. P.l. . . .__ ._.-__ '_' _ '-___. r . . . _'_"' ' ._.. .. .' _'.'_"" .._ .___ _. .._.._ __. ._ _ _ _. _ . _.. _ lender's Nama ,, ' �^ i1- IDMA Re1.M ; � . � . __. . .. _._ _ . _ _. _._. _. _.._ . _... P.C.Fee E _ _ . __ ._.. _.- Permit Pee- �� C:J ---- - - �--�-- Lender's Address ' •' • �' �� � �� .I cerfify that 1 hava read�his applitation and s�ate thot the _ ... _ . .._ _. .. . _ _... Issuance Fer- �.� � -iDhW.a/[K-'------- -- - �--- .�, . -.' :`. � obove informalion is torrecl.I agree fo comply with all County Invesrigorion Fee � ' ordinances and Stata laws relating_to building construclion, __, ..__ ___ _ __ __. . - iaal Fee--- - • - � � -LDMA�Perm.M- ` � - �� ,. , and hereby authorize represen�alive�of this Counry lo enter ' u he above-menlioned pr erfy for inspetlion purposes. • • ' ' . ..._--'-,/� - - -� -•--_.. .. - � --- �- �- --- -- -- ��-— _'-�....--_ "--' -- ------'- �--....---'---•-. ._._ __.._..--- �l��1. C�� � SEE REVERSE FOR EIIPLANATORV UNGUAGE j � �.�. i -__- _SignaroreofAppliconforAgem ."_ _ ...-.. Date__ ..; ...__..._.... .__.__ _ __.__. __ __' __ _'.___ _ __._.__- ' _ __ ..._. , . _ . _. . _ . .—_.._ C / • � . . . .: • '. � :J � i �'-' n= o o � " v' o ino 0 o n� '^c�o- -� iG� S -_ �� -- - --- o �o . r---' - \ 1 0 0 °c s T '� 3 °� .� �$ ir p � `�° ^'� °� °a � ° �m i \ o � ^ � m m� � � ° � � a '�° ° '� ;�,= ml � ti s 'n � . 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