HomeMy WebLinkAbout9450A 9153AsSRKERS' CO.'1.PENSATION DECLARATION
a Thal 1 have r e r an, t f
insuru!o arrificare VJor1 rr1s'r'
o APPLICATION FOR BUILDINGofentionsu , PERMITeracdtiliedcopythereof (Se I b. )
Policy No. Company
Certified c s er
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COUNTY OF LOS ANGELES
FOR APPLICANT
BUILDING AND SAFETY
BUILDING
Certified I
TO FILL IN ADDRESS /09
c y u y nspe
tion deport G 2. 3 Lk. d SANTST v
Delo Applicant CITY+ MnND j } . ZIP
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CERTIFICATE OF EXEMPTION FROM WORKERS' P btby4v0. OF BLDGS. F
LOT F Q
LOCALITY
NEAREST
COMPENSATION INSURANCE
This section need not be completed if the permit is for one
JNOW ON LOT GFARCHITECTOR CROSS ST.
ASSESSOR
hundred dollars (SI00) or less.) BLOCK LOT NO. MAP BOOK PAGE PARCEL
I certify that in the performance of the work for which ThisGn+
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1!
MP-SNAILESR 1 PII/L LEL. Cj U CNE MAP
0permitisissued,I shall not employ any person in any manner
as to becl1ome subject to the Workeri Compensation
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PECIALpsoP 7S
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laws.
Dale/ Applicants' '
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CONDITIONS 1
PLICA T- If, after makin this Certificate. of CT OR Hfp.) A ) U TEL '7UgE )= N0. gyp. DISTRICT GROUP TYPE FIRE PROCESSED BY 0Exemption, you should become subject to the Workers'
L Compensation provisions of the Labor Code, you must forth. ADDRrcS7((15 % ~A (` Q }-j ILL (-f -
CONST / ZONE
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with comply with such provisions or this permit shall be
n•/
deemed revoked. 7 1 5// Q Q NEL- / I11- CLr%I% CONTRACTOR I I G STATISTICAL CLASSIFICATION qPT. NDO.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chap'er9 LIC
ADDRESS I L--[ SJl Llli • NO. CLASS NO. _/T —L DWELL. UNITS_
commencing with Section 7000) of Division 9 of the Business and
Professions Code, and my license is in full force and effect. LIC
CITY, C/T T % `J^
SEWER MAP
License Number Lit. Class
CLASS
50. FT INC. OF -- . N0. OF
SIZE STORIES 1 V FAMILIES G'I'! r'
CHECK
BK' PG. VALIDATION
Contractor Dale DrcCRI NOFW 4C ••r r'Ii,'i7 t-'•hr'
ONE
NEW
VALUATION
I am exempt under Sec. L 1Z'! Q b ADD
t-
ra
BAP.C. for this reason I Sri-i.t ALTER El 9 4 0 n
EPAIR f 23
Dale.: U E OFEXISTING BLDG. CFMOL
11.31 1 98ignaturP. APPLICANT R I M A Q FiEI. FINALOWNER-BUILDER DECLARATION
I hereby I from
FRINT) NO
DATE 7^Y— rG' 1.311,98 ' affirm that am exempt the Contractor's license Lt—'
Low for the following reason (Section 7091.5, Business and ADDRESS — FINAL /i I 0630-88ProfessionsCade): FRF_ N. by IMIMINGI, as owner of the properly, or my employees with ADDRESS
wages
ct
their sole compensation, will f o the week andthestructureisnotintendedfor LOCALITYorofferedsale (Section
7044, &:sines, and Professions Code),
I, as owner of the property, am exclusively contracting
MOVING TEL.
CONTRACTOR NO.
A
7c 3 `9 1 J J A
Wllh licensed Contractors to construct the project (Sec-
lion 7044, Business and Professions Code). ADDRESS Z.{Z !; v e • • • )
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
REQUIRED TOTAL SETBACK •A xlSETBACKYARDHWYPROP. LINE
WAST.
DTH n
C1.8 4 a 6 1Z/7
the performance of the work for which this permit is issued FRO-41pL.`. 1c4 c:1; Sec. 9097, Civ. C.). SIDE
lender's Name
P L 0 8 1 4-80
Lender's Address s-G7 Permit Fen /43z.sDP.C. fee S 3 J
LDMA Ref. N
I certify that I have read this application and stale that the.
above information is
iY 6Q W Is,vnnce Fee .x .cam LDMA PrC Ncorrect. I agree to comply with all County
ordinances and Stale lows relating to building construction, tnve ug 1,o Fe
QS Tnral Fee / / Q
and hereby authorize representatives of this County to enter 1D514 Perm. N
upon the obove-mentioned property for inspection purposes. I 'SLYL-1• -S /'. JT ` T SEE REVERSE FOR FXPLAN TORY LANGUAGE
Signature of Apph-1 or Agent
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