HomeMy WebLinkAbout9450A 9153A (21)sSRKERS' CO.'1.PENSATION DECLARATION
a that 1 have r e +an=t f
insuru!o arrificare VJor1 rr1s'r'
o APPLICATION FOR BUILDINGofentionsu , PERMITeracdtiliedcopythereof (Se I b. )
Policy No. Company
Certified c s er
yl A
COUNTY OF LOS ANGELES
FOR APPLICANT
BUILDING AND SAFETY
au:LDING
Certified I
TO FILL IN ADDRESS /09
c y u y nspe
tion deport G 2. 3 Lk. d SANTST h, 13,
Data Applicant CITY+ MnND j } . ZIP
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 IOT 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+
t TaMP-SPAILESR 1/P,IQ'TlL. Cj t'.
1!
N0.
U CNE MAP
0permitisissued, I shall not employ any person in any manner
as to becl1ome subject to the Workeri Compensation
Citr
S P1 y+L 5 'F PECIALpsoP 7S 6\
r
laws.
Daley Applicants' 'Au rVY ^Y.F y
yyA
l!-T ruLo%UU ui* rZ- ZIPNOTICETO
CONDITIONS 1
PLICA T- If, after makin this Certificate- ofg CT OR Hfp.) A ) U TEL '7U
E )= N0. gyp. DISTRICT GROUP TYPE FIRE PROCESSED BY OExemption, you should become subject to the Workers'
L Compensation provisions of the Labor Code, you must forth. ADDRrcS ,5 r ~A( Q H) L,
CONST / ZONE
U
with comply with such provisions or this permit shall be
n•/
deemed revoked. Q Q NELO. l Cf- VGf CONTRACTOR I I GG STATISTICAL CLASSIFICATION qPT. NDO.
s
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chap'er9 LIC
ADDRESS I C- - di Llai • NO.
T
CLASS NO. --L D'ATU. 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. I VALIDATION
Contractor Dale
e -
Dr. RI NOF W 4C ••r r'Ii,' i7 t-'•hr'
ONE
NEW
VALUATION
t-
13 I am exempt under Sec. L + V. eQ O b ADD cv C/
ra
0.8P,C. for this reason l NG [ .( I S ALTER X 9 4 0 n
EPAIR f H • • • -23
Data.: USE OF , EXISTING BLDG. CFMOL
1 1 J 1 1.98Signature. APPLICANT HIM Q FTEI. FINALOWNER-BUILDER DECLARATION
I hereby I from
FRINT) NO DATE S• Y-' r G' x1.3 1 1, 9 IIaffirmthatamexempttheContractor's license
Law for the following reason (Section 7091.5, Business and ADDRESS - FINAL /i I 0 (y J p _ 8 8ProfessionsCade): FRE_ N. ISy
I, as owner of the properly, or my employees with MIMINGADDRESS
wages as their sole compensation, will do the work and
the structure is not intended for IOCALITY Zorofferedsale (Section
7044, &:sines, and Professions Codg),
I, as owner of the property, am exclusively contracting
MOV:NG TEL.
CONTRACTOR NO.
94
7c 3 7 `9 1 J J A
Wllh licensed Contractors to construct the project (Sec-
lion 7044, Business and Professions Code). ADDRESS Z.{Z !; • e • • • )
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
REQUIRED TOTAL SETBACK •A xlSETBACKYARDHWYPROP. LINE WIDTHI. n
C1. $ 4 a 6 1j' Ztheperformanceoftheworkforwhichthispermitisissued
FROM
p L.`• 1.c4 (:1; Sec. 9097, Civ. C). SIDE
lender's Name
P L 6 E 1 4-80
Lender's Address
G7
Permit Fen 1132.(pP.C. fee S 3 J
LDMA Rel. R
I certify that I have read this application and state that the.
above information is
iY 6Q W Issvnnce Fee .x .cam LD!+A P/C wcorrect. I agree to comply with all County
ordinances and State laws relating to building construction,
FeroveugR' 11' C QS Tnral Fee / / Q
and hereby out representatives of this County to enter lD'.l4 Perm. N
upon the obove-mentioned property for inspection purposes.
SEE REVERSE FOR FXPLAN TORY LANGUAGE
Signature of Apph-1 or Agent
L:
c
C.
c,
n
Vo
LEI
i°
U
c
Iro 0
1 I o I O e Y
I d J. o cC
C O ! b
I a
i
a O
I
1
e
z
a
N
i .
1
n
L:
U