HomeMy WebLinkAbout1127A (5) � (��,M�iw - Y'J3�u.,��.i�-- ,
WORKERS'COMPENSATION DECLARATION 4' �
- -
I hereby affirm�hat I have o rerfifitote of consenf to self e p�������.�_.�4R BUILDING PERMIT
insure,ar o certifimte of Worken'Compenwtion Insuronce, � - ��
or a cartifiad copy thereof(Set.3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
P�ol�icyNo. Company BUILDING
Certified copy ia hsreby furn�shed. FOR AP LICANT TO FILL IN ADORE55
� Certified copy is filed with rhe county 6uilding inapec- eU1to�N_Gq Z � � `�lTr C 6 �
lion depphmant. A�DRE53v�)
� NEARESi � / I� r7U
Date Applicont a ZIP CRO55 ST. l/ ��
CERTIFICATE OF EXEMPTION fROM WORKERS' �.�Bl�. A��R
. COMPENSATION INSURANCE SIZE OP LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be comp�eied if Ihe permit is fw ona USE ZONE MAP �'2
hundred dollars($100)or lasa.) T��T BLOCK �O7 NO.� NO. � /�
TEL. !I l � I `.FECIAI >
WNER NO. � CONDITIONS �+�
I certify that in the performaixe of ihe work for which this ��
ermil is iscuad,1 aholl noi em lo an rson in a� manner DISTRICT GROUP TYff FIRE PROCESSED BY J
P P Y Y Pe Y . ... . - CONSTr Z �
so as to baeome au6ject to fhe Worken'Compenaafion lows. A�REu /Q �{7� � { y� �
�1 /Y (
Dale ApplicaM Cm Z17 Jr'y_-.�`� �TA7ISTICAL CU+SSIFICATION APT. CONDO. 4�—
NOi10E 70 APPIICANT: If, oher moking thia Cartificate of ARCHItKt OR TEL. ,1I ,r
Exemption, you should become subject to the Worken' ENGINEER NO. �1q5$ryp.,�(�DWFII.11NIT5_ �
Compenwtion proviaioaa oE the Lahor Gode,you fnuat fWlh- A�RE� SEWER MAP ��
with comply with such provisions or this permit shal� 6e �
deamed revoked. CONTRACTOR Q��t�J Np. 8R. PG, VALIDATION
LICENSED CONTRACTORS DECLARATION - �C.
� 1 horeby afffrm tMt I am licenaed under povisbna of Chaptar 9 ADDRE55 NO. YAWATION
(mmmencirg wifh Section 7IX1D�af Division 3 of the 6uaineu and ���_
Professions Cade,and my ficen►e'ts in fi�ll fwee and effecf. CITY CW55 S�. 7 Qp �
SQ.Ff. NO.OF NO.OF CHECK
LicanseNum6er lit.C4aiL SIZE S70RIE5 FAMILIES ONE
Con��a[tOr pote DESCRIPTION OF WORK
NEW � S
�I om exemp�vnder Sec. � �/�y �D � [�
Al7ER ❑ DATE` �."+ I / [�y
8.8P.C.fw Ihis reason REPAiR �
\ ,,
��B' E%ISTING B �� � --F�
—
er� ; 2� �
Si nature APpUC4NT TEI. -
9 OWNER-BUILDER OECIARATION PRIM /t'd NO.�'� — �I
I hereby affirm fha�1 am exempl from the Cororoctor's licente qppqESS-� � , P/'��! �`—•� -� --- - --— � �� � - -- � �
Low for tbe followinq rcoson(Sedion 7031.5,Businecc and �
�fessions CQde�: , wt[ _ �'� �2�a �
BUIL�ING
I, os ownm of the property, or my employea wilh qoox6S #• � •• �� i
wage�as their wla compeneation,will do the work and
ihe sirunure is not intended or offered for wle(Secfion ��°`�m
704t,Baainess ond Profass4ons Code�. MOViNG TEL. � • `61,7 5
� I,as awner of tha property,am exclusively contrading T�� N�' • • •6 1,7 5�
with licensed contracforc to conatruc�the projac�(Seo- qpDRE55 �
tion 7WI,Business ond Rofessions Code). O�.Z 3-8/1
REQUIRED TOTAL SETBACK FROM EXI57.
CONSTRl1CT10N IENDING AGENCY SET BACK YARD HWV pgpp,�IN WIDTH � . . - - - �
I here6y affirm that there is a conciruct�on lending agency for FRpM
the performonce of the work for whicA thia perml�is issued P.L ,
tSec.3097,Civ.C.). 51DE ' . '..- - . •
P.l. ,
Lender'a Name _ -` '
$ P.C.Fee S Permit Fee I. � S � . . .
Lenders Addreu " �
� I tertify that I have reod this application and state that the issua�ca Fee U• S V
a6ove infwma�ion is correcf.I agrae to comply with all Counry Investigarion Fee �
� ordinonces and Sto�e laws roloring ro 6uilding conskuttion, iotol fee � �� ��
1y nnd hereby authAAri:s repesentatives of this Coun�y to enMr
� n 1 !� iloned prope ry for Inspaction purpoae�
�� /�_ �� � SEE RFVEYSE FOR EXIIANATORY LANGUAGE
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