HomeMy WebLinkAbout1536A �� ,/-� � WORKERS'COMPENSATION DECLARATION �
I here6y offirm thpr 1 have a ceriificate of�o�=e�,�0 58�, qppL�CATlON FOR BUILDING PERMIT
. insure,or o certificote of Workers'Compen3lion Insuronce,or
a certified copy�hereof(Sec.3800,Lab.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Ce�tified copy is hereby furnished. 6UiiDING � � /
FOR APPLICANT TO fILL IN A�DRE55
❑ Cer7ifieP wpy is filed with ihe county building inspeo- BUILDINGrJ�} S� � +L.�� �� �aq��N •
tion de artmenf. ADDRESS L J
Octe Applimn� CITV!/�/'�/"'L�'v��� �I��fqr'�+ %� CRO5555T. '
CERTIFICATE OF EXEMPTION fROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE Of lOT NpW ON LOT O� MAP BOOK PAGE PARCEL
(This section naed not be compleled if the pe�mil is for one / /� ` u5E zONE MAP
hundred dollprs($100)or less.) TRACI [ BLOCK LO7 Np L)-J - - Np �S �
// �.T/a/, . /Gi/,� r7/ SPECIAL �
I certify Ihat in the parformance of the work for which this y ��� ��l W CON�ITIONS O
r
permit is issued,I shall not employ a�y person in ony manner e�]� ��//"��a �/�� Q{) �ISTRICT GROUP TVPE FIRE PROCESSED BV V
so as lo berome su6ject to the Workars'Compensation tows. ADDRESS4 •�L>•� r� r—=•+ � CONS7. ZONE �
Dpte Appliconl CI��R � �ZIP TE � TISTI LCIASSIFI TION q , [ rypp. V
NOTICE TO APPLICANT: If, ofter mokin Ihit Certificafe of �"l� " �1[f�t7 W
Ezemption, you ahould become su6ject to the Workers' ENG�NEER �/�.�F—S N ��fY�/` NO. DWELL.UNITS_ y
Compensation provisions of�he Labor Code,you mus�forth- Sy�{�� ��j�je[,�.� y
with comply wi�h such provisions or this permi� shall be SEWER h�a.P �
deemed revoked. Cor�reacroa Np. BK. PG, VAIIDATION
IICENSED COMRACTORS�ECLARATION LIC. -
1 hereby affirm thpt 4 am{icensed under provisians of Chopter 4 � ADDRE55 NO. ypLUATtON
(commencing with$epion 7D00)ot Division 3 of the Business and ���
Professions Code,nnd my license is in full force and effect. piv C�A55 � S QQ��Q'
$p.F7 NO.OF ryp.pF CHECIC
license Number Lic.Closs 5¢E STORIES FAMILIES � ONE 2� �5�,�h'
ConKacto� Dale DESCRIPTION Of WORK y•�/�� � NEW ❑ E
�•• • •23
� I am exempt from�he licansing req�irements as I am o ADD
licensed architea or a registered professional engineer AliEe FINAL � •4 5 2 6 3
acting in my professionol capacity ($eclion 7051, � DATE
� BuSinBsS Ond GrOfe55ions COl10�. REPAIR � �
USE Of `�r F�NA� •4 5 2 f%J cSi
E%ISTINGBIOG. �/_�G� DEMOL �
lic.or Re9.No. Dale APP PRAN I� i�w /L i•.,[�E.i��p BY fl 4.1 3—c S
OWNER-BUILDER DECIARAFiON 6�'�1/`dC.]71�t d/v
1 hereby affirm that 1 am exempt from ihe Conirac�or's Lirense � Jz�,����( ��� (�(/"j/`f�'
, Law for ihe following rea5on(Section 7031.5, B�siness and AD Fss
Professions Code): .
❑ BUIIDING
I, as owner oF ihe property, or my amployees with q�DRE55
woges as their sole compensation,will do ihe work and
ibe siructure is not intended or offered for sale(Secrion LOCAIRV
7044,Business ond Professions Code). MOVING iEl.
� I,ps owner of Ihe properfy,am ezclusively conlrpcting CONTRACTOR NO. � '
with licensed contracbrs to mnsfruct the project(Sec- qpDRE55 �
tion 7044,8usiness and Professions Code). �'.
REQUIRED TOTAL SETeACK fROM E%IST. �
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE WIDTH '�
I hereby af4irm�ho��here is a mnsiructian lending aqency fo� FRONT "
the performance of the work for which this permit is issued p.�
(Sec 3097,Civ.C.l� S�DE
P.L
Lender's Nome �
_ lender's Address P�-Fee 5 Perma Fee �
I certify rhat I hove read this applimtion and stme fhat the issu ce Fee -
Qabove information is correct.I agree to comply with all Counry ���esiigation fee
ordinances and State laws relotin9 to building mnsiruction,
� and hereby a�thorize representatives of�his Coumy to enter Toral Fee
� vpon ihe above-menfioned property for inspecfion purposes.
SEE REVERSE FOR EXPLANATORY LANGUIIGE
Signature oi AppLmm or Agent �ate
".. ..,,_8£9y9
1..._' d !
q1 N
N O'�,il �
y `.^,dy�.p� 6�j� `3 m '�"
d� O �~' O~ Ol C�� w'O� U
� �C Q X�..`�lS�� Oi D O u ►.ti.,�+
N o, u L�"O .'�O ; D� o�,v,� 6.k�.t N'���. `O�` �� � � C .
��u,L' maY. � C�i � M v� d O m� u"a C� « a,•�,,,,� > a'V a..�,, �,^ � �
' •O.� .i��•� �V� p`�,e�C 1�A �,� �'y�, �� .,�r, "' M„�i'C F A. 1►
� p O� �'+,�'2, O y�-' O 3 w 4� p'� � � E.1 s. t�i �
�,r Td� :3 « � � $^ � � �s pe�� �:S � miy �' o °' Z
zs o 'w x �,� S m ,�,'� Rs e. �• .� '�3� � w
N p v.`ti CL A
� � .n ro x�u o, o;:; a o rr.a o,..,,�... � � 3 m
x U N y � d m 0�� g .a ��'tt T�,�. � � D m�� w � �V X�q�� �
v ro o, e�+a E=-o V �.,�� �.� a Y� e � � r
��� cag�:7 � d �`�' d � oi d�oo"� L �'o ? mx o � ° n""' ,n ,v„
CEo ���y,'� ap � � o�� �'o„'r '`O1'� y"° '' �'�3 a� � ^T'' ° o� � v,
py ° 6 �� a:•�'i �i,P' �� o u� ° d �.°e °'� �'`° d o,��.°.'��4 3� -oc �
a" : �;: ��.°1awc.�*'��.m q.� v o 03 ?,,��� �� sd ���� m �
� Ec� �° 8���? »� a.a�V ��i�.� O� .`�a� oroc ;, �°. m £
Ll x'; v " o �X�o�,° � � E yo $� do � X d ° � � �, on+ X
QL m 0 V��� ol �U� �' P�. �'« �u c ��p`� �'�'�X v� C � y•� �.5.+N �
Aa'° � �b�-n �`� K� s''' � m oc$,�i� :.�c ."'�a,�o o `a� x � �'g c o
.,.
..a.. m y ��xa.�.� � p4 � t� c�* *sM ° �s �� o,„ 6= �"ao � c
� ,-F„~ �� � 6 d H Q r i�.+�'.O O S p }� i.' ��'t' � 4� 'n�,`"L S� F 'n m � � � O
C� �„�o.. � �.,v� �o� � u"" o '^ uyo ►�,ao� � � °' 0.[]3vk�'►�7 °� o
W ,�� a,x� o� � Q ..: o y o..�,'°r x a O1 *� d �'o„a.a a,
�6a ��*�.�Noo� r��',� a,n„ 3*,°�,� �,°��.�c« n
��J �, mv �so�'°' y?,s� as�� o •� c.
so � �,'��,a�°v d ° �` ;
u � y Q ,.
...j
W
d
�
N
�
dF
V
W
d
Z
' �
• ' •
9
O
�
�
N
`� . !� '0
�
> y r ' 6
p O d a
S �a � ►
4 4p �
o - !
o �' Z C
a, � � '3 �-o
} � � � o �o
0
v , c v
o.+, d °L > :o - � o £n. ,i.
Q � u �° � ° ° v Z`� o
M � h �l'- % U I
O Z o c'' ; Y c t '"m "'1 m �od
�� p oD O T 0� 5 7 G C �
Q N a �N a 6 IC� � � V L p S,lJ �y,W ��'
0. N � � � �� a� � 4 ��p ? D D W j J
7 D � � GU �' � � lo� LL N u`.
�O
• y � � E D O a� Q y � .
O
O 4 .d � m � � ° G aU � °'
U y p 6 n �✓ �.,
d p d � t9 °'
m
� .�. W
e O _
Y 7"