HomeMy WebLinkAbout1610A (17) f � ' eeettt
WORNERS'COMPENSATION DECLARATION � �
I hereby affirm Ihat I have a certificote of consent to self .. , .
insure,or a terlifiCate of Workers'Compenstion Insurance,or APPL�CATIOi�1�-FOR �B!lILDING �PERMIT
a certified mpy thereof(Sec.3800,tab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pol�cy No. Company -
� Certified copy in here6y furnished. � --� FOR APPLICANT TO FILL IN ADDRE55 0 �0�'� �/�
� Certified copy is filed with the county buildin9 inspec- BUILDING �^ Q�j
fion departmeM.� ADDRE55 �(�f LOCALITY '"�[��^^'
dll�i.f' NEAREST V�j�,��.��fi�� ���
Date �Applimnt Ciiv Z�a —i� Ip7 CRO55 ST,
� CERTIFICATE OF EXEMPTION PROM WORKERS' � NO.OF eLDGS. �j ASSESSOR Q�8(, PnGE O Z pqRCEL �
� COMPENSATION INSURANCE SIZE OF t07 K NOW ON LOT � On�/ /r�qP BOOK v
�This section need not be compfeted if the permit is for one USE ZONE MAP � _
hundred dollars(Si W)or less.� TRAQ e�ocK ioT No. �� No. •Z 3�'� }
7EL o �.l' SPECIAL a
OWNER � ,.7� �� �J�W CUNDITIONS
I certify that i the performonce-of the work for which ihis � �
�ISTRIC7 GROUP TYPE FIRE PROCESSED BY
-permil is issued,I shall nol employ any person in any mannei V
AODRE55 .f�C�cT� �E �[ S���G Q
so as to betome subietl lo ihe Wohers'Compensation laws. O f� � td
. . . ,;.. . ..._ ._.._. . �f ..i� /�
Date Applicant � . CITY � ZIP StAT15TKAtttAS5ff1CAfN3N..- . .APi. �CON00.� - (~j
� ARCHITELT�R ��TEL.
�NOTICE TO APPUCANT:�If, after moking-this Cerfifimte of - g'�� � � .U"Q � � �� W
Exemption,� you should become suhjeci to the Workers' ENGWEER NO. CtA55N0. OWELLUNtTS 6.
Compensation provitions of the La6or Code,you muat forth- qoDRESS Z?��� � ��r,j' �� � � �� -� N
wifh comply wifh such provisions vr.this�permif shall be �` SEWER MAP � i
deemed ravoked. .. ,.. , - - CONTRACTOR (� , -- p�p. - BK. V PG, __
YAIIDATION I
� L�CENSED�CONiRAGTOR5�DECtRRAi10N�� � � � � - �- ���. � �
I hereby affirm that I am licensed under provisiom of Cbap�er 9 ADQRE55 NO. yqLUAT10N � i
(cammencing with Section 7p00)of Division 3 ofi�he Business and i�C. A '
Profeuions Code,and my license is in fult force and effect. �. CiTv - � -� - Cu�.SS ��- T � V�.� - � , � �
' SO.FT. NO.OF � NO.OF CHEIX.
liCenSe Number Lic.Closs SIZE 2 STORIES � ' FAMILIES ONE - �
� �ESCRIPTION OF WORK �{ N� ❑ $ �
Confra[for � � Date �
� 1 am exempf 6om ihe licensing requirements as I.om a � �� � �
� licensed architect or a reqistered professianal engineer . : .... . �.... . . . AUER � ��N���� � � �� ' ���-��- � I
otling in my prafesaional�capatify (Section 7051, - REPAIR � DATE I� y �i
Business and Professions Code). USE Oc �� �Ma � FINAL
- EXISTING BIDG. 8
Lit.Or Rgg.N0. DatC � APPLICANT,`' TEt. �p Y
OWNER-BUIL�ER�ECLARAiiON� � � PRiNi W NO. 5{ "' �
I hareby offirm thaf I am exempt from the Confractar's Licanse �
Low for the following reoson(Section 7031.5,Business end AD�RE55 �� ��
�Pro 9:�0�$coda�: �t b'1,0 A
auaoirvc
I, as owner of the properfy, or my amployeas wilh ADDRESS
wages as their sole compensotion,will do tha work ond �� �.�• •,�
� thestructure isnot intended or offered for sate(Section ���A��TY � ��� •3 Z 50
7044,8usiness and Professions Coda). nnOVING 7EL � . � -
CONTRACTOR NO.
- � I,os owner of ihe propeny,am extlusively contracting • � •3�Z 5 0�
wifh licensed controctors to consiruct the project(Sec- qD�RESS Q 2,2 2��8 z
tion 704A,Business and Professions Code). .
REQUIRE� TOTAL SETBACK fROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK_ �AR� HWY� PROP.UNE WIDTH
1 hereby affirm that there is a consrruuion lending agency 4or FRON7
the performance of ihe work for which this permit is issued p.�.
($ec.3097,Civ.C.�. . ' . SIDE ..
P.L.
Lender's Name Q _. . �
$ Lender's Address P.0 Fee S Permi�Fee �/ • �0 �
I certify that I have read this opplimtion and state Ihat the Issu ceFee i�� �
� above information is correct.I agree to comply wilh all County Investigo�ion Fee �J
0 ordinances and Sate laws relaNng�o building ronstruciion, an s0
ond hereby authorize represenfotives of this Co�nty ta enter Totol Fee J��
q upan�he above-menlioned property for inspection purposes. �
SEEREVERSEFOREXPIANATORYLANGUAGE
� Siqnalure of Applicont or Agenr Da1e ��
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