HomeMy WebLinkAbout1059A 3728A 3729A WORKERS'COMPENSAiION DECLARATION • � .� � .
�- I hereby��firm that I have a cerlificata of�o�,e�„o,e�f � - APPLICATION��FOR �BUI�LDING PERMIT
'i^ture,oi,�certifiwfe of Workers'Compensation Insurance,
or a cert�ffed copy thereof(Sec.3800,lab.C.) COUNTY OF l05 ANGELES_. _ . �BUILDING AND SAFETY
P❑o1lcyNo. Company eUiIDiNG •
Certiiied copy is hereby furnished. i FOR APPLICANT TO FILL IN nooeess �.��� ��R
� Certified copy is fi�ed wilh the tounfy buflding Inspec- BUILDING �/1
lion deparlment. ADDRESS �-t - IOCALITV C
NEAREST
Data Applimnl Cltt ZI7 CROSS ST. -
� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF eL�GS. ASSESSOR � . '
COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP 800K PAGE PARCEI ,
(This section need not be comp�eled if the permit is(or one ^� u{5��ZONE �P ` ��
TRACT3�� BIOCK LOTNO. .J.� �"�� SPECtAL `
hundred dollars(5100)or less.) . . h cy y �
I I cerli that in the erformance of 1he work(or which this , OWNER I � - O �..�� CONDITIONS 1
fY P DI 7RICT GROUP TYPE FIkE� PROCESSED BY � �
permit is issued,I sha�l not employ any person in any,manner ' -� CONST. Zpn�l� y �i
i A�DRESS lJ �
so as to become subject�o the Wo�kers' ampensation ows. , 1 �O '."7 3 .�t"( C�Q w .
/-�/�!� CIN 1 ZIP , �S �� l V Q
Date!l��Appli[an} . -f� STATISTICALCLASSIFICATION, .: APT. CONDO. �- �
NOTICE TO'APPUCANT: If, ofrer maki this Cerfificote of � ARCHITEROR " W
�Exemption, you should become su cf to the Workeri ENGiNEER 0.�3 '�J`-�7� QASSNO.�DWEtL.UNITS +
[1.
Compensation provisions of the labor ode,you must forth- , qDDRE55 7 -- �� �� SEWER MAP . , y �
� wi�h comply with such provisians or this permit�shall be 7E1. �
deemed revoked. � � CONTRa.QOR NO. BK. ' FG, VALIDATION
LICENSED CONTRACTORS DECLARATION , LiC. �
' I hereby affirm that I am licensed�nder provisions of Chapler 9 ADDRESS NO. VALUA]ION�� ._
(commencing with Section 7000)of Division 3 of the Business and� � LIC. :\\ 1f„�-� , - "
Pro(euions Coda,ond my license is in full force and effett. � CiTV CLA55 �b��` .
. . SQ.Ff NO.OF� .'^ O.OF CHECK � � �
licen3e Number liC.Class SIZE STORIES��IU.. fAMILIES � ONE ?1 p S 9 A
g P �
Conhactor Dale DESCRIMION OF WORK AD ❑ I v/ �� � a �'z 3 ,
❑I am exempt under Sec. � q�7ER � FINAL Q �/� . � " � Q 2�Q
B.BP.C.far�his reason L � � REPAIR � DATE-� e =
Data: � u5E OF . DEMOL.❑ .-..FINAI� - ." � �2�O O c�
E%ISTING BLDG. - gY y,� -
Signature AP�PRIMT U(i nio. - . - 0 1,1 7-8 4
OWNER-BUILDER DEQARATION � , ' ;
I hereby aifirm thot I am exempt irom the Controdor's License . _ _ __ _ _ _ , ._
Law for the following reason(Section 7031.5,Business end ADDRE55
Professlons Coda): � PRE ENI .
O � BUILDING --� ���
1, as owner of�ha property, or my employees with ADDRE55
wages as iheir sole campensation,will do iha work ond � � � � ,
_ the strucrore Is not Imended or offered for sale(Section ����N --- . "� " - �- " �
� 704<,Business ond Professions Code). � MOVING TEL , � ' -
I,as owner of ihe properfy,am exclusively contracting � NTRACTOR No. �3 i 2•8 A
with liCensed cOntroctors 10[o�struc�the projed(Sec- ADDRE55 k• •�• •2 J
tion 7044,Business and Profezsions Code�. -- -- - � � .
' 2FOUIRED TOTAL SETBAIX FROM EXIST.
CONSiRUCTiON IENDING AGENCY � SEt sn[K YARD HWY pRpp��NE wi�iH I •�• •�J�
I hereby offirm fhot there ie a conshuction lending agency(or � FRONT -- � � - � " '
� �he performance of�he work for which this permit is issued v.l. , > " • •a 3 1 �
_ �Sec.3097,ci�.c.). Pioe _ - 0 6 0 7-8 4
� lenders Name ' �
� P.C.Fee f `O 1 Permil Fee �G��� � �
Lender's Address � ' �`' ,
p �� • U!
� �cer�ify that I have reod this applicotion and state that the . ,l j� Issua ca Fae ..SO v pl pl • J �
a6ove infwmation is cortect I ogree to comply wilh all County � in.esrgaro�Fee � . / _ __. . , _. .
� � ordinonces and Sta�e iaws relating to building consirotlion, � Totol Fee L•73 � �� � ^�
iY and he�eby au�horize representafives of thfs County to enler � J� � �
� - upon t�abova-menli/nydi�p/rEperry for inspecfion purposes. - � -- ��� - - � �U-' �
� 1%!/l•GG� � C-J . _ .. - . -. rH. .
a � rY1-e��� SEE REVERSE fOR EXPIANATORY IANGVAGE
5' ture of Applimnr or Agent �e � ' / -�
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