HomeMy WebLinkAbout1684A (19) _ .WORKER$'COMPENSAlION DECLARATION . . � - � � .�
I hereby-affirm thot I have o ce�lificote of consem ro self . � APPLICATION FOR� BUILDING PERMIT��
insure,or a cerfi(icote of Workers'Compens�ion Insuronce,or
' a certiiiedcapy rhereof(Sec.3800,Lab.C.) : � - COUNTY OF LOS ANGELES � BUILDING AND AFETY
Policy No. Compony � BUILDiNG J
� Cerrifed topy is hereliy Fumished. FOR APPLICANT TO FILL IN ADDRE55 ���J b a/L 0. (.tt k�
'���Cer�ified copy is filed wirh the county building fnspe[- BUIL�ING �7 �3 �1TA
ti0ndepartment.- ADDRE55 O�� � S�/'//� //1� IOCAIITY �Q/kQ
!�� NEAREST /�� � d
Do�e - Applicant � CITv��� /J/yR ZIP CROSS Si. 'Q Q t/lR.1A
� CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR
� COMPENSATION INSURANCE ' SIZE Of LOT NOW ON LOT � MAP BOOK PAGE PARCEL
(This section�need not be compleled if Ihe permit is for one - U E Ot�E nMP /O 0 ,7�� �
hundred dollars(5100)or less.�' • TRACT BLOCK lOT NO. � NO. d�J }
TEI.�-p -^,� 60 SPECIAL ' . a
I certify ihat in the performance of the work(or which Ihis � OWNER M �M�S. Q f�1t/l�c+e'N0..7/g"-�c� O CONDITIONS . - Q
' ermi��5 issued,I shall not em 10 an erson in an � DISTRICT GROUP TYPE FIRE PROCESS D 6Y
P P Y Y P Y manner... � . V
ADDRE55 �3O f CONST.� � �`�� O
so os to become subject lo the Warkers'Compensa�ion laws. � 1.6 [7� `� �� �
/���� Af�lnde 13 ` "
'-"�Dafe��y�Appli[ant �—�"r . . CRY ZIP STATISTICAlCLA551fICA710N APT. CONDO. ~
NOTICE TO APPIICANT: If, after moking Ihis Cerfificate of - ARCHITECT OR iEi. � W
Exemption, you should become subject to the Workers' ENGINEER NO. M55 NO.�DwEtt.UNiiS d �
H
Compensalion provisions o4 the lobo�Code,you musl forlh- �- - ADD2E55 �� � SEWER MAP z
ith compiy with such p�ovislons or this permil shall be TE�
deemerJ fBVOkPd. � � ' CONTRACTOR N0.3 BK. PG, VAIIDATION
' LICENSED CONTRACTORS DKIARATION � tIC.
I hereby af(irm Iho1 1 om licensed under pro�isions oF Chopler 9_. AD�RE55 /G�U• C �NO. 3 VAIUATION
(commencing with Section 7000�of Division 3 of Ihe Business and ��� ,e, - �
Professions Code,ond my license is in full force and eifect CITY � C1a55 �'� S ,�V�
� SO.FT. NO.OF NO.OF CHECK ' '
license Number Li[.Closs SIZE d S70RiES r FAMRIES ONE �
Contractor Dale DESCRIPTION OF WORK
^! NEW S
� I am e�empt from the licensing requiremen�s as I'am a � � �0� ADD�
licensed architeci or a registered professionol�engineer., _ , _. „ AtTER � FINAL �
„ aciing in my professional capacity (Section 7051, REPAIR � �ATE ��'���Z
Bustness and Professlons Code). USE OF � FINA ' " �
� � E%ISTING BLDG.� A M/� �L✓� - DEMOL ❑ �
Lic.ar Reg,No. Da1e A7MICANT p r TEL. BY 1 - !
� � OWNER-BUIIDER DECLARATION -� " -'fPRiNT)�00 L- - - N0.�3 —Op �
I here6y offirm that I am ezempt from ihe Contrattor's License r l`Jf �
, Law for the following reason�Section 7031.5, B�siness and ADDRE55 ✓ � ..S' I
P�fessions Code): ' pgE��Ni �
suaoiNc �,(g3o $1 6 8.'4 A
I, os owner of Iha proper�y, or my employees with A�DRF55
wages vs their sola tompensaiion,will do the wcrk and - � •
� the strvdore is not intended or offered for sale(Section' � �OCnuiv /+/!t - j�;•,• •���
7044,Business and Professions Code). MOVING 1EL. . 2'�V 5�
� � I,as owrier of rhe property,om exclusivety coNroding ' CONTRnCTOR NO. � ��,��•
with licensed commcrors to consuoU the prolect(Sec- qDDRESS ' •,' �2�S O�
tion 7044,Business and Prolessions Code). � � --�� - - � - � � .
12EOU�RED TOTAL SETBACK FROM EXIST. ' '
CONSTRUCTION IENDING AGENCY SET BACK YARD HWY pROP.IINE WIDiH O 2 2(�.�$2
I hereby offirm rhai there is a constrvc�ion lending ogency tor faOM � " .
the performance of Ihe work(or which Ihis permil is issued v.L � '
(Set.3097.Civ.C.�. . . SiDE � . . � .
P.L.
Lender's Nome �' y � '
$ lender's Address P.C.Fee S Perm�i Fee �3"U�7�U , �
w I cenify thot I hove iead�his applicmion and s�ote that ihe I:suonce Fee �.�V
aobove informotion is correct.I agree to compiy wiih all County._ i�ve.+�ga��oo fee .. C . .
ordinances and Sfote lows reloting to building construction, a d � sd �
� and hereby outhorize repieseNatives af this County b eMer imal fee � � .
m ' 'upon the above-me���/JJ��..��ned operty for inspeclion purposes.' " . � - �
< f_ ,�{� (a� /�`' SFE REVFRSE FOR E%PLANATORY LANGUAGE -
� S�g�arv�e o�Applicont or Age�� Dme ' - � ��
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