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HomeMy WebLinkAbout0881A (4) I WORKERS'COMGENSATION DECLARATION � I hereby affirm that I have o ce�tificate of consan�to self APPLICATION FOR �BUILDING PERMIT �insure,or a cerfificate of Workers'Compenstion Insurance,or a certified topy the�eof(Sec 38W,Lob.C.) COUNTY OF l05 ANGELES .9UILDING AND SAFETY Policy No. Company . �j� � � Cenifled copy is hereby fumished. FOR APPLICANT TO FILL IN qo REss � � �/' �t � � �+C!//t..�'",/�rV f�3��!J s ,r✓, � �Cerlified copy i:filed with ihe county building inspec- BUILDING �,i-�; tion dgPa�fm6n1. ADDRE55 IOCP.LRY � � .� NEARE55 Data Applicani CI7V ZIP CROSS ST. f/ - CERFIFICATE OF EXEMP710N FROM WORKERS' ND.OF eLDGS. ASSESSOR , � COMPEN$ATION INSURANCE SIZE OF lDT O NOW ON LOT MAP BOOK PAGE PAR�L . �This section need nof be completed if tlie permit is for one USE ZONE � MAP � hundred.dollars(5100)or less.) TRACT � e�OCK �or No. �No. 3 3 y � TEL. SPECIAL y I certify fhat in the performance of the work for which ihis OWNER NO CONDITIONS � . p¢rmit is issued,1 sholl not employ any person in ony manner DISTRICT GROUP ivPE FIRE PROCFSSED BY V ADDRESS CONST. so as to betome sublec�to�he Workers'Compensation Laws. `Z �� � � O Da�a Applimnf ��TM Z�P STAi15TICAlQA551FICATION _/�/ AM. CONDO. (~j NOTICE TO APPLICANT: If, afier making thls Cartificate of - ARCHITECI OR TEL. ,n ,� T W Ezemption, you should become su6ject to the-Workers' ENGINEER NO. CtA55 NO._�G_(�DwELL UNItS_ � Compcnsalion provisions of tha Labo�Code,you musf forth- qppRE55 � SEWER MA7 Z.' with comply wifh sucb provisions or fhis permit shall be jEi . � deemed revoked. CONrRACroa -� No. BK.�� r�, YAUDATION LICENSED CONTRACTORS DECLARATION LK. I hereby offirm thot I om licensed under provisions of Chopter 9 ADDRE55 NO. VAWATION i (commend�g with Sec�ioo 7000)of Division 3 of Ihe Business and LIC. � Professions Code,ond my license�s�n futl force and etfect CITY C1A55 E �dL.�7yf„� I SGt.fi. NO.OF NO.OF � CHECK � License Number Lia Closs SIZE SiORIES � � FAMILIES ONE - �j Co�«pctor pQ�e �ESCRIPlION OF WORK NEW $ 1G� � 1 pm exempt from ihe licensing requi�emeNs as I am a � ADO � � J]���� v � litensed archifact or a re9istered professional enginaer Al7ER � FINAL �� �V acting,in my professional mpocity (Sectian 7051, REPAIR � DA7E ^`� � Business and Professions Code). u5e OF t�t . � ExISTING BLDG. DEMOL ❑ F�NA� �"1 .F . BY t Lic.or Re9.No. Date APPLICANT ie�. � ��� - OWNER-BUII�ER DECLARATION PRINi}- - ND�. / I haroby affirm that f am exempt from fhe Contractor's litense . r'" ' law.for the followin9 ieason(Section 7031.5.Business and aooeess Professions Code):. ' vRE E � . - p BUIl01NG �€�'- � �• I, os owner of Ihe properly, or my employees wifh ADDRE55 woges os their sole compensation,will do ihe work and ,'�,'ir��� �+ � the structure is nat in�ended or offered far sale(Section �OGa�17Y - , 7044,8usiness and Professians CodeJ. MOVING TEL � ��+ ���]��(. � I,as owner of the property,pm excl�sively conlrpcting CONiRACTOR NO. •• .z 7 = with lice�sed coniractors fo ronstruct the project(Sec qD�RE55 � � C C tion 7004,Busineu ond Professions Code). CONSTRl1CTION LENDWG A ENCY REQUIRED TOTAL SETBACK FROM EXIST. •S�G�T—F� $EiBACK �ARD HWY PROP.IINE WIDTH 1 hereby aFfirm tho��here is a cons�ru - n lending agency for FRONT - �he performance of the wo�k for ich th�s perm��is issued - p.i � (Sec.3097,Civ..C.). . SioE P.L. Lender's Name w, $ P.C.Fee$ Permit Fea �. "�./ � Lender's Address w i certify fhat I have read ihis applimtion ond sfa�e fhat the issu e Fee � . I � above information is forrect.I ogree to comply wifh all CouNy Investigarion Fee ��� y {� or inonces and State lows relofing to building construc�ion, Totol Fee J [�� on her ent tives of Ihis County to enter � up � ab ve i ned o erty for inspection purposes. - � < ��� " J SfE QEVERSE FOR E%GIANAiORY LANGUAGE " nature of ppl��mnt or Ag t +Dnte �s � r sd % Ns � � ° m �� 0�,�3 '', � � -�� � o u oi '� O ,�„� �M � O � wg�'i�' X eG � S�� �..n� m � ?a 7-O b O u '�3 m ` J� . N � ?`�'�'� ",7� O O M�� o.�N',�+ �� � 4V �� � - � Y . � v ��„fl,�Q N Y v a o'�, w •r��� N � �a o� � �-s.i� �`�� o� �`�^ m � �i. $.�at a���3 � � 'r" ► ��es �n y� �� ,a rn.,�,.�� O i� T�i --� � .C � %V v� Q m N r�.`�i'''.`�.. .Y o� e `�►�.".L O« � m m ?'�"m � 4� N 7 0� K'.R `� N� . o" 3 � °'"'� � a,a K u� E� ���.a m'�`�'g.�c p i�j ° �c+� V � Y `�' �� ��r5'�.,a m�o:..�p T-°p `o c Q �'� o ii�.�c o `° "���N y� Wo. 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