HomeMy WebLinkAbout0737A 1586A 18872 I WORKERS'COMPENSAiION DECLARATION
f hereby affirm that I have a cerli4icote at�o�5e�„o 5e�f � _ qpp�iCAT10N. FOR BUILDING PERMIT �=�"�`��
_inave, or o certificate of Workers'Compens�ion Insurance,or , "
a certifi ed copy thereo4(Sec.3800,Lab.G) � ' � ' , t���
COUNTY pF LOS ANGELES BUILDING AND SAFETY
Polr,y No. Company � �y �" rsc�.
� Certified copy is hereby fumished. FOR APPLICANT TO FILL IN � Bnooecss d� �. `(\ Q�S C.
� Certified copy is filed wi�h ihe counfy building inspeo- - BUIIDING �` �
ti o�deparimenf. ADDRE55 � W L /�, j� IOULI7Y �
NEARE57 ��� \r` C\,��� �.
Daro ApplicaN Oiv �v � ZIP CRO555T. C. �\
CERTIFICATE OF EXEMPiION FROM WORKERS' NO.OF el�GS. .455ESYJR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT O MAP BOOK PAGE PARCEL ,.
(Thii seetion need no�be completed if�he permit is for one / U E ZONE MAP ,Q a 3V
TRACT BLOCK LOT NO. (� �� NO �
hundred dolfors($100)or less.} . � >
- tEL 1 V SVECIAI i,`�
. I cerfify that in the performance of the work far which this OWNER (,V /2d�v ,cv ebNo. -9yE6 ��� CONDI710N5
permii is i55ued,I sholl not employ Ony person in ony monne� . 1 DIS RICT GROUP TYPE FIRE PROCESSED BY
' so ai to become su6ject to the Workers'Compensation tows. A�RE '� CONSi. Z�ONF �
Dale Applicant CITY ZIP � . � r
ARCHITECT OR -IEy.. / S7A715TICAL tlASSIfICATION APT.� C�NDO. V
NOTICE TO ADPLICANT: If, ofter mokiag lhis Cerlifim�e of ENGWEER � NO. - `. �Na �-I w
: Exemption, you should become su6ject �o the Workers' DWEIL UNITS_ y
Compensotian provisipni Of Iha La6or Code,y0�must(orth• qDORE55 � �� SEWER MAP =
wilh comply with suth provisions or this pe�mif sh011 be
deemed tevoked. TE�� � BK.L PG. � � VALtDAT10N
CONTRACTOR /Y ^ NO.
LICENSED CONTRACTORS DECIARATION i��.
1 hereby affirm thot I om licensed under p�oviaions of Chapter 9 RDDRfSS rvo. _ yp«yp7�pq . ' ���I
(commencing with Sectio Y7000)of Division 3 of the Busi�u and � ���. �C„�`�G �� I
Rofessione Code,and m liaense is in foll force and eHeU. arv Cin55 5 . _,�'�3.� �
/� � 5q.i7. NO.OF NO.Of CHECK
license Number �4��f Lic.Class_J�;L.L— SiZE � STORIES FAMIllES �� - � � ---
f�1 s -�,} he •(�i
Conlroctor ��l�w��Dote '�4,���� DESCRIP710N OF WORK ADD y �,��j I�"fZl ' a;�.��/�
❑ Ky' � " v
I am exempi fram the licenaing requiremenis as 1 om a
lic e n s e d a r c h i t e c t o r a r e g�s t e r e d p r o f e s si o n a l e n g i ne er AUER �� fINAI/�� �3 e e j y.; �_. ..
acting in my professional copacity (Sec�ion 7051, � DATE
B�siness and Professions Code�. use vF n REaA�R � � ( 1
�EMOI FINAL r�C-F'
Ex�STING BIDG. C �"�S ❑ 8
Lic.ar Rag.No. Dole A7MKP.NT TEL. �
OWNER-BUItDER�ECLARATION PRiNT A%- �� NO. �'
I hereby affirm thaf I om exempt from ihe Contrac�or'e License 7
Law for the followmg reasoo(Seciion 7031,5,Business ond p���Es . / fJ ��/,
Professions Code): aRESehI �'� �•"b�
BUIL�iNG � �� �
� I, os owner of tbe poperfy, or my employees wilh A�DRE55 �� � � �'��
oges as their sole compensation,will do the work ond
the strv[ture is not intended or offered for sole(Section LOCALITY �� • � �]']6!VI1
7044,Business and Professions Code). MOVING TEL. � •���'�b"
CONTkACTOR NO. � ♦ �
�I,os owner of the property,om exdusively contraUing , � � �� '7���
with licensed mn��octors to mnsiruct the project�Ser qDORE55
tion 7044,Business and P�ofessions CodaJ. p��(�fi'��
REQUIRED TOtAI SETBACK FROM E%IST -
CONSTRUCTION LENDING AGENCY $Ei BACK yAR� HWY pROP.IINE WIDTH � -
{hereby affirm tho+Ihere Is o consiruction lend�ng ogency for FROM , . � #� �� •��,
the performance of the work 1or which this permit is issued P� � � I 1.1 6 b.5 0
(Sec 3097,Civ.C.). SIDE , , ,
[' ' '` • , • 1.1665d�
j � Lenee:s Name /�d�"'''� ' o . _._.......... ... _ ..
g I a.eFees �7� b ��d ve�muFee /� �D " ' 0218-82
lender's Addrass I /
cerlify ihat I have read this application and state thot the �
W I � I I�• 4'U Issuance Fee �..JLr
obove infamotion is correct.I agree b wmply wilh all County . Invest�go:wn Fee
� or � s �ate laws relotin to b�ildin construclion, �L�
i !/�.'G�.
d liereby ou�Vi ize e r nta 9es af rhis Counly to enter 7oiol Fee
� upon Ih a6ove-m erfy for inspecLon purposes. � , � - •
� �r�a�prr�� SEE RFYERSE FOR E7fPlANAiONY LANGUAGE � ' . �
^ Signomre af App6<anr m Ageni Dota - • •� ' � ��.
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