HomeMy WebLinkAbout1425 1519A (8) � WORKERS'COMPENSATION DECLARATION
i hereby affirm thaf I have a cerfificate of consent�o self APPLICATION .FOf� BUILDING PERNIIT ,
inaure,or a tertifimte of Workeri Companstion Insurance,or .
a certifed topy thereof�Sec 3800,Lab.C.) � COUNTY OF LOS ANGELES' BUILDING AND SAFETY
Policy No. Company �
� Cert'rf ied copy�s he�eby furnished. FOR APPLICANT T PILL IN ���o�� 'y .�f
❑ ADDRE55
Cartified copy is filed wilh the counfy building inspec- BU�LDING ,,•s�
�iOn d0partment. ADDRE55 �OCALITY m'�•�/
NEAREST �
Dale ApplicaM Cliv • 21P CRO5557.
CERTfFtCATE OF EXEMPTION FROM WORKERS' � i 5 /'�� NOW ON`IOTs MAP BOO�K PAGE PARCEL �
COMPENSATION INSURANCE SIZE OF l0T
(This sec�ion need no�he cnmpleted if the permi�is for one USE ZONE MAP I
hundred dollars(5100)or iess.) reacr ioc� ior No. ,�� No. U� '�3 .
TEL SPECIAL a I
I certify thal in the performanc for wh�ch fhis OwNER NO. rZ.C�OPO CONDtTIONS O
permif is issued,I sho�l not p oy any per5on a y ' oIStRICT GROUP TYPE FIRE PROCESSED BY (�;,+
ADDRE55 CONST. Z(JNE
so as to betome subjecr ro he Worke�s'Com ws. ` Q ' � / O�•
� CITY ZIP � ` G,��
DOtE �-"�- �pplican � STATIS�ICAL CLA65lFICRFION APf. CON00.
ARCHRECT OR TEI. V
NOTICE TO APPLICANT: If,-efter making thls Certificme of 'n ui
ExemptiOn, you should become su6jecl fa ihe Workars' ENGINEER 2f� NO. CLA55 NO.��WELL.UNITS_ p,
Compensalion provisions of the Labar COde,you musi forth-� qpDRE55 � � �..KL 4,7 SEWER MAP z
with comply with such provisions or this permit shall be -
deemed revoked. , � tE�� - �3 VAUUATION I
CONTRACfOR C'�1.�.�' Y�.?Ll'�S NO. �BK. PG,
llCENSEO CONTRACTORS DECLARATI�N q �/ � �iC. . �E l.���/
I here6y affirm that I am licensed under provisions of Chnpter 9 AD�RESS e� C. O.c -[ VAIUATI N - {�
(cqmmencing with Section 7000�of Division 3 of the Business and ��� p ^�� ������g�v
Professions Cade,and my license is in full force ond effecr. C�TY i�i ..CLASS !T g j 8
SQ.FT. NO.O / NO.OF l CHECK ' Z
License Number��f�� � Lic.Class� SIZE STORIES ( FAMIlIES ( ONE 3
Coniractar ��"'� �r��^') . .. � DESCRIPTIONOF WORK NEW g � � . .a _/
�ote�'� I_�Z ADD �I!.Y�0'
� I am exempl hom the licensing requirements m(om a � �� ��-,� " , - - - -
litensed architeU or a registered professionol engineer ALTER � FIHAL ��3��y
oding in my profesaional copacity (Section 7051, � DATE I a� ,�'3
REPAIR
8usiness and prafessions Code). llSE OF -
EXiSTMG BLDG. .v L� /�' ��. DEMOL ❑ FIN
LI[.Or Reg.No. DatB APPLICANT TEL BY 1
. .. . .. PRINT _. ._. . f..._. NO." -J
- OWNER-BUILDER�ECtARATION -- `
I hereby offirm ihot I am eaempf from the Controctor's License � � �_ /'� �� 1n�-e_�.N�`�
Low for the f011owinq reoson(Seclion 7031.5, Business and A�DRE55- / � -�-� y' �
ProfeS5ion8 COdB)' PRE EN �
❑ . . _ . . BURDING .... . , . . ����
I, as owner of 1he property, o� my employees with A�DRESS
woges os their sole compenwtion,will do fhe work and
� rhe strucrure�s not�ntended or otfered for.wte(Section iocAurv a: dt.--
7044,Business ond Professions Codej. MOViNG iE�
� 1,as owner of tMe properry,am esclusively contracting � COnl7aAC70R No. � � � � -
with Iicensed conhactors to construU the projact(Sec- qDORe55 • - �
tion 7044,8usiness ond Professions Code). �
REOUIRED TO7AL SETBACK FROM Ex�sT. �1 51.9 A
CONSTRUCTION LENDING AGENCV SEi BqCK �ARD HwY pgnp_�iNE wiDiH
I hereby offirm rhar there is o consiruction lending agency for� � FRdNT #� �� ����
the performance of the work for which this permit is issued P i
(Sec.3097,Civ.C.). 5� I •4 0 6 5 0
P.L. .__ . _ __ _._ __ .
. _ . . . .. _.- ..
tender's Name /II �i4— .nJ •�4 p b 5 0�
� lende�s Address P.C.Fee E � .Q Permii Fee . �I/
�� 020.4-82
I certiiy Ihm I hove read this opplication ond sfate thai ihe Issu re Fee
- a6ore information is correct.l agree to mmply with oll County �,,,,a,r�goroo Fee �� `
^ ordin s and Slo�e laws relating lo building construction, �y �
� n ere y itho7ze r tatives of this County to enter To�ol Fee �lJb/S
�'U opon the abo d proper�y for inspec�ion purposes. � „
� ` _ G. (f�.J-.�J� .SEE iEYERSE FOR E1L7LANAlORY lA(iGUAGE_ - . .... _ _.
� _.. _._ � .<—�= . . .. , � �
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