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HomeMy WebLinkAbout1710A 2178A 2179A ��` WORKERS'COMPENSATION DECLARATION . �_.-� � I here6y offirm tho�I have o certifica�e of�o�,e�,to ge�f . APPLICATIC�N FOR BUILDfNG PERMiT insure,or a certifimte of Wo�kers'Compenstion Insuronce,or o ce�tified mpy ihereof�Sec.3800,1a6.C.) COUNTY OF LOS ANGEIES BUILDING AND SAFETY Policy No. Company BWIDING � Certified copy is bereby furoished. FOR APPUCANT TO FILL IN ADDRESS s� [tJ � Gertified copy is filed with ihe county boilding inspec- BWLDING tio�depaNment. A6DRESS IOCAIITY �� � � ZIP CROSS ST. Oofe ApplimN CITY CERTIfICATE Of EXEMPTION FROM WpRKERS' , NO.OF B�oGS. asSessOR � COMPENSATION INSURANCE SiZE OF LOT • NOw ON l0T MAP OQOK 7AGE PARGei _ (This secNon need not be tompleted if the permit is for one U ZPNE MAP hundred d011ars($100)or less.) TRACT BLOGK lOT NO. � � NO. a� � 7EL�f oO� SPECIAL d I cerlify that in the pe.formance of ihe work for which this OwNER NO. ! �' CONDIiioNS O permit i5 iSsued,1 sholl nol emPloy ony parson in any manner r �D� �ISIRICT GROUP TYPE FIRE PR SED BY V A�DRESS � so as to become subjact lo the Workers'Compensat�on I.ows. � �O �� CON57�. ZONE O jr `' �/�� / � 7�. Dote��sl�Applicant CITY ZIP U STATISTICALCLASSI�ON APT. CONDO, u IARCHITECT OR Tfl. p / NOTICE TO APPI{CANT: If, ofler making th� Certi4i te of ENGINEER NQ 7 CLA55 NO. • �WELL UNITS� pW, , Exemp�io�, you shoutd become subject to �he Workers' , M Compensatio�provisions of�he labar Cade,yo�must forth- qpDRE55 5[wER r.uP Z with comply wi�h such provisions or this permit shall be T�i �p p�� � deemed revoked. CONrRACToe �' r�.�l5�DVr� BK. PG, VALIDATION , LICENSED CONTRACTORS DECLARATION - ��C. � , f hereby affirm thai l am licensed under proviaions ot Chopter 9 ADDRE55 NO. VALUATION � � (commencing w�th Section 700�1 of Div�sion 3 of the Business ornl ���, �� ���' �� Professiom Code,and my license is in ful�force and effect. CITV QA55 3�V w w . SQ.FT. NO.OF NO.OF CHECK License Number Lic.Closs SIZE STORIES FAMIUES ONE �]�1 1Q(y . _.. $ o.._ . Conlrocfor Dafe DESCRIPTION OF WORK NEW � 1 am exempt from�he litansinp rqq4itp,lAenfs ns l.am.o � A� � _. �e� �]�.Q a I icensed architet�or o regislered professional engineer ' . _... . Al7Es ❑ - FINAL - r „k� . -----------�� DA7E-��:��-.�[ ,•. acting in my professional tapocity (Sectlon 7051. . 1tEPatR Q - . - - -. .� �.��� �23. .. Businass and Professions Code). u5E OF_ .. . �Q � -""� -- �� � � � EXISTING BIDG. y� pEMOI � FINAL � tic.or Rag.No. Dme AP�IICANT p TE�. � ey �f-�nJ f Ss%-G;:r 'I • •6 b,4 b OWNER-BUIL�ER DEClARA710N PR�NT� H "°. 'G J�,s��C.i-•'-?�J �•• •b�4 0 u ,F I hereby oftirm ihat 1 am e.emp�from�he Contractor's License �Q� �`b(�S Low for the following reoson($action 703L5, Business and P�OORE55 � t7• � 0�,Q 2`$2 Pro{BssiOn5C0(1B): . . � PItES . � p`� . BUILDING p 4.� 1, as owner of the property, or my employees with AODRE55 �r� '� ��d � � woges as their wle compensa�ion,will do the work and �2� �.8 f{ the shuc�ure iz nof intended or offered for sale(Section LOCAUTY I 7044,Bosiness and Professions Code). MOVING TEL. #����!• •'Z 3 � I,osowner of the properry,am exdosively contrading CONTRACTOR NO. ' � _j wi�hlicensed wntraciors ta mnshuct the praject(Seo _ _ --- - � - - - - --- ��'-�"�-5�6-Q ' � tio�7044,Business and PrOFe55ions Code). --- . - ADDRE55 - - - ----- �- - - "-- .. ._------- ---- -- RE4UIRED TOTAI SETBACK FROM EXIST. •'' •5 7.6 = / CONSTRUCTION LENDING AGENCY SEi BACK YARD HWY pROP.uHE WIOTH O�' , I hereby affirm Ihat Ihere is a constructwn lending ogency for FRONT 0(�� 2,�8 ihe performance of Ihe work for which this permit is issued P.L r . 2 ;Sec.3097.Civ.C.�. � SIDE �2� �9 A P.l. lender's Name ' i .. ..... .. .. #• � � . ��� $ lender's Address P.C.Fee S � Permn Fee �1 �� I cer�ify �hm 1 have read this applicn�ion and state rhat ihe Cj � 1L�.S issu ce Fee _ � �6�5� obove information is correct.I ogree�o mmply with all County Inveahga��on fee._.-___.- -- �n + �� 1 6 3 5 0 e=i � ordinances and Stote laws reloting fo building conslroction, To�ol Fee ! ��.�� and hereby authorize represenlalives of this County lo enler �Q,�2••$2 upon the a6ove-mentioned p�operry for inspectian purposes. _ . � _����•/"7��- ��� SEE REVERSE FOR E%PIANATONY UNGUAGF �"'t"��"` ' 't� , ` •� - , � i • � ��. 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