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. _ .
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