HomeMy WebLinkAbout1710A 2178A 2179A (10) ��`
WORKERS'COMPENSAiION DECLARA710N . �_..�� �
I here6y offirm tho�I have o certifica�e of�o�,e�,to ge�f . APPLICATI�N FOR BUILDfNG PERMiT
insure,or a certifimte of Wo�kers'Compenstion Inwronce,or
o ce�tificd mpy ihereof�Sec.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Poli[y No. Company BWIDING
� Certified copy is hereby furoished. FOR APPUCANT TO FILL IN ADDRESS SQ [tJ
� Gertified copy is filed with ihe county boilding inspec- BWLDING
tio�department. A6DRE55 IOCAIITY
Oo�e Appliconi C�TY�� `O NEAREST
r Z�P �RosS s,.
CERTIfICATE Of EXEMPTION FROM WpRKERS' , NO.OF B�oGS. as5es50R �
COMPENSATION INSURANCE SIZE OF LOT ♦ NOw ON l0T MAP OQOK PAGE PARGEL _
(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� �
TEL oO� SPECIAL d
I cerli4y thot in the performonte of ihe work for which this OWNER NO.� �� CONDITiONS O
permit is issued,I sho�l nol employ ony parson in any manner r �D� �ISIRICT GROUP TYPE FIRE P SED BY V
A�DRESS �
so os to become subjaa lo the Workers'Compensorion I.ows. � �O �� CON57�. ZONE O
.y
/ �
Dote�Applicant —J CITY � ZIP U STATISTICALCLASSIFyyy^A710N APT. CONDO. V
ARCHITECT OR Tfl. p ,y
NOTICE TO APPI{CANT: If, offer making th� Certi4i te of ENGINEER NO_ 7 CLA55 NO.��WELL UNITS� pW,
, � Exemp�ion, you shoutd bewme subject ro �he Workers' , M
Compensatio�provisions of�he labar Code,yo�must forth- ApDkE55 5[wER r.uP Z
with comply wi�h such provisions or this permit shall be iEi.�.�p p.�.�
[Je9med revOked. CONTRAQOR �' No.�lS 91�7'+� BK. PG, VALIDATION �
LICENSED CONTRACTORS DECLARATION - ��C. � ,
f hereby affirm thai l am Ilcensed under praviaions of Chopter 9 AD�RE55 NO. VALUATION � �
(commencing w�th Section 700�1 of Div�sion 3 oP the Business ornl ���, �� ���' ��
Professiom Code,and my license is in ful�forct and effect. CITV QA55 S�V Y w .
SQ.FT. NO.OF NO.OF CHECK
License Number Lic.Closs SIZE StORlES FAMIUES ONE �]`Z'1Q(�
. _.. $ o.._ .
CoNrocfor Dafe DESCRIPTION OF WORK NEW
� 1 am eMempt from�he litensinp rqq4itp,A�enfs ns l.am.o � A� � _. �� �]�.Q a
I icensed architect or o re is�ered rofessional en ineer ' Al1E& . FINAL_�`
4 P 9 __..---� ----__... _.. . ❑ - r �'=�-..^.-t -:,..-.
DAiE-C�� �L . ..
ac�ing in my professional cnpocity (Secrion 7051, . REPAlR Q - - " - -- � �.��� �2.�
Buzinasa and Professions Code). u5E OF_ .. . �Q � -""� -- " � -
� ExISTItvG BtDG. ys pEMIX � FINAL �
tic.or Reg.No. Dme AG�IICANT p iE�. 8Y �"!ti1 i�s%-G;✓ �I • •6 b,4 p
PRINT
`�� OWNER-BUIL�ER DECtARA710N �� NO� �� 'G J�J,.$�yl i-•'-?�J �•• •b�4 0�
I hereby oftirm ihat I am e.emp�from�he Contractor's License �Q� �`b(�r
Law for the following reoson(Saction 703L5,Business and A�ORE55 � t7• � 0�,Q 2`$2
ProfessionSCode): . � PBES . �
p`� . BUitCING C
4.� 1, a5 owner of ihe property, or my employees with AODRESS ��� ' �jd � �
woges as their sole compensa�ion,will do the work and �2� �.8 f{
the shuc�ure iz nof intended or offered for sale(SeUion LOCAUTY
I 7044,Bosiness and Professions Code). MOVING TEL. #����!• •'Z 3
� I,as owner of the property,am exdosively contrading CONTRACTOR NO. ' �
' �'•-•5Z6
_� wirh licensed wntraciors ta conshuct the praject(Seo , . _ ---- --- -- - � - - - - --- -Q
' tio�7044,Business and PrOFe55ions Code). --- . AQDRE55 - - - ----- --- - - "---- �----- -
REqUIRED TOTAI SETBACK FROM EXIST. •'� •5 7.6 'Z
/ CONSTRUC110N LENDING AGENCY �r gq�g YARD HWY pROP.l�nlE WI�TH O�'
, I hereby affirm Ihat Ihere is a constructwn lending ogency for FRONT �(�� 2,�8
ihe pertormonce of Ihe work for which this permit is issued N.L r . 2
;Sec.3097.Civ.C.�. � SIDE $2� �9 A
P.l.
lender's Name # '
• � � � ���
$ P.C.Fee$ � Permir Fes �1
= lender's Address , ^ • �6 3,5�
� I cer�ify �hoi 1 have read this applimuon and s�ate rhat ihe Cj � �,.y Issuance Fee -
obove information is correct.I ogree lo mmply with oll County Inveahga��on fee._.-.-.___ ... .. + `'� �• 1 6 3 5 0 0
� ordinances and Stote laws reloting to bui!ding constroction, imol Fee ! ��J.�l1
and hereby aufhorize represen1a1ives of this County lo en1er �Q,�2••$2
upon the a6ove-mentioned p�opery for inspectian purposes. _ .
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