HomeMy WebLinkAbout0837A 2274A WORKERS'COMPENSATION DECLARATION
I hereby affirm ihat I hove a certifitafe of consent fo self APPLICATION FOR BUILDING PERMI� �
insure,or o certificofe af Workers'Compensation Insurance,
or a rertified c thereo4(Sec.3800,Lab.C.) .
Policy No.
�����Company �`j���K. f-z.s�r� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING� �����- R ��
ADDRESS � � .
�Certified copy is filed with ihe county building inspec- BUILDING �q/�' . �..,_.
tion departmenf. A�DRE55�JgGY��~ vS� �
Date T✓`r����Applicant���/'� �_� [.-"t"��'�C�iq CII��� �w1i�� ZIP �.9 l k�" ' IOCALITY -�� i
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. NEAREST -C` .
COMPENSATION INSURANCE S¢E OF LOT NOw ON�07 CRO55 ST. F.;,' -.....5 i�-.1�+,�a��..�._� � .1��,��"�.�,a;�..
(This section need not be completed if the parmit is for one ASSESSOR
hundred doilors($100)or less.) TRACT BLOCK LOT N0. MAP 800K PAGE PARCEL `.
OWNfiB. 1,�'��L- �lf.�✓r •�- NO� ��, _� USE ZDNE P ,���.� C.
I certify that in the performance of the work for which this NO. �,,;
permit is issuad,I sholi not employ any person in any manner SPECIAI p„
s0 os fo became su6ject to ihe Workers'Compansation Laws. ADORE55 �. CONDITIONS �
Dafa ApplitaM CITY ZIP r�
NOTICE TO APPUCANT: If, after making�this Certifitote of ARCHITECf OR TE� ` DISTRICT GROUP TYPE FIRE PROCESSED BY O
ENGINEER i ���.. I'1'� /✓ND. BT��l L CONST. 20NE �"
Examption, you shauld become subject to the Workers' a s� � -_.�,���.�-�;-� ,,,,r� r, fa
Compensation provisions of the Labor Code,you must forth- qDDRE55 �� 9+� �^ �`�� fG� 1.l.,'s 1\� 'u �_-- �g� `�.` �
with wmply wifh such provisions or ihis parmit shall be i TEL.�7�i� STATISTICAL CtAS51fICATION � APT. CONDO. WJ
deemed revoked. CONTRACT {p�/ �+.s.c/�y NO.J�' '� l!�+ {'� ; �
LICENSED CONTRACTORS DECLARA710N ��� � CLA55 NO.�L—DWELL UN�TS
I hereby affirm that I am litensed under provisions of Chopter 9 ADDRESS �-�'� � '�. ��fGh's-� NO�� . �
(rommencing with Section 7000)of Division 3 of ihe Business and � ��� y� SEWER MAP
Professions Code,and my license is in full force and eHect. CITY �'1"N"s�'�� /�.°� C�A55 r"=� BK � VALIDATION
1� �" SQ.FT. �dyyyS�NO.OF NO.OF / CHECK
License Number������� Lic Class� 51Z -�'�STORI S FAMIUES 1 ONE
} VALU TIO
r�,w a�F I ers-/ress E^�'-rr-S¢s �ESCRIPTION OF Wok - �» -, New � --�.Y-- -:•'C S�`,7'�
Contraefcie� Date -_'�".. ,
ADD •'-� ... "
❑I am exempt under Sec. — ��'"�r ' :� �n � '�� I r� ALTER � //_ �':°r a � �•�" `
8.&P.C.for this reason f� �i;7t'�i�':`� �J���.�'�✓'�'✓�'-�- REPAIR s �'�F� ���
O �5 � f ���2gb5
USE OF r1
Date: DEMOL
EXISTING BLDG. u e;_
Signature APPLICANT +;� ry� . TEL. s� s PIN ,.p 3 ��r�.(:��v
OWNER-BUILDER DECLARATION PRINT).-4.�L'T!V il r`�s�G'G��S NO. �a����if�' pA�'���7 ��.� � _��
I hereby affirm ihat I am exempt from the Contractor's Licensz �
:a�v fo�the follcr�ing reason(Seclion 7031.5, Bosiness and ADDRE55 ����.`1%1 d��'99e%8l/�71sBY� �'�. FINAL �
Professipns Cade): PRESEN gY "�
ni, as owner of ihe property, or my employees with ADDRE55
— wages as their sole compensation,will do the work and ;,�,-
the structure is no�intended or offered for sale(Section LOCALITV _ ' ._�_C�l,�l I�l
7044,Business and Professions Code). MOVING TEL. , �
� I,ps owner of ihe proparty,am exdusive�y canfracting CONTRAG70R NO. �{° �' ° �� � I
with licensed coniracfors ro construct the project(Sec- qDDRE55 i o�/1�,L r
tion 7044,Business and Professions Code). -
RE�UIRED TOTAL SETBACK F
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE WIDTH "' o�4. ;.(i(J�
I hereby offirm Ihat there is a construction lending agency for FRONT
Ihe per4ormance of the work for which ihis permit is issued P.L � C i�7,_�8
(Sec.3097,Civ.C�. SIDE
P.L.
Lender's Name r C� / �n � IDMA Raf.A
Lender's Address P.c Fee% ��',). � Permu Fee �V�� '
I certify that I have read�his applicalion and sfate that ihe Issuan<e Fee �t`-,Q LDMA P/C X .
above information is correct.I agree to comply with all County lo�esfigafion Fee /
ordinonces and State laws relatin to building construction, To�al Fee /i�� LOMq Perm.R
and eby authorize resenf es of this Counly to anter
�pon the abave-me io ed pr erty f inspection purposes. /7 ��.���/��
� �*"�'r ' ��"r�"��1 SEE REV RE SE F R EXPLANATORY LANGUAGE
.._.. Signoture ,Appliy nt or Agent Date
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