HomeMy WebLinkAbout1074A - WORKERS'COMPENSATION DECLARATION . ��
I hereby offirm tha�I have a terfifitate of�o�,e��,o self , , - �� .APPLICATION FOR BUILDING PERMIT
insure,or a certi(icote of Workers'Compenstion Insurance,or
a certified copy�hereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND$AFETY
PolicyNo. Compony
� CerriRed copy is hereby fumished. FOR APPLICANT TO FILL IN nooeess o?//� �iu��
� Certified copy is iiled with ihe county building inspeo BUiL01NG !p n / � /J �
lion deparlment. ADDRE55 �I/ /�N Le��7� LOCALITV �«..w�+e�� ,p s(�(/
� / NEnREST � ��
Dale Applicanl � CITY � Hph�/ Qr ZIP fROS55T.
CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BLDGS. ASSESSOR
� COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MA7 BOOK 7AGE 7ARCEL
(This section need no�be mmple�ed if the pe�mit is far ane //n n u5e zONe hwP .
hundred do�lors(5100)or�e55.) TRACT �(/(+d/ BIOCK lOT NO. /Q �/ Np. }
TEL SVEGn.L d
OWNE ., rhPr NO. ��d CON�ITION$
I cerfify that in the performance o!iha work for whi<h ihis 0
permil is isz�ed,I sholl nol employ any person in any manner DISiRiCT GROUP TYPE FIRE PROCESSED BY V
AD�RESS � � //�S H!� CONST. ZONE
so as�o become subjec�to Ihe Workers'Compensation laws. �/ • �
� 1/ � CITY � /11D/�L/ /� ZIP /a '�3 � � ,
Do�e AppliCont STAi1511CA1 CLASS�fICA110N APT. CONDp. V
NOTICE-TO APPLICANT: If, oifer moking fh icaf of /RCHITECT02 � 1EL � W
Exemption, you should betome suble[i fo fhe Workers' � ENGiNEER NO.- CLASSNO.�� DWELL.UNITS_ f1,
. Compensoiion pro��sions of the Lobor Code,you mu5/forih- ADDRESS SEWER MAV w
Z
with comply with such provisions or �his permit shall be TE�
deemed revoked. � CONTenCTOR(/fF •No. BK. PG, VALIOATION
LICENSED CONTRACTORS DECLARATION �J i��, �
I herehy ofFirm thot I am licensed under provisions oi Choprer 9 A��RESS /�� �'¢ NO. � VALUATION
Pmmmencin wilh Section 7000 of Division 3 oi the Business and /�/�
rofessions Code,and my license is in full force ond ef(ect CiTv/�.C+• 9/73v c1A55 C—�q S �U'¢'�
/ $Q.FT. NO.OF NO.OF CHECK
li[ense Number ��Oa �ic.Class L � SIZE ' $TORIES FAMI�IES ONE
Contracto�V�r�T����'f Dofe Z�� DESCRIPTIONOFWORK / �P NEW ❑ s .
� I am exempt from the licensing requirements os I am o G 7�as � ADD � �
licensed archi�ecl or a registered professianal engineer _ , ALTER � FINAL
acting in my prafessional capacity (Sectian 7051, REPAIR � �ATE
Business and Professions Code). USe OF DEnnO� FINAL
� E%ISTING BLDG. ❑ g
Lic.or Reg.No. Date nPPIiCANT iEt. Y
OWNER-BUIIDER�ECLARATION (PRINT) NO. w�� � _ nn_
I hereby offirm Ihol I am e�empt from the Contraclor's license _ /�=�+'�� C�� �� ��],�j A
law for the following reasan(Sec�ion 7031.5,Business and ADDRESS .
ProfessionsCade�: -��'�n,; ��„�, ,�/vt�z-C�Gi.. ���`• • • • �
OeUiLDING V �
1, as owne.r oI the propeny, or my employees wilh ADDRESS � • �3 1,5 0
woges as�heir sole compenso�ion,will do Ihe wo�k ond L N 7(�• GJ�Z��f1L
fhe structvre is not inlended or offered for sole(Setlion LOCnuiv
70d4,Business and Professions Code). MOViNG TEI. �p/�/�z �h,��V��� • • •3 1,5 0 c=i
� I,os owne�Of the properly,om ezclusively Contracling fON7RACTOR NO. ( �/- '
with licensed coNrodors to[o�strucl the projecl(Seo- qDDRF55 YLU'1�� � C 7.{— �2 2� �a'�
lion 7044,Businesz and Proiessions Code). J��� �
� REOUiRED TOLAL SETBAIX FROfd ExIST. at �:
i, CONSTRUCTION LENDING AGENCV SEi BACK �AR� HV"Y PROP.uNE wiDiH �p �� '�+" � ��e..�. '
' I hereby af(irm�hoi ihere�s a construction lending agency for FRONi '
�he performance of the wo�k for which Ihis permit is issued P L. � — /� �
(Sec.3097,Civ.C.). SiDE � 'K/,� it_�/y�
P.L. V
Lender's Name _ ��� M/�j��j�
.-. /v G
m ' Lender's Address . P.C.Fee 5 Permii Fee `,
W I certify ihal I have reod this appiimrlon and sraie�har the �ss�o�ce Fee 6'�v �v�v �(/l��T� ` .
Qobove in(ormotion is corred.I ogree ta comply with all Counry i„�esngonon Fee y7
g ordinances and Stote iows relating to building mnslruclion, � Torol Fee ��(/ '
and hereby outhorize representolives ai this Counly to enter
mopon fhe bove-menfioned properfy�or inspeclion purposes. � .
a �����/Ji� _1,(�/- SEE REVERSE FOR EXPLANATORY LANGUAGE
ctr�
� Signmo I A a�olyR9en� . � 2t
G (/
. � �
a o
G� -"• c o
N T� � a p � ^
Q � O 9('.1 � m o �' � 'S C�
p � ^-- �� �a � t� � m T+
r R� -n o �' m� _' ' F . �� O a o �' ^ o
s = � �
r p � � d-. ;- `� a � n� � ^ o
,,,-n f�S o 0 3 6' a, o.o �9 0 � o v m � � °
0 0 � n i+ i ,o o v � � 3 n
� � � S � � m C�: g �c 7 'ci N c, o o m o
� a, � � ` �p -c � p� � � Q o � va ? � •e
o � =� x �"c N ^ N. �� b • yQ �.^.. r
� P�� co o a c V) a o- w � � y
p O� O � :!) �� � � . N
, ' N �j ( O r O � �i
� O
fJ ^ � � Q O
0.� � p � � �
O �
P �
� 0 C• � 9
� 7
� � � � d �
M �
` U �
JD
�
� , . 0 4
i' --� . q� v
1D o A v
^ v
� � o
N ' O �j p.
` O"Q.
K:
7
s
c
0
. �
. �
�o
._ �
. • • O
A
. .. VN
, z
' � O
, . �
m
N
j
� i
', ,7 p ^O�.� C���� m S
�t q p C�.A„ �0 � ... a O
' ' Q„V L""y "�`� A� C! � ❑C...T.Oo �V O C`"S p h ��„ � �
�,,,��! - p..� � o p � � ...� ,� `a C..o o N:.�,'� � r''� �
nb �y O w �e � F c x '� ty� c ��=.� �„� ^ Q Q a � Q,C
•y �� ❑'O cQ,' e -'�.�� ° o. � � a n k +.wC..C^r A 3� � �t,
,� ' '^4 =:7
p N ^ � N N f_ � ``t�."= �p �"' cC, N�p G d ~S� � ^ p n f 4 � "G !"�
. o o n F " m bs-� o ., «�e��; x s ic S ^�' �N H``=. ? o ° 3 .,"ti
, '� � ti � !"N -Q H,0 S �"' T'.. '^ �A";; ^' £ r 6 w,n C q{�n � ^ .+N
� � �.^ � N N O C O R7 Q+� O q qpS O O �� O 4 o i�p rn'A'6 R' F. D i" O p '��^
� `^�� a.� N � N=.��.'' � �'Q�-'.� o o b y o'6 N z..� o N —r
X r A � n P 0-� p � C A;� ~ S� ,��'. � ^ -�i �� X(`��b'O � p 3 d
V x � � S .G. : p � N O A^ M W L.A � F •+ A
� o p �r^,-, ^0.�p �'Lw,,,� p� fi c 7 3 � «�t � s � � p'� o O� '�
� _ � ,,y� ? ��o �t, R� � �Q,� `N Q,�...� ^.� �� £ � G
. c � � p � Q � � �t p O C1 O-7 p �. � � �.ti C " p' � 3 (^
'^ o �o c 4� Q o �G„�� A' o� 10.'. p o-� �~�o'�b�0 1� ���� t"
I m N H� O�n � �� � � o; ��7,� � �„ � O M•O� �� r p ��
O n �'" P v' � K »7 A � h0 M`w n f0 �L O� ~ c��+.U n » c�`. A p 3 tt � 3 9
} `•c.a o d"~ e a'c7 a-�3 � cy, F.. i� r'�';p�n� -c• T .�+
� � �� P.N 3 fi C„»���LS-��� aK o 4"•C'A � � in 4 � � O(1�
� � �p � :;�C CJ � �•.1 �. lp y ,n O m .O N R. 'i" il. K
1 • � . 0.n 1 � ,x, �'� G. o ~ ti a .3•v Z p x Q•„�'r��^a o a x n ?
e, .Q,o o '�s� � p o ^��e o n m o « ��k p � �.Q ,�, ``._ �o
v� O -zi �;�n ca � ,:.:�-c 16'E.-ain�•� inow��"'� �� o � u�
� � � � A Q Q O � � �F'M � � o r^ �M o A �' �-y o� �•z'^; yo
i 'O 3 ��i'l �l9 f+ O C Cp Q'n �'n v� �L �`� L"'.Y � � «N C`L+ N
-„ K � o o .`�:a w
n "��cQ .^. � m - o �;,,...M aa � . ctia
,'= o ° � Fo �o ��"m:�3 '�' �'o .�a.
F 's �'^�.c h^ �
0
_- �