HomeMy WebLinkAbout1372A (221) � 1
WORY�:RS'COMPENSATION DECLARAT;ON '
I hereby oilirm Iha1 I have a cerrificate oF consem to self qpp�ICATION FOR BUILDING PERMIT ��
insure,o�a certllico�e of Workeri Compensaiion Insuronce,
vr a certified mpy�he�eof(Sec.7800,lab.C.) COUNTY Of LOS ANGELES BUILDING AND SAFETY
PolicyNo. Compony
� Cerrified copy is heieby furnished. FOR APPLICANT TO FILL IN sunoiN� 9�.7/O � G
A�DRESS •C.
� Certified capy is filed with tha counry building tnspeo- gUiLDiNG �� � � ��
lion deporiment. AD�RE55 �/in�r/(� �/�,1
Da1e Applicant CITY �/c2Mt»d [J�r ZIP �p�,q��Ty
CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF LOT��O��07,C3/�NOW ON�LOTS O NFqREST '
COMPENSATION INSURANCE c7 CROSS ST. Lt
�This�etfion need not 6e complated if fhe permil Is for one TRACf c77 7 D BLOCK t0T NO. ���� AUESSOR U
hundred dollars(y100)or le7s.) 3 MAP BOOK PAGE PAR�EL �
/. y TEL.
OWNER C'�lz ��.v�-� NO.H/Y X�61 U` USF�ZONE N✓aF �
I cenify�ho�tn�he performance of tha work(or which th's ��� ��.NO. /��—�5`/
permit is iss�ed,I shall not employ any person in any mann r qDDRE55 . Qp p�0, SPECIAL . �' '
so os lo become s�bject to tha Workers'C mpensotion lo � CONDITIONS Q
1� ' CIN �.. . _ . � ZIP ' U -
xDare �� APPlicant � .
NOTICE T�T: If, offer making�lhis Certificete oi ARCHITECTOR � / TEL. ' DiSTRICT GROUP NPE fIRE PROCESSEDBY O '
ENGINEER G �GY'liq^� NO. '— ��/
E�emplion, you shauld became su6�ec1 fo tha Workers' // � CONST. ZONE I— �
Campensotion provisions of�he Labor Coda,you musl foAh- qDDaE55 9 ��. L✓i�X$��i..itL ��val. /l'�/02 (,� • e �/'r' . �
wi�h comply with s�ch provisions or this permit sholl be .
deemed revoked. ,Q �� T��• STATISTICAI QASSIn ATIpN APT. CtlNDp, �
CON7NACTOR��'�+� �I'�• ' Z .
LICENSED CONiRACTORS DEQARATION � �� Qn55 NO. � DWELL.UNITS
I hereby a(firm that I am licensed under provislons of Chapter 9 ADDRESS p�p. ' .
(commencing with Settion 7000)ot Division 3 oF the Business and . . ��� SEWER 1rtAP -
Professions Code,ond my license is in full force and efiecl. CITY CLA55 BK. �. VAlIDA710N
5�.F7. / NO.OF q � NO.OF � CMECK
license Number Lit.Clas� SIZE !G 7 V STORIES .L FAMILIES ONE '
� VALUATION ��_ "., ��.�f1
DESCRIPTtON OF WORK
ControUor Dale � • NEW � f 2.y�3�6. '
/' _/ AD� � � �1 e • • a a � .
�I am aKempt under Sea �v��� jL'� qUER
� s � e � �+����i i
B.BP.C.for fh�s�eoson REPAIR �
Date: use oF . . � C�j,U n� ,
E7(ISTING BLDG. DEMOL
Si nafurp APRICANT TEI. FINAL ' I
9 oaiNt No. 0 9.0%—o II
OWNER-BUIIDER�ECIARATION DATE �
I hareb offirm�hat I om a:empt from tha Contracror's License '
Law I r ihe fol�owtng�eason(Seclion 7031.5,Business and nDORE55 FINAI �
Prof ssions CodA): 9y ,
BUILDING � .
I, as owner of the property, or my employees with qoDRESS � ,
wages as their sole tompensation,will da iha ork ond , - .
�the struc�ura is nol iniended or offered Iar sale(Section ����TY •
704G,Business and Professions Code�. MOVwG TEL. /
I,os owner of!ha property,am eztlusively con�raciing CONiRaROR NO.
with licensed centrecten to conslru;l the pro�eU(Seo- pDDRE55 �
tion 704d,9�siness and ProFessions Code). i '
REOUiRED iOTAL SE�BACk
CONSTRUCTION IENDING AGENCY Sei BnCK YARD HW1' PROP.LINF WiDiH
1 hereby affirm fha�there is a construUion lending ogenty ior FRONT
iha performonce o/�he work for which�his permit is issued p.�, .�
($et.3097,Civ.C.). 9DE � '
P.L.
lander's Nome_ �����.
/��� 1"}� I�MA Ref.N
m Lender's Address P.C.fee f Ge.mil Fee Jv ,
� I cerlify Ihat I hova read ihis ap Icolton ond slate ihot ihe Iss�ance Fea �'�`�' LDhW P/C N
' obove informolion is correct.I ogre to tomply with all County Inves�igatian Fea 7 �
'q ordinonces and$lofe lows relolin to building conslrucHon, To+al Fea / /r�Q
' and hereby �horize represemo�i as of this County�o enter IDMA Perm.M
� �ponp fhe ab e-me .' n d prope� for inspection pvrpose�.
v`-'� SEE REVERSf FOR E7(PUNATORY UNGUAGE
S�gna�ore of Applicam o.Agenr pore
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