HomeMy WebLinkAbout1552 0027A (444) �' � WORKERS'COMPENS TIO DE lA TION � � ""�Y �3 �
!, , ,�.aby affirm rhat I hove a ; �a af o���o� a�; � � qpp��CAT10N FOR BUILDING PERMIT
_ � insuro,or a ceriificote of Workeri Com anscAi ' uhanc �
ar a certified cop r f ec B , �
P�l��d � , . CQUNTY OF LOS ANGELES BUILDING AND SAFETY
� cerr�Had�o �e b r �s . r : , . '� - FOR APPIICANT TO PILL IN ADDRESS 32 O n,o�� �.
� Cenified co is filed with the cou buildin � 1 /�n
� PY g inepet' BUItDING 1 ( v/ TA M•` ��.
Non de rlmeM. ADDRE55 �3 �/Cl.{.��G
oote ��^ C� qpplica�t ciTr �IIM�IDNA �f�'L_ zir �,�,Ty
CERTIFICATE OF EXEMPTIDN FROM WORKERS' NO.OF BtDGS. PFAREST
COMPENSATION INSURANCE S12E OF LOT Npw ON LOT CROSS 5T.
(This be[lion need not be tomplafed if the permil ie ipr One TyKT •3 1V BLOCK LOT NO. ��7 '�ESSOR
hundred dollars(E100)or leas.) MAP BOqC pqGE pq��
OWNER � (.l^ CO NO�ZT� � USEZONE_�. MAP /r1-33
1 terlify Ihol in the performance of the work for which this �( ' NO.
permit is iseoed,I shall not employ ony petson in ony manner poDRESS WE� 5�: S.k�,�'.� �O� ,C� ' � �At e �
so as fo become subjxt to the Workara'Compenmtion Laws. CON�ITIIXVS 3p� ,Z,. �.
Daro Applicanr GTv [ ��S C�Z�a qyv� �:
NOTICE TO APCIICANT: If, oher making ihis Cerlificate of ARCHITEC'f 0 . h�• SI� 7�I DISTRICf GROUP TYPE FIRE PROCESSED BY O
Exempfion, you should become eubject to �he Workeri EnIGINEER �fh) O. � U
Compenaation provisio�s of the to6or Code,ynu mus�forlh- q ��,O� ��Z J�1 W
wirh eomply with euch provlalone or this psrmif ahall be ADORESS E� �j� ST. � ��$, /030 Q
deemed revoked. "
t+^.�u_ �'a.S.F����•.„_ STATISTIGUClA551FIG4TION APT, C DO, tn
CONTRACTOR f-o Z
LICENSED CONTRACTORS DECtARATION M� .�y� p T;�_: � anss Poo. ,•r oweu.uN�TS �
I hmeby offirm that I am licensed undn provisions of Choptet 9 ADDRE55 g�p (A�� rt• ' +!. � NO.
(commenting wNh$ection 7000)of Division 3 of tFe Business and ��� SEWER AAAP
Profe�sbro Code,and my licenx is in fult torce and effect. QM� �'.� �/� np,�
. /.�p .e� . . . SO.FT �w NO.OF NO.OF CHECK 8K. PG. VALIDATION
Litense Number 7 /J/SI Lia Clase � S2E � .�VO STORIES Z FAMILIES ONE
(� 'J C VALUATION t-`h
rConfrocto�� `"'lvS'TQ(ltiT��a�s �J��-7(� �ESCRiPTtONOFWORK Q�fC.0 � � ..�: �� ,�`' , � �JJa(�
ADD U v(J
❑I am exempt undar Sec. ALTER D ��
8.8P.C.for fhis reaeon �PA�R ❑ j �S�G,�g
Date: USE OF
EXISTING BIDG. DEMa ❑ - - . . . .
SignalVre APPLIUJTT r� TEL �J FIMAL / Io7-29.8�
OWNER•BUILDER DECLARATION ' DATi (U-3�-4a
1 henby affirm tha�1 am ea�mpt hom the Conrcoctrn'�License App�R�SN'�j,g�/ (�1Uj7#�.�0 (�9r 7(p
Law for the iallowing roason(Section 7031.5,Bveine�s and FINAI
Profeesiont Code): �
� I, as owner of rhe o y p Y BUILDING
pr perty, or m em lo eea wifh �DDRESS .-G G Z�%Ci
wogee a��heir aole compeneotion,will do the work and
fhe ehucture ie noe infended or offered for sole(Section ����TY - � � , �
7pM,Business and Profeasions Coda). Mby11�1G --- ~' TB�, ' �- � ' ` - �;��s,� � i ��
� I,as owner of 1hs proparty,dm exclusively contmcting'�� ° R�G7DR , Np..
with licensed roMratlOn to Conahucf}he projecl(Seo-4, - �s�� °� �r�"��, .`.. - ' -' C Z,v��,��
tion 7(144,Busineu and Professiona Code). '�� n
RE�UIRED iOTAI SETBACK •Z,:i S•i, ' -_
CONSTRUCTION LENDING AGENCY SET BACK �ARD HWY pROP.LINE WI�Tii ��` ��
1 hereby affirm that there is a consvuc�ion lending agency for FRONi � �i C G.,.F�;.
�he perfotmontE of fhe wark for which Ihia permit is iss�ed P.L.
(Set.3097,Clv.C.). Sloe
P.L.
lendar's Nome
'23 33 �nn.v,aet�
m lander's Address P.C.fee i Perm��fee �
� I cerfify thol I have reod Ihis applicafion ond stofe ihat}he lauan<e Fee '? '�� LDMA P/C M
� above informotion ia conecf.I agree to comply with all Counly ���������Fae x�-Q i� /�
8 ordirwn e nd State laws relatin to building tonstruclion, iowl Fx ��7 /.`�'� tpM,q perm.Y Cl Q
� and h e vu�hor'e repreee t'Qs of�his Counry ro enter -
� upo obove- nfioned pro far i ction purposss. � - . -���, _ , .. - _ .. . .
� � SEE REVERSE FOR EXMIINATORY LANGUAG[
SignaNro of Applicanf w Agen p�a
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