HomeMy WebLinkAbout1335A (145) WORKERS'COMPENSATION DECLARATION , �
� he�eby aff��m ,�o, � ho�e a�e„�f��afe of consent to 5e�f APPLICATIQN FOR BUILDING PERMII�
insure,or p certificaYe of Workers'Compenstion Insurance,or
a cert fied wpy Ihereof(Sec.3800,Lab.C.)
1�T � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No��'rJt^!7�%-� Company�C's'�1� 6UILDING N ,
� Certified mpy is hereby f�rnished. FOR APPLICANT TO FILL IN ADDRE55 z 1�� �,�'r'K.tv'7 ��}(�lr� f-��a�
rj1 Certified copy is filed with ihe caunty building inspec- gUILDING V '
���� tion department. ADDRF.SS � �� \ LOCALITY �� 'j�}'if�.'L ,
� NEAREST
Dafe�-Z.'1"i-�� Applicqnt,� ��' GTY ` CROSSSL
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR �
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP 600K PAGE PARCEL
(This seciion need not 6e completed if the permit is for one USE ZON[ MAP
hundred dollars($too)or less.) Tencr alor.K �or No. No. �
7"' �{ iEL. SPECIAL @,
I certify that in the performance of the work for which this OWNER 7-�'✓�/L�„ !� NO. � �>� CONDITIONS �^�
permil is issued,I sholl not employ any person in ony monner � ^� DISTRICT GROUP TYPE fIRE PROCESSED BY (a
so as to become subject to the Workers'Compensation Inws. A�DRESS . � . � J� CUNST LONE �
❑/�7 \O �.�� � ��c�, �
Dat�- Applicqnf��'�=� CITY � �� Z�P y7q115TICALClA551FICATION APT. CONDO. (,�,)
NOTICE TO APPLICANT: If, after makiny thls C^rfificate of ARUIITECTOR TFi. �
Exemption, you should become subjecl to Ihe Warkers' F.NGINEER NO. C�ASS NO. DWELL.UNITS_ �
Compensation provisions of the Labor Code,you must forth- qDDRE55 • SEWER MAP �
with �omp�y ith such provisions or �his permif shall 6e '"
deemed revoked. � TE�""r+ / gK. pG, VALIDATION
CONTRACiOR NO� (, �k�
l ICENSEU CONTRACTORS DECLARATION p � �i��
I hereby affirm thal I om Ilcensed under provisrons of Chpptcr 9 _ ADDRESS � IC NO. � yqLUATION
(commencing wiih Section IOW)of Division 3 of the Business and ��� • r�r��V
Professions Code,and my license is in full force ond affect. CITY � CLASS�' � �� �=��-�
�j,[�. � SQ.FT. NO.OF NO.OF C41ECK
LiCense Numbel �-��/-/�%�� lic.C�ass r."7f�> 517.f S10RIE5 FAMILIES UNk
Contraclor 9� J.1� Uate � lI,J"�O� oESCRIPiION oF wORK NF``N ❑ '
� I am exempt from ihe Ilcensing requirements as 1 am a �� .��C� ADD �
licensed architect or a registerad professional engineer AtrER � FINAL , •� .�
acting In my professional capacity (Socfion 7051, � REPAIIt � DATE � _
� Business and Professlons Code). USE OF � �
EXiSTING BLDG. DEMOL ❑ FINAL :, �
Lic.or Reg.No. Date APPLICANT TEI BY ,�
V i,l..;`�;
OWNER-BUILDER DECLARATION (PRinli) - NO., ��° , , � � �
i I here6y affirm that I am exempt from the CoMracror's License �/ p�
Law for ihe following reason(Section 7031.5, Business and ADDRE55 pY y
I Protessions Code): peESFNT
❑ BUIiDMG
I, as owner of the proper�y, or my employees with ADDRE55
ages as their sole compensarion,will dn the work and �
ihe struc�ure is nor intended or effered for sole(5eciion �OCnuTv
7044,BuSiness and Professions Code). MOVING TF.L. .7
� I,as owner of Ihe property,am exdusively roniracting CONTRACTOR NO `�'� ,�3,5 A
with licensed contractors to cons'Irucl ihe project(Sec- qDDRESS �o s e • � '�
tion 70a4,Business and Professions Code).
RE(�UIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION IENDING AGENCY Sfi BACK 1'ARD HWY pRnP.IINE WIDiH I • •2 5,5 0
I hereby affirm ihat there is a consiruction lending agency for FRONT
�he performance of ihe work for which ihis permit is iSsued ��L s
. « 0 25,50�
(Sec 3097,Civ.C.1- SIDE
P i.
Lender's Name (� ��'2`r`'_8 2
P.C.fne b Pennir Fce .V)�
Lendor's Address __ �y
I certify Iha�I hove read this application ond state thot ihe Issua cP Fee D,+��
Qabove Informafion is correct.I qgree to comply with all County Invesegnrc��oo
ordinqnces and State lows relotiny to huildinq mnslruuion, �"
� and Viereby oufhorize representotives of�his County ta enter TO�O�F`�" �`��
aupon ifjq o- ve-mentio d property for inspenion purposes.
a �If; � 1��ti-�,�� SEE REVERSE FOB EXPLANATORV LANGUAGE
S�yn Appl'ican�or Agent �atc bs
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