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HomeMy WebLinkAbout1675A 5328A (225) � WORKERS'COMPENSATION DECLARATION ry � ha,abY affirm thal I have o cer�ifica�e o,consem,o se�F APPLICATION FOR BUILDING PERMIT �� insure,or a certificaia of Workers'Compensation Insurance, or o cer ed c'o1py thereof(Sec.3800, a�b.`C.n) CpUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyN� "{�bf�ampany �`U�U��(V�� eUI�DING � Certified copy is hereby fornished. FOR APPLICANT TO FILL IN ADDRE55 :� «�d c_e �'+ �-��..: � Certified copy is filed with the county 6uilding inspec- eUIIDWG..�-�.�_ � ,.,-� ' � J fion(�ep fineni. �y AD�RE55 � �' LOCAIITY �+'�{. �..�.d�� /y ��I� NEAREST Date llpplicant �✓C� �,a��/ CITY � � '� ZIP CROSSST. °•'���"��-� CE IFICATE OF EXEMPTION F WORKER3'✓ �ry O.OF BLDcs. n55E550R COMPENSATION INS ANC��y�� SIZE oF tOT „J NOW ON Loi MAP BOOK PAGE PARCEL � (This secfion need not 6e completed if Ihe permit is for one � r�C ' ,+ �,„ USE ZONE MAP . � ) �• hundred dollars($100)or less.) 7RAGT .� ���� eLOIX LO7 NO. �,.'.,.+ �� ND. � t3 �' .J� � . TEL SPECIAI � I certify that in the performance o4 the work for which ihis OWNER NO., C ��'��°� CONDITIONS ��,. ermit is issued,I shall not em lo an erson in an manner r DISTRICT GROUP TYPE FIRE PROCESSED BY � � P P Y Y P Y ;, �ti.�' _. ,�. ;,, so as to become su6jecf fo the Workers'Compensalion Laws. AbDRE55 ;� CONST. ZONE `I,� , � %d.� � � ,� Dafe ApPlimnf CITY . Z�P STATISTICAL CLASSIFlCATION APT. CONDO. p• ARCHITECT OR TEL. NOTICE TO APPIICANT: If, after making ihis Certificale of �"') r��7 '+� ENGINEER O.'�',�I��-� CLAS$NO.�_�WELL.UNITS_ ibS Exemption, you sho�ld become subject to the Workers' � Compensation provisions of the La6or Cade,you must forth- � :'�'�•�" •C-�-•f �� �•-- � '� SeWER MAP ''n ADDRE55 with comply with such provisions or this permit shall be � deemed revoked. TE�� t ' VALIDATION � COMRACTOR NO.� - BK� �', � LICENSED CONTRACTORS DECLARAiION ,. ��� � I hereby affirm thai I am licensed under provisions of Chap�er 9 AooRE55 y(j f� , �_.'-''Ew � �-NO.�, %+G^ VAWATION � � (mmmencing with Seclion 7000)of Division 3 of the Business and ��� z i b 7.5!, Professions Code,and my license is in fall force and effect. �iTy ��q� �..(;<�� ' $ ��l�� , �� 8 q Y,�.� / ¢' y� SQ.FT�- NO.OF ' NO.OF CHECK� � LicenseNUmbe��"�J�� Lic.CiaSs -CJ SIZE STORIES . FAMILIES ONE � n /J/� , � I � a 25�00 k Conlractor�+'C�� �"�•lJ�W���Date � DESCRIPTION OF WORK s NEW o A ,�^ @ A�D � �'�JU�Iu ; I am exempi under Sec . -� ALTER � FINAL •�` !��e, r�2^1 v E y, ¢ B_&P.C.for ihis reason � + - ��" �'�� � �'? REPAIR � DATE �`��' : . ` R �, USE Of Da�e: � EXISTWG BLDG. .ry ' �EMOL � FINAL � ' BY Si nafure , APPLICANT . TEL. 9 OWNER-BUILDER DECLARATION PRINT) � NO.r, n I hereby affirm that I am axempt from Ihe Contractor's License ,,�..,- , Law fOr the foilowing reason(Section 7031.5,Business and ADDRESSc �y� '�{ ' �=."•,' F a:. . p Pro4essions Code): P 7 o ¢ � i, as owner of the property, or my employees with ADDR 55 �����ry�� � wages as their sole compensafion,will do the work and ' , the siructure is not intended or offered for sale Section �OCAUTv �� ( z�32�A 7044,8usiness and Professions Code). MOVING iet. � I,as owner of the propeny,am exclusively contracting CONTRACTOR N0. ` �a • o e a � i ❑ with lirensed coMraclors to construct the projetl($et- qDDRE55 � m o 5 Q 5(� � tion 7044,Business and Professions Code). ttt REQUIRED TOTAL SETBACK FROM EXIST � CONSTRUCTION LENDING AGENCY 5E7 gq�K vaeo HwY pROP.uNE WioTH ► b . ��,yO� I hereby affirm that there is a construction lending agency for fRONi Q'$,�i —8(j the performance of the work far which this permit is issued P.t. . 3 (Sec.3097,Civ.C.). SIDE - P.L. lender's Name (''� $ P.C.Fee$ ��' � Permit Fee �J Lender's Address � I certif that I have read ihis a lica�ion and s�ate that the � �� Y PP Issunnce Fee � above information is correcf.I agree to comply with all Couny Imesrigation Fee g ordinances and State laws relating to building construction, iowl F�e � ,r�a � and hereb authorize representa�ives of this Co�nty to enier $ �pon ove-m�e fone operty for inspection purpos s. �� �/• / �/� r SEE REVERSE FOR E%PLANATORY IANGl1AGE re o4 Applim eM, te �s � �� Z � --�----- � -s- � rn�n��;-r 1 - m T n ' -v^ �! =y � s {n i i �-- '. .,...� l 1 c- S f S �_�__T_� � c y o --�!__{�o o�� �'cc � �D cz �, � c�u � co Q � !�_� � e i ��{ y 9 'Z � � ' °.� ( ic- � c. Q m .� � � � .� � � � � I ce 2 cr � � `'' � " ^�o ' � ro v p � � r , �_ :I �" (�� � T '� Q r O „`? r: O (C =. C' I � p� s F 1 � r� � '_ 1 `° � _ �-= - I-�-�. 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