HomeMy WebLinkAbout1397A (427) , ...----..__........_.. ----..,.. _.
� WORKERS'COMPENSATION DECLARATION . . ,
, �e�BbY affirm ihwt I hove o terlificale��o���„o=e�, qpp«CATION FOR BUILDING PERMIT �
insure,or a certificate of Wwkers Compenwtion Insurance,
or o ce�rified copy rhereot{Sec.3800,�a .C.)r 3 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. __ . .Company. '
Cerfified eo is here furnished. BUiIDING � ''1
�❑ PY �' fOR APPLICANT TO FILL IN ADpRE55 S 1 QW �
Certified copy is filed wi�h the county building�inspeo- WLDWG 3�3 W� ��� u
tion deporfinent. ADDRESS
�a,e���o,����a.r c�Tr (nI 4 �l zir ioca.irr W/�</7/N7
� CERTIfICATE OF EXEMPIION F WORKERS .� ..._.... .. . . ...HO.OF BLDGS. �+�ST. �e�Q� C(��L 1 M
�' �'���^��COMPENSAT�ON INSU ANCE � • �• SIZE OF LOT NOW ON LOT CROSS 5T.
(This secfion need not be�completed f ihe permit is 4or one TRACT�7� S BLOCK tAT NO. O ��R
hundred dollars(S100)o�leu.) MAP BOOK � pAGE Pnit�l
TEL t15�,P� E �
I certify that in the performarice of the work for which this ��� G �C N�� ��(( �. l-3a
permit ia issued,1 shal(not employ ohy person in any manner � . SPEC�At 6
so as to belome subject to the Wo rs' -m Mrs. aDDRE55 (��Da CO��iiOtaS u
Dma�` arr �V��e zir p�
_qpplimnt "
ARCHITECT OR TEL �
NOTICE TO�APPUCANT: If, after aking this-Cerfifitnte af �i57xiCi GROUP ttPE ; FiRE PtiOCE55Epgy
Ezemption, yoo ehould betom subject to�the Worke�s" � ENGI EER NO. �pµST ZONE
Compansofion provisions af the l 6or.Gode,you must forth- ADDRE55 . � (/v�G.�, ('� pW,
wi4h comply wifh �ucb•provisions or this permi� shqll be y�
cleemad revaked._ � � � � a �y� ��� Q STATISTICAL C1A551FICATION qpT. CONDO. 2
- �-� CONTRACTOR �,p,
UCENSED CONTRACTORS DECIARATtON d v i��.r�� J'a G --aaSS w0.�DYJELL UNITS i
1 hereby affirm tFwt I om licansed under provisions oi Chapfer 9 AODRESS �O S C `/�` NO.J 7 O
�tommenting with Seclion 7000)of Division 3 of ihe Business and / � `` q ��� SEWER MAP . .
Aofessions Code,and my license is in full force and effect. CITV �•� M(�w�y CIqS$ �� �3� YALIDATION
� 'y/ X�T SQ.hT. NO.OF MO.OF CHECK �.
License Number � `�" -'Lic,Class �����- SRE � STORIES FAMILIES ONE �
nQ`,�{. y,��/� y///��,�/ �/ VALUATIQN
Vf7N'+�U!�'�J �Dafe�� DESCRIPTION OF WORK ....... NEW f V V Q�
COnV4CfOr ADD � �
�I am exempr under Sec. - `� - �• t� AtTER �
B.B,P.C,for�his reason W �pA�R � S
- � - - � �ate: � USf OF ❑
EX{STING BLDG. �FMa
�SignWure - ' AVPLICANt-. .. iEL. ..._HNAI :-i 5 Q 'F.
OWNER-BUILDER DECIARATION PR�M NO. �E-- �y
I hereby affiww�hW lom esempt from the Contractor'a License -.... _......� . '"'t.-.... _. . ---- - y o . • n �j -
law for the following reason(Sec�ion 7031.5,Business and ADDRESS FINAI �� -
Professions Coder..... .. _ . .---.._...__.._._ . � . .$ � w;� '-„�
_ ... _ y_ ...., . . _ ., �.,�
❑ 6UILDING
�, as owner of the property, or my employees wilh MORE55 �_ �,.,r�
wages as their sole compensorion,wiil do the work and � • � -.
the sHucture is not intended or offarad for wle(Sedion ����TM • �
� 70d4,Business and Rofessions Code). � AhOY1NG� �� � 7E1. ��.� .� _ ��
� I,as ownet of ihe property,om eztlusively coMmcting COMRACTOR Np. � ;� - ,
-wRh licensed�ororoctors to constroct the project(Seo- '" - qDDee55
tion 7044,Business ond Professions Code).
' ---��CONSTRL1CT10N LENQING AGENCY . . - SRE�T BACK � VARD 'MWY'. .7�'L�.LINE WIDTH ... .
I here6y affirm that thare is a consvuction lending agencV for FRONT ��
the parforrtwMe-o€-ihe wwk-#or-which thispermNyrissned ... P:L.
(Sec-3097,Civ.C.)• SI�E .
P.L
Lender's Name ry q ��
m _. . . .. .__. _ ______ _ ___.- . P.0 Pee S Permil Fee ao�5� . LDMA Ref.9
- Lender'a Address �v �
� 1 certify that Lhave.read this applimtian md state.thot�he ...... ...._.. ._. ... ..... � w�a�.ce cee �� IUMA viC S . .
¢ above information is cwrect.I agree w mmply with all County invecrigation Fee "
g ordinances and Stote lows relating to building wnstruction, /�3�f ,
u and hereby authwize representatives of this Counry to enter iowl Fee iD/uw verm.M
m u th abo -menti ed properry for inspaction purposes.
� DN Y� -Qj
SEE REVFRSE FOY EXPLANATORY LANGUAGE
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