HomeMy WebLinkAbout1321A 1322A (22) �' G I � �$' �+�� � � °
'� WORKERS'COMPENSATION DECLARATION �
I hereby affirm �ha, � have a�a,f�,;�afe of�o�senf�0 5e�f� APPLICATION FOR BUILDING PERMIT ���
insure,or o cenificate of Worke�s'Compensfion Insurance,or
a certified copy thereof(Sec.3800,Lab.C.J
PolicyN�compony �IV� COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Certified copy is hereby fur�ished. FOR APPLICANT TO FILL IN Bu����N�' ly�3 W�a•�-r y �,
AD�RE55 O O CJ
ertified copy is filed with ihe county building inspec- ftUILDING t `'`�W�� ��
tion depnriment. ADDRE55 "��� W �OCALITY �
} [��7 l L}-r^-o��7 �
Date �`L��(JG. A I� CITV �R,,, Gt�'�i/�� NEARES7 �U� � I
pp I /JD Z�P � ,� ceoss sT. t � � d-
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS � ASSeSSOe
COMPENSATION INSURANCE SIZE OF LOi Q � � NOW ON tOT MAP BOOK PAGE PARCEL
(This seclion need noi be compleled if Ihe permit is for one TR�Ci Q�� BLOCK LOT NO �� USE Z NE MAP
hundred dollars($IODJ or less,} ,�� NO ��- ..�%�J �
/' /' TEL. d SPECIAL �y
I certify thnt in the performonce of the work for which this UWNER l7� E, (7Q�7(npil(� NO. $�A7� �L'�t CONDITIONS
DISTRICT (;ROUP TYPE FIRE PROCESSED eV
permit is issued,I shall nof employ any person in any monner 6i
so as io become subjecl lo Ihe W�rkera Compensqfion Lows. AD�RESS � � {���} � CONST 70NE �
arr ` (�t�f iiP �11�6'S ��% �Glrr• -�' �r.e�a..c/ C;
Date A licant F
PP STATISfICAL CLASSIFICATION APT. CONDO.
NOTICE TO APVLICAM: If, afier making ihis Certificate of �RCHITECI OR �. T[L. �
Exemption, you should become subjcci lo fhe Workers' FNGINF[R NO. CIA55 NO. �'� DWEIt.11NITS_ ps
Compensoiion provisions of�he La6or Code,yoo must forih- �
wifh comply with such pr�visicns or this permii shall be AD�R[SS SCWER MAP �
deomed revoked. �E��
CONTHACIOR S Np,7�§_ � BK. PG, VALIOATION
LICENSED CONTRACTORS DECLARATION I.Ic
I hereby affvm ihat I am 6censed under provisions ot Chapter 9 ADDHtSS �7 L, Tu�.-�a NO �10Z yq�UATION
(commencin�with Section 7000j of Division 3 of ihe Business and I iC
Professions Code,and my license is in full force and effecL CITY rJ r��y bTIE. C�A55 L S 3 5 3���
SG1.FT. NO OF NO OF CHECK
license Number ��S�Z- Lic.Class ��� SIIE � STORIES ` FAMILIES " ONE
'�on}ra[tof��. fGCiS...s Dale���'��"" DESCRIPTION OF WORK NEW 5
'� I am exempt from}he licensing requiremen�s as I am a �� �,2., 'w� AD� �
licensed architect or a registered professional engineer �,� G ALTER � PtNAI /a��� >
� acting in my professionol capacity (Section 7051, ��� REPAIR � DATE l ;� �/ 1�1��G� 1 j{
Business and Professions Code;. USe Or
EXISTING BLOG. �Pi`�'�.b e*'�Q„�Q DEMOt � fINAI
Lic.or Reg.No. Dafe APPLPR NT) Q„] ei�y,.k_ NO. ��lr- BY ' ' �� �• s • .2 5
OWNER-BLIIL�ER�ECLARATION I • � 1 0,0 0
�I hereby affirm that�am exempt from ihe CoMratlor's License , ,�` y� /��
Law for fhe follawing reason(Section 7031.5, Business and P.DDRE55 .r.�lL.�' d�JN'rA; !`/� • p � '� (�,�`I C�
Professions Code): aRESF.N
❑ BUILDING �` �2.,���
I, as owner of fhe properiy, or my employees with A�DRESS
wages as their sole compensation,will do the work and
the struUure is not Intended or offered for sale(Section LOCALITV
7044,Business and Professions Code), MOVING iEt.
� I,as owner of�he property,am exdusive�y conrrocfing CON"rRACTOR NO.
with licensed coniracfors to consiruct fhe project(Sec- ADDRESS '��`3 2��n
tion 7044,Business and Professions Code).
REQUIREO TOTAL SETBACK FROM EX15T. f s e e s e�
CONSTRUCTION LENDWG AGENCY Sei ancK �A "�' Peop iwE wioiH �'
I hereby affirm thaf there is p constr�ction lending ogency for FRON?
the performnnre of the work for which this permit is issoed p i � � • 1 8.5 0
(Sec.3097,Civ.C.). SIDi
P.t ee . 18JG��
Lender's Name
(d,Grl1 � 0 1.2L'-�3G
� Lender's Address �'C Fee 5 ve� ��Fe� G"'Z� .
w I certify ihat I hqve read this upplica�ion and staie ihat ihe Isso ie Fee -��L'
Qabove informotion is correci.I oqroo to cemply with pll CouMy Invesagnrinn Fnn �
0 ordinances and State laws relnting io hullding cansrrucrion, �oi�Fo ��'��
u
❑nd her by authorire re�resenlatives of ihls County io enter
� � upon th abora-menti property for inspection purposes.
a (L'��O �" SEE REVERSF FOR E%PLANATORY LANGUAGE
Sio iarure of q plicnnt nr Ager� Dute � �s
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