HomeMy WebLinkAbout1636A (224) � WORKERS'GOMPENSATION DECLARATION I�
�� � he�eay aff��m �ha� � ha�e a�e�f�f��afe a,mnsenl to se�f APF�LI�ATION FOR BUILDING PERMIT �
insure,or a cenificate of Workers'Compenstion Insurance,or
� a certified copy rhereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Campany BUILDING ��•��,, ,/�.,�,
� Certrfied copy is hereby fur�ished. FOR APPLICANT TO FILL IN ADDRE55 ,��Y7"=C.J t�.�.Z.> �l� � �
� Cenified mpy is filed with the coomy b�ilding insper BUILUING ;�' I / /" �+r" ��+y„ /y/
� tion deparimenf. ADDRE55 - r. �J ,�,; (_�(_j�/ LOCALIiY -,l6�I�:���/�'7�,�
.o � �y� ) NEAREST ��, J �y�1
Dafe Applicant CITY _ ZIP /�1��?� CRO555T. fl .� -�f-!'j/'i�`.t'����.F�-� �-r+'�"�-�
� CERTIfICATE OF EXEMPTION FROM WORKFRS giZE OF LOi (YJ� �.f�.Y.3 NOW ON IOTS ! MAP BOOK PAGF PARCEL
COMPENSATION INSURANCE
This setlion need not be com leted it the e mit is fo�one �-7•-r USE ZONE MAP �, �i
( � P � ,�" '� 3 3
hundred dollqrs($100)or Icss.) . TRAQ ., '�) BIOCK l07 NO. �„ / NO. }
' / J TEt. ��/J �j SF'FCIAL �,
I OWNtR /5 � �� NO-p-,.i'/ ( ��� CONDITIONS � ,�
I certi4y ihut in the performance of ihe work for which this uiS�RICi GROuv ivPt tiR6 PROCE55Eo Bv y„j
� permit is issued,I shall nof employ any p rson in�.p ny manner � .'.7>f'1� L/ ) [ J •LL �•�� _ ,.� ��
ADDRE55 �{'Y'(3�.1 C L"'J '` CONST. Z E
so as to become sub�ect to tha Workers'Compef[a'sation Laws. �
p arr zia z"` /�� ,���!� �.�!�.. i�a<.<.�.,c.r O
p Date, f � °�Flppliran `, '��'��� � � STATISTICAL CLASSIFICAiION APT. CON00 �
ARCHITEC(OR TEL.
� NOTICE TO APPLICANT�. If, nftcr making t is Certificate of ) �
p Exemption, you should become su6jecf to ihe Worke�s ENGINCER ��- CLnSS NO. �f DWELL.UNIfS_ »
tlCompensnlion provisions ot ihe Labor Code,yo�m�si forth- qppRF55 SFWER MAP �
A with comply wi�h such provisions or +his permir shall be )
� deemed revoked. CONiRaC70 ,"�P;{J,� 1 NO y_���„3� 6K. I'G. VALIDATION
� LICENSED CONTRACTORS�ECLARATION ,�;�..
y .r �y
I heroby affirm thnt I am Ilcensed under provisions of Chaptcr 9 AODRt55 . � `.�� ����/ ` " NO_�.�/ .i�"'! VALUATION
(rornrnencuiy wdh Seclion 7000)of Drvision 3 of fhe 6usine.ss and r / ��� �
� Professions Code,and my license is in full force and effect. UTY �i 7'� .D CtnSS ,.� S ��
5(].FT. NO,Oh NO.Of CHECK
� License Numbey+'� � Lic.Class� ' S17E STORIES FAMILIES ONE �
� .'� �' 7.•.sy V �^�j�� f DCSCRIPTION OF WORK NEW
� Canfractof=� � �.�- s. Date ,f . ADD
j � I am oxempi from the licensing requiremenis as I om a � �
� Ilcensed architect or a reyistered professional engineer � Ai�ER � FINAL
� acting in my professionol capacity (Section 7051, � REPAIB � DATE �/ d � �7�
� Business and Professiore Code). u5E OF
EXISTING BLDG. i DEMOI � FINAL
� Lic.or Req.No.-----oate AVP�vaw��_ � ,7 .��CL� NoC� „..� ev � 1�3Y2 c.� / �1 6'J.b�1 ;
�+� OWNER-BUILDER DECLARATION
���'ry I here6y affirm that I qm exempt from rhe Contre ctor's License ,/ �° • • • • �
� Law for ihe followinq reason(Section 7031.5, Business and � ADDRFSS ti�.;�" ti,F'� � f,.!'✓ �
Professions Code): � P ESENi � " �?_5.5 0
� ❑ - � BUIL�7ING '
I, as owner of ihe praperty, or my employees wilh ADDkE55 ��5 O`
i1 woges as the�r sole mmpensation,will do ihe work and � � ° �'
'{ the structure is not intended or offered for sale(Section LOCALiTY
�oaa,e�s��ess ond P�of�ss�ons code). nnoviNc rE� 0 2 2 3—8 2
�?) I,as owner of the properry,om exdusively mnir�cting �UNTRAQOR _ NO.
�a � with licensed contraciors to construct tf�e pro�ect(Seo ADDNE55
� tion 7044,Business and Professions Code). ,
R[�UIRFD TOTAL SETBACK FROM EXIST.
C.ONSTRUCTION LENDING AGFNCY SET B�CK YARO HWY pR(�P IiNf W�DTH
I hereby affirm iho�there is a construction IPnding agency for pRON�
the performance of Ihe�,aork for which ihis permit is issued P i
� (Sec.3097,Civ.C.�. SiDE
PL
� Lcnder s Name .__
P C Fee$ Vermii Fee . �U�
����ders ndd��s.5
I cenify Ihat I have recd ih'is application c�nd stote ihat tha ` Iss e hee ��.7 �,
� obove infor tion is mrrecf.I ogree to comply with oll County Invesrigaiion Fea ���
ordinance and State�laws relniing to building consiruction, � lo�al�ee '� <".�� ��
ond herr y nwhori representa�ives of�hls Counry to entcr
Q "on t above-� ntloned p�operty for Inspeclion purposes.
,��`----- /�"'%�?"�"�'�--
a � SEE REVERSE FOR EXPLANATORY LANGUAGE ��
Si9n Iu e of Appli<nnf ar Agent Date �
, �
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