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HomeMy WebLinkAboutNo Permit Number (2198)WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C. ) Policy No Z/i' 67y�(Compony FAJ%F*1*q IA6 C0 Certified copy is hereby furnished. Certified copy is filed with the county building inspec- tion department. , S Date �`J,3 Applicant iIA,A4 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Lows. ate —Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit %half be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Number Lic. C103• Contractor Date I am exempt under Sec. B.SP.C. for this reason Date: Signature OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 70311.5, Business and Professions Code): 1, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). -� I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby pf.irm that there is a construction lending agency for the performance of the work for which this permit is issued ,Sec. 3097, Civ. C.). Lender's Name Lenders Address I certify that I hove read this application and slot& that the above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upo h a me tione�f pr party for inspection purposes. `8.j3 Sigrwtura of Applicant or Agent Date APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING / ADDRESS 5,90BUILDING A�P Z/j ADDRESS O eZ A(FF LOCALITY p NEAREST CITY / ZIP CROSS ST. NO. OF BLDGS. ASSESSOR SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL TRACT BLOCK LOT NO. US — - d NO. /©O 112,3 3 TEL. OWNER Y/ NO. SPECIAL CONDITIONS �}� )� DISTRICT GROUP TYPE FIRE PROCESSED BY ADDRESS �P v & •I F� CONST. ZONE /� ' /� CITY /v Ally ZIP ARCHITECT OR TEL STATISTICAL CLASSIFI TION AFT. DO. ENGINEER NO. CLASS NO. DWELL. UNI75 ADDRESS SEWER MAP BK. PG, VALIDATION VALUATION 10 CONTRACTOR lL—�7� G NO. dd ADDRESS S L D Aid / CITY CLASS s ci c2 SQ. FT. NO. OF NO. OF CHECK SIZE STORIES FAMILIES ONE $ FINAL DATE DESCRIPTION OF WORK NEW ADD ALTER ,Y �C REPAIR FINAL USE OF (STING BLDG. DEMOL By APMNT AC 1( ON/14 N. ADDRESS PRESENT BUILDING ADDRESS LOCALITY I•• J G 1 3 • a " G Ju. MOVING TEL. CONTRACTOR NO. ADDRESS REQUIRED SET BACK YARD HWY TOTAL SETBACK FROM PROP. LINE EXIST. WIDTH FRONT P. L. SIDE P.L. P.C. Fee S Permit Fee �bT l—yy Issuance Fe (/ , V v Investigation Fee / C Total Fee W • J SEE REVERSE FOR EXPLANATORY LANGUAGE :I 0s •O N .{. 'y O m O S� a 1 L G-O' —' C y `ti O U C S .'•", -_ OOn ac \ "e `1 NM wh C +a 4, z y,. O h •7 xN-"i ,a O U O U :. V O of r O p uen �`nd� S •� S ^O N �. o` <t^ T.O r 4 tl > arc •aa _e c p^ R fi R S -0 it ("•� F. n E O c C O .v. �" a �•I U 4 C` .�.. C 4 .dJ C •� i' •.N+ N '3 c G E o, 'Ir o � � � � � �' p:-I w o � ' .- YO •.. �• r Z'. y Otis A C w v f. 4 ii. ^ .y •.. ix). X ._ V Z: �„ c c y ti F• +4.. 4 4 M.C., „• IDO C C •G"`� w •C v a C C C C 2; 4 JC` .. ` C- _ G: G o ° Itro p -z, r++ Le ~ r b � � ` r L C � n� G f •� U, 0. ti� � C 5: •J -r,ti C tZ C O w C .; it C N �� iC. Q b C� v im^, tl c T ` y .p .� c� N i. V `'` C � ✓7 q: :.0, w U c a c cC O Lo v. I {� I y � I a iE