HomeMy WebLinkAbout1746B WORKERS'COMPENSAiION DECLARATION .,,. � �
I hereby affirm thot 1 hava a certifitate oF�o�,e�„o 5e�f . APPLICA�TION FOR BUILDING -PERMIT � � �
insure,or o certifica�e of Workers'Compensrion Insurance,or ,
a cer�ified copy thereof(Sec.3800,leb.C.) COUNTY OF LOS ANGELES � BUIIDING AND SAFETY -
P❑o�'icy No. Company , BUILDING �
Cerrified capy is hereby fumished. FOR APPUCANT TO FILL IN ADDRE55 �
�� CerliFied copy is filed with 1he county building inspec- eURoiNG/�� �1 y /'
tion deparfinent. � ADDRE55�(J`�/ik�vriVE � O LOG4LITY /`��"�"�'�`� � '-��
- '� NEAREST
Date Applimnt � CITV MO !7 f� � ZiP CROSSST. '
� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF Bi�GS. _ n55E550R �
� � COMPENSATION INSURANCE SIZE OF lp7 NOW ON LOT MAP BOOK PnGE PARCEI
�This section need not be compleled if tha permit is fpr one TRACT 3�OSI USE ZONE MAG .
hundred dollors(5100�or less.� � . BLOCK LOT NO. ' NO. �
! /��� TEL. SPECIAt q,
I certify tha�in the'per(ormante o(the work for which Ihis OWNER L A JOL� C�/Z!� NO. WNDITIONS 0
permif is issued,I shall not employ any persan in ony manner DISiRICI GROUP TVPE fIRE PRpCE55EU BY �,1
so as lo betome subject to�he Workers'Compensoli0n�aws. <.DDRE55 �/,�/� CONSt. ZONE O
7
Date ' Appliconf � C1TY T aR r ZiP TFI. STAl15TICAl CLASSIFI[ATION APT. CONDO.' V
NOTICE TO APPLICANT: If, a(ter making this Certifica�e of ENGwEEa E� LN�' NO. f�/ w
Exempfio�, you should become suble« <a 1he Workeri ^ CIASS NO. DWEtt.UNITS_ 'N
Compensotlon provisions of�he lo6or Code,you must torlh- � � nooaE55 ZZaII D � U.<'S�/tVE SEWER MAP � -
wilh tomply wi�h such provisions or.fhis permif sholl be —
deemed revoked. , . �� CONTRACTOR NO. L BK. PG, VALIDATION
� LICENSED CONTRACTORS DECLARATION uC. . �
I hereby offirm thal I am litensed under provisiOns of Chopter 9 ADDRE55 NO. VAWATION
(commencing wifh Seclion 7000)of Oivision 3 of fhe Business and � LIC. f � R� I Q,6 C3
Profess�ons Code,and my license is in full force ond e(feU. Citv CtA55 E �. ��
- - 5�.FT. NO.OF NO.OF CHECK i#• • • •�3
license Number ' �ic Class SIZE STpRIE$ FAMI�IES ONE ,
I� Conlractor Dale DESCRIP710N OF WORK NEW ❑ S • � � �71'2 O I
� I am exempt from Ihe licensing requirements as I am a /J(� L(„ A�� � � � � � �7� ����
licensed orchiten or a registered p�ofessionol engineer . _. AITER � FINAL
. acting in my professionol copocily (Seclion 7051, aEVAiR � DATE , Q.�,���—�j 2
Business and Professions Code). USE OF � � '
. EXISTING BLDG. DEMOL ❑ FINAL
Lic,or Reg.No. Date APPIICANT TEI.�/`p�� J BY
- � OWNER-BUILDERDECLARATION � ' " PRINT)�EVC KtJMaN NO/�7 ,�caJ�+ �
' I hereby offirm fhol I om ezempt from ihe Convac+or's license �;p//Pj�JO�C/�1dKST� U,VT/�ryDd� �
law for the following reason(Section 7031.5, Bosiness ond� � aDDrtE55 �
Professions Code):. � F�z�seNt - -
---❑ . - 9UILpwG . . � .- ,
I, os owner of�lhe property, or my employees wilh ADDkE55
wages as their sole compenso�ion,will do the work and
� the strutlure is no�intended or o(fered(or sole(Section - tOCatrtY� � -
� 7044,Business and Professians Code). MOVtNG TEL. _ '
� I,os owner of Ihe praperty,am exclusively contracting CONTRA�TOR NO. ,,/� �
with licensed[o�f�a[fors lo conslrucl the project(Seo- qD�RE55 /��/�3
� tion 7044,Business and Professions Code�. � � -
CONSTRUCTION LENDING AGENCY REOUIREO yARD HWY TOTAL SETBACK FROM EXISi.
SET BACK PROP.�INE WIDTH�
I hereby affirm Ihat there is a canslruction lending agency for � FRONi �
ihe per(ormance of Ihe work for which ihis permif is issued p.�.
.(Sea 3097.Civ.C.�. . . 5ioE - .- . . .
P.L.
Lender's Name ' . '
$ lender's Address P.0 Fee S ��D Perm�i Fee
W� I�erlify thal I hove read ihis opplicolion and stote thot the Issuonce Fee� �
aabove iniormofion is mrreU.I ogree to comply with 611 County_ , in.esngoi�on Fea � � - - -
ordinances ond Sroie laws relating�o building constrvc�ion, � io�ol Fee
and hereby auihorize representmives of Ihis County�o enfer , . .
� upon the above-menlioned properfy for inspet��on purposes _
a` � � ,SEE REVERSE FOR E%PLANATORY LANGt1AGE
� . . Signar�re of Appli<ant or Agenl.. . . Dote . . . .. . _ . `. . . , , - �� /
A �
7 T (�= O �" T 'n
iD O �c ?' � O 0 O � N� t1 '-
� � n�c � ?b � � � � p-o �- O o� n� � G� '+ _ � .
!bZ � �.� � g �° o D � d n^- nN o ° ° o o , 1.2 �
" v` m o f F� v a A „o' y_ o °- v % ' �o c
o' 03 � Q � ° a,l t' . � ' � � m s
' A� ° + o N „� � � ,o �'' n� o m o p � I
� �
Q o o ; � � °�. � b ti a
� n. .; o „• o 0 3 4 „ a
� " � ' ' � �� _ 'n' b ,
��..7' "� � 3 Q � O
� m' < O
� o � o c
� � ; A
m ,
a
o �o
m I � �
D
�+„
' N
I M � 9 O
I c o �
'� � t
« z � C r-
O r1
� O O ='
. p . � 0. 2
.. -� �/
N
q �
�c , o n
. � �
� n _ . D�.. •
� 9
e' �O ;;, D
� ° c
0 K ,
ao 0
a �
d
z
. H
b
m
_ _ y
� . �
, 70
Yi
� . . O
�
N
/,
v
co � a �o,�
Q o � ��•0.n �� �'6 • � F c • �-�' �^ m� m�e e o o�a L^•'L''�`i n (�,^ r
. � 7 Q n h �„ F � A �; ` C ` � N �n fp 0.3 ^ � n �•q ��„ n�
o ^ fi i (e�.C�7_ ti ��o � o°'� o n c �'b � �.vo �.Q'b � �• � c
• 3 � F ...A �,�. N C ti.� ' ii �C cn. A � � - O w•�, y O a �.ti�h,4 O C
X riC�b qh � ° o;' W" h•� o �� T� �`p � ���"�A'a Q a o�p
3 �n^•A o ; q m � ,�,, c,m�i o �'q b'^��-f .°.. �b '�'`° � w�b A, F �<
Z � woMaq_^' �°vo`.'�� � �'�O�°o $ � � -°�� 0.�17� �oti � } '7_
�n c w � o o, �. �� o t�".N .� � n � fi•c ty ti � w o 0 3 r.-
. v , �y �. �� Q",,: # A ? w > n °. �� n �•�,d u .. � - '�"7`
n e n '�'*4aom : � � Aoo'mo � �; o'S � .�i � Ow 'sop
� N `o o�,�o'a �m� � o�,� M a-3 a n�,�c � c'�j� C'� ° � ° �
� G
A7 n `' � �.�'n b (�C ` '`t A �` O �4�� `�. :.� O A���y �' N O � O
, z �.` a N ° w ri� o �� O F 0.° Ov e r o �.�� � � � e p 3 n
�•0.a �.� a " e 0.,�, " o .m ��°:�'ti p ti o w „ 0. F X �
� i & ° 0 3 0 ° e-� 4�� � '`� �;� c^ o'\ b l.,o °.a � o G
' N � oa �oa3 o��.m` oc° a�°,"�m ' 0 0..`�. s � 4�10�..,,� ��mb ('n•')
� � oi C � -z-.',n''��^ o' o a'F� � �o�aa'� o � fi•�^ � �t-
� • � � o L,�,.. 0.s :.•-, 0.Q'b �.o a.� aa ,�C� ` a A q " � ° �
' p, z �i '0 � �• ,°� K o R,i-o � n o � r, �,��.c,a ta o•pa'�b o ? 3 a
- n n R b a°..r �.`� i " 7°tt ° m ° �° � °.o a�`a'� a c ^ �T �1
o,� 4 V n �� •N � p"aa�F�°c ���+� ybW�N��' c m n0
� o o ti c� a o o � C c „ o � o m h �Z•o g ., � R,x�^ o �
� • ., c F �v,� o �' a';�e•� Q,��,�',-m o a �o��.Q a � ��C 5
� N C�.� y �D O w O "�C � �" �" n�p V
• oC�oy., n � �m��qi ���2�-~�c".'.4�,�, ; xa � �L`n,r' �o
N