HomeMy WebLinkAboutNo Permit Numberuca UOMPENSATION DECLARATION
I hete9y o certificateI have r certificateCompensation Insurance; to self ,,..'APPL'ICATIO.N sFQR BUILDING -PERMITs
heTe
or o certificate of Workers'
Coote
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Non (enure ce
or
a certified coEy thereof Lt c. 3800, lob. C.} - j
P'I 101832A'' jvj{Qc gL r COUNTY OF LOS ANGELES' BUILDING AND SAFETY ar
o icy No. _ Company
Certified copy is hereby furnished.
EaCertified copy is filed with the county building -inspec-
tion department.
Date 1' 3/984 Applicant C•-Tic3Q
CERTIFICATE OF EXEMP110N FROM WORKERS',
I COMPENSATION INSURANCE:
Tliis section need not be 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, l shall not employ any person In any manner I
as to become subject to the Workeri . Compensation Laws,';
4
Date Applicant .
NOTICE TO APPLICANT:Jf,after making this Certificate of
Exemption, you should becomesubject to the Workers; '
FOR APP•LICANTITO FILL' IN
ii
ADDRESS
BUILDING
1\,• •... ADDRESS •'t" 1 L.:•T\. t! ..2:+ LOCALITY i.i.
r f':}
CITY '-AKS• k ZIP NEARESTCROSSST. 2`•-' '•. .1 ti. \.— .
O. OF BLDGS.•
52E OF LOtT NOW ON LOT' •'0'
ASSESSOR
MAP BOOK PAGE' PARCEL
TRACT t1 '3L'l53 i'.L BLOCK LOT O.. .'102 -
USE 'ONE
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11 ttMAPIC_} C( "'T•,9 w1 i )
OWNER S f J JeYtOf £iie 4W+. NO.' S. J40"0, 0 • I t- 00 SPECIAL q1
CONDITIONS
t •,. I .' f'.. "1600' ADDRESS s a60O '' "%II I l/iVE . I :'• .
DISTRICT GROUP TYPE FIRE (PROCESSED BY .
CONST. l ZONE
CITY.ji; Elea61' i'' ZIP 92660`, Jf_e
ARCHENGINEER OR i Lc I-fSl 63.vLO06
STATISTICAL CLASSIFICATION • ,,
y ) AI
CONDO. •
O.'
c
CLASS O. DWELL. UNITS{_ FII
I,; Xqm enation provisions of the Labor Code; you must forth- . t P P Y
i ' 1038 c al( "'""'J" ADDRESS' 4 .«.,LVt3e : SEWER MAP - jhw
with comply with such provisoes or this permit shall be
h i .
S
q, TEL,
7 BK. TK, VALIDATIONATIONdeemedrevoked.
LICENSED CONTRACTORS DECLARATION.
r I hereby that I am licensed under of Chapter 9,
No.
S 289294ADDRESS - O. VALUATIONaffirmprovisions
commencing with Section 7000) of Division 3 of the Business and I: UC. -
i S "'' ''C F
Professions Code, and my license is in full farce and effect. C11Y !. CLASS
SO. FT. NOOF NO OF CHECK
i
lypfp;. 289274.1LicenseNumberUc. Class
s
SIZE ! • 2103 STDRIES 2 FAMILIES ,' 1 ONE t 1 A i ,'
ssC}{
CSF SD. CM. 3/9/84.
Date
DESCRIPTIOMWORK NEW
Contractor ADD
Ell am exempt under Sec. ALTER Q FINAL
DATET..
B.t .C. for this reason REPAIR
Date: •
AUSEOFBL-'" EXISTING DG - DE OL.. FINAL - Ij Illt
Signature' - .. 1'11
P1 INTT
TEL,
tA..It Dr'1mS 540 0500
By.
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License
Law forthe following reason (Section 7031.5, Business and ADDRESS M
Professions Code):
BUILDING Ji S, 0 Q. I, as owner of the property, or my employees
wages as their sole compensation, will do the work and
f
the structure is not intended or offered for sale (Section ' LOCALITY I i Q {S i
7044, Business and Professions Code). MOVING - .TEL..
CONTRACTOR ' NO. rr 1`.I S•r r. 1, as owner of the property, am exclusively contracting I I
with licensed contractors to construct the project (Sec- ADDRESS I
tion 7044,Bvsiness and Professions Code). :.
CONSTRUCTION LENDING AGENCY
REQUIRED ` TOTAL SETBACK FROM EXIST,
SEi BACK -YARD HWY. . PROP. LIN 'WIDTH r
I hereby affirm that there is a construction lending agency for FRONT
the performance of The work. for which This permit is issued 1.1;
Sec. 3097, Civ. C.). - SIDE .' ri- P.
Lender's Name
P.0 F.E ' r'i' , !'J .. Pe mR Fee : . ._•
LendefsAddress "
1 certify that 1 have read this application and state that the
t
Issuance Fee %' — (i
above Information is correct. 1 agree to comply with all County I stigoti F e r
inances and State law relating ro building construction,
and hereV—tfwn¢e rep/esentatives of This County to enter
Tot I Fee G•
upon theSSbove-'onli ped property for inspection purposes. I,,S; . • .;:., t •;, `•
3I9/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Istwatire of Applicant *,'Agent Date
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