HomeMy WebLinkAbout0823A (6) WORKERS'COMPENS...�N DECLARATION � - �� ��
I hereby affirm thai I have a certificate of consen��o self �pp�fCATION FOR �UILDING PERMIT
insure,or a certificafa of Workars'Compens�ion Insurance,or
a certified copy thereot(Sea 3800,Lab.G.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � �
Policy Na. Compony
� Cer�ified copy�a hereby furnished FOR APPLICANT TO FILL IN BUIL6ING .1 � � �
ADDRE55 0(�
� Cerlified copy is filed with fhe counly bVilding inspec- 6UIL�ING J
tion department. ADDRE55 Z 4 E�U.Uti1f N t�,Q/�,� iocnurv �.ncsG .�.t.�
/ NEAREST
. Date Applicant CiTY�` MbN Zia � bS CRO555T. .,.ttw�-�—rsL_
-� � CERTIFICATE OF EXEMPTION PROM WORKERS' NO.OF BLDGS. ASSESSOR
. COMPENSATION INSURANCE . � SIZE OF lOT NOW ON LDi ' MAP BOpK PAGE PARCEL
. (This secfion need no�be comp4eted�if Ihe permit is for one �"�� USE ONE MAP
hundred dollars(Stoo)or leas.) iRACT 7r li 0 B�aK ioT No. � ,�� No. —33.3
/'A�t� /'b �/ (� '
OWNER ry Tj p �'63Ia �C)OG� CONDITIONS d
I certify that in�he performonce of rhe wo for which�his O
permif is issued,I sholl nof employ any pe,on ony mannei �,��J �j DISTRICT GROUP TYPE FIRE �ESSED BY V
, sa as to 6ecame subject to the Workers' �' ��Qy,,y, ADDRESS2I77"T'�JCUA�N( CONST. � �
Date- ApplicaYr� ' aTr / /} zia /�5� �� '�`� � R'"�`� 0
ARCHITECT OR TE S7ATISTICAL CtA551FIUT10N qpJ. . [ppJpp.
NOi10E TO APPLICANT: If, afl�r making this Certificat p�Q n / V
^ Ezem tion, ENGVNEER TorlN �� ALt � I�+/rJ CLA55 NO, c� W
oweu uNirs_
p you should 6ecome subject to 1he Wor'ers' N
Compensatian provisions of the La6or Code,y0u mus Ofth- pDORE55 SEWER MAP 'L
with compiy wi�h wch provisions or Ihis permit 11 be TE� �
deemed revoked. . CONTRACTOR Np gK. . PG, . VALIDATtON �
�� LICENSED CONTRAQORS DECLARATION� i��
1 bereby affirm iFw�I om licensed utrcler provisiom oF�Chapfer 9 ADDRE55 NO. VAlUAT10N
(commencing wilh Section 7000)of�ivision 3 of the Business ond ��
Professions Code,and my iicense is in full forc¢ond effect. CIN C1A55 $ �
- SQ.FT. NO.OF NO.OF CHECK .
L�cense Nurr�ber Lic.Gass SIZE � STORIES FAMIUES ONE '�
Con�roc�or DESCRIPTIONOF WORN �ATO l..fi✓� NEW � $ ��E?Q �
Dafe
� I am exempt from fhe licensing requiremenis as 1 am o ADD � � � I
licensed architect or a registered professional engineer qLiER � FINAL �
acting in my professional capociry (Sec�ian 705i, � DATE 3--���
� Business ond Professions Code). REPniR
USE OF � FINAL `
ExISTING 9LDG. DFN�OL
By
Lic.or Reg.No. Date APDtICqNT �/ ' TEL.
OWNER-BUILDER DECLARATION (PRiNT� �J((L y�yV NO. IFJ,; �J �
� I hereby affirm Iho1 I Gm exempt from fhe Contmcioi s LiCe�Se p�
Low fo�the following reoson(Section 7031.5, 8usiness and ' ND�RESS�I ���/+UQi Li�cq/�1('/{�.,E�!}14iW p��
Professions Code): ppE E
� �, as owner�of the ro ert or m em (o ces with bUILDMG . � � �Q 8 2 3 a
P P Y� Y P y AD�RESS
wages as fheir sole mmpensa�4on,wNl do ihe work ond - � -
the sirutture is not iniended or oifered f0�safe(Section �«A��TY #• • • •-�.�
7044,Business and Professions Code). MOvwG iEt.
� I,asowner of the properiy,am extlusively coniracting CONTRAC70R NO. � • �3 7,5 p
. with licensed coniractors to construct the project(Seo- qoo2e55 � • e o�i�5(��
tion 7044,Business and Professions Code).
REOUIRED TOTAL SETBACK FROM E%IST.
E CONSTRUCTION LENDING AGENCY SET BACK Y'4R�� MW� VROV.IINE WiD7H I i,2 5-8-1
I hereby aftirm thot�here is o construction iending ogenty for FRONi
�he performonce of the work For whith this permit is issued p.�.
� (Sec.3097,Civ.C.J. . � . SIDE.. . .
P.L.
le�der's Name "
,� , Lender's Address P.0 Fee S � Permit Fee - �'��1 '
W I certify that I hove read ihis applicotion and state Ihal�he Isw ce Fee .�"
Qabove information is correct I agree ro comply wi�h oll Counry In�esiganon Fee �n
ordinonces and S�ote Iows relating to building construction, ..3 • 7l1
� and hereby rize representatives of this County lo enler Torol Fee G�
upon the a ve n n o�ed praperty for inspection purposes.
� —2,]'� . SFE REVFRSE FOR EXPLANATORY LANGUAGE .
� . .. .Signoture ah Applicanl gent pore � �,-�,...
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