HomeMy Public PortalAbout9560BISBY ST_Building (7) tA±ORKERS'COMPENSA_nON'AE�TION '
I` sure, affirm that I haW rkers' Come ns cl Int to self APPLICATION FOR BUILDING, PERMIT
Insure, or a certificate of Workers' Compensation insurance, _
or a certified r thereof ISec.'3800, Lab. C. `
_ COUNTY OF LOS ANGELES WILDING AND SAFETY '
P.gllcy No. CompanyilG�. _ - -
F. Certtfted copy Is hereby fumished. FOR APPLICANT TO FILL IN ADBIJDREM NG � Q "
f� Cer!tfI d copy Is filed with the county building Inspec- BUILDING 1^ O 6/sp
I�`J t{on•departmenf. ADDRESS , lJ
57
DateAppllcdoT CITY. zip 91 LOCALffY 1
/ / NO.-OF 9LDGS. - NEAREST
fICATE OF EXEAAPTION FROAA SIZE OF LOT 60-X NOW ON LOT ST. -
COMPENSATION INSURANCE'
(%is section nbed-not be completed if the Permit is for one - TRACT — BLOCK _ LOT tJ0 — ASSESSOR PAGE PARCEL
hundreq dollars.($1,00)or less_),
'/ Ta-NO /
I certify .t at In the perforrrtQEZ.
ncp pf,the work'fci vfhlch this N sI A '
permit Is Issued, I'shall'not em�foy any person Ih any mannerUSTr s?.-as.to become iubject-to the Workers'Compensatlon'tgws. ADDRESS
. / 7JP ..
Date Appllcant ' C1lY
NOTICE TO APPLICANT: 'if, after'making thls'Certlficafe of A��T TH DO-R!ZT _ P. TYPE -. Fl RE BY
Ek T`!( lE n; you should become subject to the Worker' INEH2 � NO. � ✓� CONST ZONE
Compeniatlon provisions of the Labor Code,•you.must forth- 60_ N3• J FJ
with cpmply with such proviiloru or this.permit.shall be - T }� STATISTICAL
AFT. _
deemed revoked.. CONTRACTOR /' NO
LICEN5ED CONTRACTORS DECLARATION,. LlC CLASS'tJO. D1Nl3L'UNrTS
I hereby,affirm that I am'llcenso under provisions of Chapter 9 ADDRESS No.
(cgmTn¢ndng with Section 7600)of Dtvblon 3 of Whe Buslnew and. _ LtC_ SES AAAP
Professlohs,Code, and'my license Is In full fdree and effect. (7rY CLASS BK PG. 3 VALIDAT"
SQ. Fr. NO.OF / NO.OF SEDC.
License Numbef 2 LIC_CI - 51Z9 ST6R1E5 / FAM LES ONE VALU
�yyy�, Z NEW- A) 9 X46 1,3A
Contractor bat t3 "r DESCStIP„ON OF WORK = VV
❑ 1 am exempf under Sec. 4 '2 / ADD-
TER
AL
1
BAP.C_ for this reosonREPAIR
Date: USE OF �+ _
DUSTING BLDG.
SI iriatureMER
si� L S7 CkNT TEL. FINAL
DECLARATION / " DATE ?j -
1-herebycfNrm that 1-am exempt from the.Controctors License
Law.for the followrnq reaion (Sbctidn 7031.5, Business and ADDRESS III R
'Pr6fe3slom Code):' PRERM
by
El
BUILDING
I, as owner,of the property, or my employees with ADDRESS �
waQes'as their sole compensatlon,will do the work and
the stTucture Is hot Intended or offered fof sale(Section LOCALITY
70.44, Business and Professions Code). MOVING TQ ' -
❑ I, as owner of the property, am exclusively contracting CQNTRAC7TOR NO
with licensed contractors-to construct the project (Sec-
ADDRESS
tlon 7044, Business and Professions Code)_
TOT SETBACK
CONSTRUCT10N LENDING AGENCY SET BACK YARD FIVVY PROP. LINE WIDTH -
I hereby affirm that there Is a construction lending agency for FRONT
the performance-of the-work for which this permit Is Issued P.L. - #=
(Sec 3097, Civ. C.). SIDE ;249 8,7A
8 P.L. -
Lender's Name # • 0 0 0 0 1
LDe4A W. 1
Lenders Address PC F"t t P«mft f~
$ _ 1'•.39.7.5.0
I certify that I havesead_this-.application and state.that the Inuonce Fee Zo r LDNW P/C f ,r ;0,e 3 9 7.5 0 tT5
above Information Is correct. I agree to comply with all County Inv.stlgaHon Fee
ordlDances and Stpte laws'relgting to building corl;tructlon, TOtaIfee LDMA Form I 1 0,709-86 .
and hereby authorize representatives of this County to enter
upon th bove-mentioned property for Vu4>edlon
purposes.
r / / SEE NYRE!103 UULAfiATORY LANGUAGE
- re of App cant or Agent bale,