HomeMy WebLinkAbout0061A 2928A (6) WORKERS'COMPENSATION DECLARATION 2�J �
APPLlCATiON FOR BUILDING PERlU11T 4
� " I he�eby afiirm Iho�1 hove a certificate of tonse��to self
insure,or a certificote of Workers'Compensation Insurance,
or a cenified copy thereof(Sec.3eW,lab.E.� COUNTY OP LOS ANGELES BUILDING AND SAFE7Y
PolicyNo���r D�� Company SvnG�r�. Nafi,eN,r�
� Cenified capy is hereby fumished. FOR APPLICANT TO FILL IN BUILD�NG U � a�
ADDRESS
�Certified capy is filed witb the county building inspeo- gUqp��
tian departmenl. . qooRE55
U01e �d�I `�'( Applicant n/�'L W 4`S✓�- CIiY ZIP IOCAIITV !+�C ���
CERTIFICATE OF EXEMPFION FROM WORKERS' NO.OF Bl�GS. NFAREST
COMPENSATIq�INSURANCE S�ZE OF i0t NOw ON lOT CRO55 ST.
(This seclian need not bo completed if the parmit Is for one 7RAC7 / BLOCK LOT NO. � �R
hundred dollara(�100�or leu.) MAP BOdC PAGE PARCEI
iEl. �ZONE M!W
I cenify�ho�(n the performance of fhe work for which Ihis �'NER NO. � � /!� ^3'3
permit ia luued,I sholl nOt Bmploy ony pefson in any monner qDDRE55 �'�� �� SPK�a' O'
w os lo bocoma wbject fo the Worke�s'Comp�nfalipn�pws. CANDITIONS
CITV ZIP � V:
�ate App4itant ARCHITECT OR � TEI. �.
� 7TICE TO APPLICANT: If, pF1er moking fhis Cerfificote o} DISTRIR GROUP 7YPE FIRE PROC�SSED BY O
emption, yo� nhould b�eoma subjecf to the Workera' ENGinIEER �� �ppyST. 20ME F-
Campenwtion provisions of rha Lo6or Coda,you muat forth- q�RE� � S �� /f�� W
wllh tomply with �uch provision� a thi�parmil sFwll ba
dsamed revoked. ��/ � STATISTIGiL CLASSIFICqTIDN APf. CANOp, N
IICENSED CONTRACTORS DECIARATION CONTRACTOR �{L6L1.W �ron^ S.-�,vo.Zl3 63¢•�133 •
C �p� p IIC. CU155 NO. DWELL.UNI7$_ ?
I hereby affirm rhat 1 am licenmd under pravisiom of Chapter 9 ADDRE55 Z�dtr�.fu¢G�4i�trLf. Np.�3 S/D7�
(tommonting with Section�000)of Division 3 of�ha BuNrre�a�d .P L � LIC. 3�'�R NU1P
Professlons Code,and my litense Ia in full forta and eNec�. CITV .�1 /�'ribpUni n,q�5 B VAUDATIOH
S(i.FT. NO OF Np OF CNECK �. �'.
LitanaaNumber �357� IIc.CIo� SIZE � STORIES Zr FAMILIES ONE
Contrxtor��W 4���I ata � gJ ��R iOt�O�WORK � VALUATION
NEW
A� 4 C� l7 �GOb1 A
�I am exempt under Sec.
ALTER �f� • • �2"
0.8P.C.tor thi�reason REPAIR s
pO1e: us�oF � I • 1 1 i.4[:.
Fxisr� �p�. ! � �a ❑
Sipnatura '1`P��GM � �NE� � HNAL • • � � %.`"('_
OWNER-BUILDER DECIARATIQN PR�NT OATE �^�'��
1 hereby offirm that 1 am exe�npt from the Gon�roctw's License pDDRE55 h/� � / i, ��,L 2-U�
Low for the following reaaon(Section 7W1.5,8usiness and FINAL
Profsasione Code): �-�-- -�� -- -���-�- - 9y
j � BUILDING
� 1, os owner of the property, or my employees with ADWiESS
� woges as thair sole compensaiion,wifl do fhe work and ��y�ITY �
the strucWre is no�intended w offered far wle(Saction .
7044,Busineu and Rofessions CodeJ. MOV�NG h�. �L 7[;��F{
� 1,as Owner of the property,om exclus�vely conhatfing NTRP'ROR Np.
with Ifcensad contratton to construct tha projeCt(SeC- qDORESS �++ • o e �
tion 704I,Business and Professions Code).
CONSTRUC110N LENDING AGENCY �Qgq� VARD Hwr TOiwl sETenCK � a � 4 y^`�
7ROP.LINE WIDTH
I heraby affirm that there is a conslruclion lending agency fw FROM
�u j �;�C.,:
the ps 'vmance of the work for which�his permi�is issued p.t. _,.
(Ser Civ.C.). SIDE ��
V.L I �,O �-Lt�
� ^ ` �-+ lOHV1 Ref.M
� ' 7.C.fee S � I t Mmit Pee / �
�d this applim�ion and state that the luuanc•Fae j0-� tDMA P2 N �
\ �ct.I oqree lo tomply wilh all Counry Investipotion Fee �[,(�
"felating b building conshuction, iowl Fae ,T/��� IDNW perm.M
�nmtivas of�his County to enfer
��perty for inspectlon purposes.
� /�_ fE!REYERfi f011 E](�LANATORY LANGUAGE V
n
r
�
� "s
_.: �
J F l r� O
t� y. � C1 C .'4
. ,y CJ � � +1� a' T 4 .�`,. 1.,
� . CV
a � ;� � 4.N Z O. `4�
-d a ^�'-�,�% ' Y` ?' p � d t G.� '� � i W
S 's G 3 �.c �-� � w r o c F :� „, m h
. `.c�: ,^.�, 3 a.�' y.L �'^ �, 'Y�. '� a a��c.� � d
G � j a� C a O
� S'�^�J � F�r, n� � C 'V �n�„�"_ .:�..0~ 1r ��,,, �. u•ey' � t
✓ �tf,�.a�.n r 'V ,..; �i.�. C � T 2l✓� � r 1[ ..�� i +� � i� . X �„ ' J1 �
.�"�'"'�, .vF.�r � 61 N ` ..ri' �. b � i .�r N � " "� �� � \ `
MG'�Y� � « `^� ��r � � �s u� Y., a,.evy-�� .a pC;j � ^s��. �'j � \
`- ='^� y '" ''i^� m �::� c c o � �. •�-�•^%�s � �o z-s �..., d `u ; \ \
° c ,y Y—.� � � t N_, v �� �� �;,� c..v � ='� �� m o � c �.� ,� �' � , � � \
I.� :P i .. G �.w � � y1 4 �' � y � 4 .L. S"�3 O `� +� �' � �.`S � � \
D ra— ^ � .. ? s v a�.-.Y e`s ° a',` `-'c '� � �� ° o "" s..: ��? c � �
.� .t .. �n � �� c . � ' c t' " - ' �r.,ti aU'�-� m ' �
� '�p ra' � c q`� G F .'",. X � O O Y � .L. � R � � �� N � > .�.. �F v 4 '
'� -'�' • ca•:: e'c' x o o a a � �'� �,� r p' - ; � E ` ` 1
� ` � -r.w.�:'..y�, e. ,�,c',n K o �-o V ..� x o �, , �-c N+ � m ` \ 1
e ^^ ,c, n � .. m m �s e a'"' ot .. a ' r _ :, n x
� r �,Q y M w Y�.«s .� w.� � ��� � ��» ys x Y c� VK�.� N � � � �
y � _ � ,,, ^. c.�. .., t a � p : � • s ,�c»"� �
�
,^� x. o� L ��. n z"` � K �� o � � .:.c.�� �,°a c.,=c o �� ���„� :" ' c
� G v :F C..�F V R �'"� �^ ��G ��Y C � s � ��, a S � y p `y � r` P c
,r�r �'" �' i. u x ., p c. � � n '= �. " t� v`C�c. �' .K'C "'.C 6> G
i ' ., ,3 y,C.�5"T' « � �� 7i ^'J ;� i+.... * s-' }� � �C
♦ .- y Y` �'�'1�"� ��Y� .l^. Q S' V' � � r.. � Ce 4� y &�.; � if!'C w i �U
.� . � n'Y v `I `��' �� 1t 6 � J N�� �y�W d * ,. S G O .,a
r ..r y`s.Mz.,,.! C � �. u M C ,� O M a�-3 »x F '" y � `
�',', E.�.'- �. i. .,s. °. ^*� w ,c,,"r„ '" � �. ` : .YCC• .
�=r f � c..� y" c *�«� �..: 6,y � q k= �'
�..-V � ,s }'�... -y p �.�'S �.. D t S'�^-
J }i i. .... �r°�, +i�� v �.r.'m 3 \
� �, � L,..� � �.. 4
4' '� ^S t`'. u � !'� 3 �
y � ~ �, �.,e s •
; �, *'- ' , ,
"r. �1
\
�
. ,
.. ^+ `` . `
, '' ' ` . 14 � `E
, � ' \ � �
y � 1 � �
� � � �t � �t �
V , � , ! '� ,1 � �
Z � . �`�� , � � ,' �
� ; �
° " � ' ��'� � ...�--�
� .� �- � � � �
i ` � - • , . � il ; tt ; t �
. � . ^ .� y� ! E '�� .�t k �
�
,�� s . \ 1 , �, ,� � � �
� ' 1
4 ,• t i ` ` ;
1 , , j
. .� , , �' t i � � ;, � � �
� � ' � �' � t � '� �
a \
, � �
.a ,, �
� ��1. ���., � --.\ ` �'\
, 1
�4 ` = �� + �' ��`'. ��' 1 � \
"� �' ` ...-%-'"' � u"-, i � � �
o �.a.4 � � � �...� � �� �
``� \ -�'��1 "''
o� � °�° �� �� ' "��� �� N� �� i ��
,` j �
�� `� � � �'� �� � 1� ��� �,������� � ��� �� ¢�
� � � �, \ "".��" � ` :� � c � � �n °4 �
� 'X�� J C�
� � A � � •� � � �j-,.-`''"r�..--'�'� � � �� �, -o ti � � �1.,-�,'� d d5 , c
d � - � 'Os� t , ..-='r."'�` , 5j "a t ' ,n �} C� � �- � '� d � �W;� �'.,L�
J 9 �"' ; 1�� � � 7�, o ,�'. �r c `C%e. �c .✓ .
n � ''/i � � �` ,' � `�� �V� :� � � S '� .,�„"" 4t
c °`' 0 1 � � n � '" , � a j,`t C"v1 �; ; . � 't ,: ..
� � 1 � \ �� a r t, � '� ���� �� ..� � � � ; � .,.
Cj `?5 ` ''i . N G �a C G,� ,� �G.b � � .� �i �i�,.--^::..�,...-.
z l\ � � ` ° ` �"� � ` °' ,, °�,"�-~,_�-�-`�
�, �, �� a � � �. �
.s. � � � c �'� �, c a. r '\ � � 'S, i
` � � � �� � • �� '�� o �� �� �� � � �
� o }
°" c ` �n � " �' o c r•- i�
� d� ` �' , � � � °- � ,,` -{' � -�c � �n`� �.�-s.,---'� .,
V
° 1 \ 4 � " y �� Q-t�� t s. a�.. ,
� � m , "o : 'v ^ `��` �
� ` C ', i^�., , �--"
` ; ' �
.ti o � o l t
r �'