HomeMy WebLinkAbout0298A 5764B 0299 ,, » WORKERS'COMPENSATION DECLARATION /,J)J, �j (jV �`�`i��S ,
>
� I hereby affirm that i have a certifiwte nf consen�to saif APPLIC�.T,I FQR BUILDING PERMIT
insure,or a tertificate of Workers'Compenwtion Insurance, Q�_
or a cerrified copy rheroof�Sec.3800,tab.C.) _ S'„OUNiY Of LOS ANGELES BUILDING AND SAFETY �
Policy Na. Gompany
� Certified copy is hereby furnished. BunD�NG h `
FOR,APP ICANT FILL I A�R l�
Cerlified capy ie filed with fha tounly 6uilding insper BUILDING
tion eport ent.� aooRE
"rDale � PPlican� Clir ,- P.� t ' . , IOCAl1TY
�TIFICA E OF�xEMPT10N FROM WORKERS' ��OF 61OG5_ _A� NEARESl •
COMPfNSAT�ON INSURANCE SIZE OF t0T NOW ON lOT V CRO55 ST.
(Thic saction na�d nol be compleled iE Ihe permit is for one TRAQ BIOCK � LO7 NO. S� �E
� hundred doilars($100)or less.) �� hWP BOOK PAGE PARCEI
- - � ' TEt. USE ZONE � MAP
1 cert'rfy that in the performpnce of the work for which this OWNER NO, � � 3 �
! permit is iesued,I stwll nm employ any parson in ony monner - �[�� �/ yEqq� �
so as fo betome Subjecl b fhe Workers'Compensation taws. NDORE55 �� �/C�/ ���/ ���T�� (� �� � ,
� •' Applicant C�Tv � }� �i�i z�P�
� U '
ARCMIIECL lEl:.1 � �
JICi i0 AP�LICANT: If, ofler making�thie Certificate of �-P� �I� I TRIR GROUP tYPE FIRE SSEDBY O �
'� ENGINEER �/
nplion, you should batome su6jed to Ihe�Worker� /) � "/✓ CONS N� ZONE � F-
.npemation p�ovisioro of the Labor Coda,You must forth- ADDRE55 . - Q/{/ � /tl � / � Q'2 ��( � W
�, with comply wilh such provisions or thia permit shalt be 1f �
daemed revoked. CON7RACfOR(/ .- . Nl. _ -- STATISfICAI CVSSIFIGF,TION qpT. Cqdpp. z
� LICENSfU CONiRnCTORS UEUARATION — - aass rro.�L.DWELL.UNITS
� 1 hereby affirm tFwt l am licensed under proYisions of Chapter 9 AobRE55. '��S�QA- �� pp.
't (commencing with Section 70WJ of Division 3 of the Busineaa and .. � � �K . SEWER AAAP
k Profassions code,ond my IiCenSB is in full fortB ond eff9c1. CITV~ • �� �� .
� r SQ. NO.OF'. .�f N0.OF ... . CHECK, 8N. PG. YALIDATION
j License Number--�Ca Class� SIZE �STORIES�. 7^. FAMILI . ONE
� •�. _ YALUATION #:Q 2�i��3
. Conlroclo � �w te DESCRIFTION Of WORK �W'-� •
i ❑I am eKempt�nder Sea ,__-��' � � • �.• � s � ��L Q 7 Q 2 5
� AL7ER . �,( �/
� 8.&P.C.fa this�eoson r , REPaIR f s/� 7'�Q� � •F V%�"�-r'`-x
oo� F%59TNG BLDG. DEMOL p 0 2 3 0—8 7 1
, Sianafure APVLiCANT . y�'r TEL FiIiAL
OWNER-BUILDER DECIARATION PR��`�T Iy N�NO. - p
I heraby affirm tFwf I am exampt from the Contractor i License �* �j�} ,/� / DATE ��"/���9
�� Eaw!or Ihe following reaaon(Sstlion 7031.5,Bucineu ond ADORE55 �IJ ��^^���/�� l Ip��� fl�lAJi", �-�y 'F,/1=�
��Fessions Code): �i�� _ _ _ , . ' q � �f �• .
�,;' � �� '- as owner of fhe property, or my employees with AD�RFSS , ` '-"
T vi�gay as�hei�sole compensation,wiil do the wprt and ��D�
� the structure is not intended or offered for sale(Section ��+��n' � . � G�'� ..:��
7W4,Busineu and Profeuiona Code). MpVING TEL. ,
� � 1,os owner of the property,om exclusively conhacting CONTRACTOR NO. `�� „:,,. .:
with Ilcensed contratlorl to conatruct iha'project(Seo- qODRE55 I ��� � ��� ;—•''1
tion 7044,Business ond Professions Cods. � � �
E UIREO TO AL BA K l
CONSTRUCTION IENDING AGENCY SET BACK YARD MWY pqpp,��NE WIDTN I
1 hereby affirm Ihat Ihere is a construclion iending ogency for fRONi 7�s0�8 7
1he perfwmanee oF the work for whith thia psrmie is�iaued -- -p,l. � � .,6��,�.p�p
(56C.3097,Civ.G.)• SIDE � ��� ri V H a!U W i
P.�. . D�99
lender's Name
.J D_ IDMA Ref.k
Lander's Addrau P.C:Fe�f . Permlt Fee��-/ � ,Z' �
1 certify tba�1 Fwve read this applim�ion ond sta�e dw�the - /� Iseuance Fee }' �..� LDMA P/C N � �aQd� �_
o6ove informofion is correct.1 oyree to comply with oll County investiqatio Fee /
ordinances and Stats bws ralaling to 6uilding conslN[tion, s,�+-'^' �`Q L�I ,�.�� IDMq parm.M
and he�eby authorize represen�ulives of this County fo eNer - Total Fee ��
upon 9 obovs-mrntarwd prqperty fw iospection aoa. -.' - -- - � - . . . . , �`�O^
� ..J__ -- -- -- - � a/ .
�iC.x�J SFE REVERSE iOR FXPUNATQRY LANfAIAGE.�'�J_ _ __. .. .
. . . .._ _: _.. _.._.. .. .__ _ .. _.. _,
Siqnrnun of Applimm w Aqel ' __._... . ., . _ . . .. .. .. _ . �
�
. - s ``~ .
- L' . �„ � ^ Va =�s � � ;� .
� r �r "'ro w`^ ° ✓, :. � : � o � .
C S ' 6 X- � " v G ` - � `"i
�r F � �..� � � 3�,� � �'�,„e " c - � " � -= .. cl � \
�� �"f ✓ �v. �= J Y •� , M' n ` � � � y = � 4 ` •�
� o � + :, .T"^= ;y a�� "' r � : `° � w'z � c ° � ��•� 08 a � Fi
� ' '' � �.,�; r ,�i-k� , ^- � a..' � Y co
= .�!._. i. a= „ .. r�. � a "s a�=v„���� � m u� 3 �
n '� ' "`- v�-� � � � e �- ti a-c j � � t S ^`� � r
I. C! c; x "�� �t c � F �� a, c "C° .�`. � ��� .„�t c� �~ ` ^ �' O W � ,.�
C ✓s. � _ _ .. x ;� ; i c� `• `�t
�e _ � T� o r � :, s =�.� �; � � 'V
� �- = � �- ^s^ �� _ :�?^a� ,a E ^a i � Z t ^ �Y' �
"�� Y t.- � � �-. L y � -p J c..� ^ � � � o c v ..� yV yi � x a� y
� �' � � � G` � Z�`F �'C �t� �ZS�VOF'E NOF'� Y� � � � t�., e
- ` r� lc��wt ;�� a °e � � ry .-�c, ��'+'. ^ v. y�:�'�. . v> V ��� 6.
.% rn a; �= ... c. ���• y G c Q.,s �„� w'� F c a o � «� `y. � � J ,
� - _ .. • - � W v r � .� c : � ^=, w.-G, a'v�:A,s. � ss 'o v� 1 e.l 1.° �1 �
,. 3 ,� � ^� z � � ° ^�., amdv �.� _ L,y vo � y � .. c 2 j e". v
'y; ' O � � " i; G�� " � � � y G� � �s C C,� C � s �C. �: � � � � } , "-�l (�..
' � " L a ` � ^. O ., a 1 1
,, c „ r �`<x'�. c c�, fi `� � ��� ~ � ° ' g � �m ° �e x r'' o. E �J � i
.... "" C ;,.c � :. st¢ �' ° � ; ;�. � cro " _� i n o � - ^ � m , 4 �" v , �]�,-s.,
c� s _ v � �
~' � r. � ; y C o. i' � Q:G O �'�i _ i .9^= '�'^, 3 c "'"� cy: .. C � � "3 f ;1�
� - -=�= � �-� .�.�r � a � .n N � r s� �y�, � O d �' � � '^ � � � �t ...
x � ^ : w-~ �s "-�..,��c M ti-� 3 ` C' j .� y � C^�' _ M 1 � C � � (�t ' \
�'� i .. z �` �... O i �� _ � C_ � D � ti. , _ � .,�,y ,.J
• ^ � � � ~ � �
I -i. ,� } r .`. � M ^« � '�3` D j N i �~ pi l a` � t'�. _:F �.C� ` .,^ M � � �
j G � � �` 3 '.�.� J��' � O J ua ^ 1 � � � `1 Zi ' R'y.l'-y' T .J O •
^� 3 3 y.r� = A ��. N � � 3 w d y,ti f.'„l . a�'Q .0. /: � C7 �
.J � .. �v� C-„J C-r Q1 �`r.� � n S 3 4 . _. C O'w 2 L" Q
C C) � �3+^• �=3� �� � _ a 6> .'!.3 l� �,� �,-C� ` h ~� _) \
a y � 1_ � t7 �V � 4 � '�` ~ � `C � � �
"� V -� 4�'`� L�u Li 5 a �'
� w. �- � �
a , � �
a �i �
S � o � ,�� �4[[
� V �P 1 � �
' V i ��'_` ~ � � � J �
:• � � i��( TI C, .. .. 1.. � . � y
r � '�r . V ;, y� � � 0
ieN's ' � �� � �
�y � I'^+ , Y.
+. � �, � L. ,�' � ',� � � �? �� ' T `` , ,,' M '.-,
� ',� ti.:� .�; �' ` `� v . � ��"�.,:� `� � b
"� ` � �' �' •'�- ,�� . � t •�• �E. �` �R' +s ca
l' ' ` �� •-� �- � v i° � N �S
�.� Vr1- t
�.-�� � �_ ,��,�.. � �" � �,r.. ��G%�0 ;'" �+ `�`• ^� q � �t � �� � �
Y 1'1 "" / �.• : � " L- ��� �: q :wr' _ � � �`� �. M � r.
p � ,�,W� 9 y -� f_ �, W � ��, .<J 1 �, � � � " � M'°( N �
� �� NC` , �.� �r +„ 1T� � ' � Q., v � I� � ti � U.. i�p � �j 1 `-
v, � Q . i:� U1 . I . '1A� �b ''C � .\ ,� ;; �y ��' v
oc .� . �� �i ��..� �.,_ •`- �1'-�` �'�:i � � .� -�p _, `9
O �� �` '� - .�j �y.� , �' ... � � t� � � s � � S Y S� �
a �: � � �' `^ f� �•' "?��'� • ' `t �: a�11 `�' 1 j �1 ` � � � �,•M �0 �I
� � � t ' �, .
v+ � ;'- � O ��. � N � h � �
2 � ,� }� � v , f- ':s .� ' 2�e � Z, � � � � � � O„L h � p, a- �
��1 �L �` .� �d � � `` �e�y' n ��� � �� �-S � i � 1 L u �' 'j
`Tl � � �' � �c s�_ .��' �. � ��. �.` .� �, � c�3 ��j.',� �` { �i ', � '�� �y�, F� p ' �
'�,� ; � � t .�•� y,.. � �' 7�;. • y i � � �' .o�. �•-
l� l� � � � . F .(,� � � bw L � tJ � �� �� „_ � �� E 3 �
�� V��4� 1 ��� � '; 'n �.i � �� � ��•� ^ .. �
�` � ," `S 1�' � G
. � � � ` v .;�.. , � � i � ,s
� m � I r t �
D �
a o � I �
m I y� . .; m � � � �• 1
p � s o ` Sn � i �1�, �1 : � , , �
� � Q f •ff ~ 1' 1 � �
Q , �Q � .fi`=� . � � � _ ± � ; 1i �
a a ' °' , �� �� � �
� 0 + i
`� � 1 ' 1 �,;., � I 1' \`� ` � va E
..� 4 � � 1 E .S }
azc c ��� I''' m Z � " ' �'4 �I�j,,`�. ' c�l v'� ^7 aJ �, vy � "7 4
v � � � 'a � � � m .I � s�� �.� "° �� � ` ��J � ��
� ' o ` � a' • a 'i �� "� � � '" t
a � � ` � p �� 1 � { 1 1
>
0 Zr ' Ii � � ' I ' 1 � - .� �'R
� i ' � � � � � � ' � c � � �`
� 1 � ¢
� ;' ' a c3 ' � � � ��� � � � � c F a � � ��
a Vt o � � i ',1 o ° � ° c m �� � C` :
I � M W ,,, � I � 0. v O l 7 ` � ob G � � C y,�.'. X' Z - O �(( T�
O ` O O � N 4 � � .'� c' � l a �x �' 1 � y �, n c w j � ° a "�{ �
c c`;
0 � `s w a E � c 4 �u 'c !_ c i Q 1�° � i i E w s = i �^•�`a� ..:µ. L_--�
c, �� � a � � � o,-� � { o � o_ Z
� 1 a � � a � •� � l s,a �o � ;, � � �__ 1�`c�n ,° i .n i�;_4_"'_—
+ ' _ C a. � � �LL � _ � �..- �"�
, - � � 3 "' �' _ --'1---"'
o �
� z 1_-a--- —__