Loading...
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--- —__