Loading...
HomeMy WebLinkAbout0407A 0447A (6) VJORKERS'COMPENSATION DECLARATION . i � - . � . ' . . ._ . � insureborafc�eHiftatelofWorkerseCompen�i�°���°o�°eso': - � APPLICATIQN�� FOR BUILDING PERMIT , b�er�ified copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. - Company� - � Cerlified co is hereb furnished. BUtL�iNG ❑ pY Y ' FOR APPLICANT TO FILL IN AD�RE55 l�I� ��G �s � Cerlified copy is filed with the county buVlding inspec- BUILDING /j /� �� � � tion�deporlmenl. ADDRE55 � LOCALITY/cY��rNMa.�� �7-CLj/� � � - � � � � NEAREST JA� _ �/ Daie - �Applitan�� � - Crt�� fa�j��fL. Ziv - CROSSST. iClii-r� '�•— � � �CERiIF1CATE OF EXEMPTION FROM WORKERS' y � ! NO.OF BlDGS. ASSESSOR • . "� � - �COMPENSATION INSl1RANCE - . 512E OF l0T G„ � , NOW ON lOT MAP 800K PAGE PARCEL ��(This sec�ion�need not be completed if�he permit is for one - � Q`1�.1 u5E zONE MnP �3�/,r hundred dollors(E100)or less.) �. . -� TRACT BIOGK LOT NO�—i �i NO. �.J , } � TEI. ��3 ' SPECIAL - y OWNER � NO. � CONDITIONS 'I terlify ihat in the pe�formance o(1he work for which Ihis � � pelmii i5 i55ued,I shall nol employ any person in any monner � .�,n oi51RiCT GROUP TYPE FIkE PROCESSED BY �J 'so as fo become sub'ect to Ihe Workeri Co AD�RE55� � �t�c CONST. ZONE � mpensation laws. !Q O �7 ��,.1� < Date ` Appli[anl CITY �• Q+�+]V Z�P STqT15TICALCV.551F1 ION APT, CONDO. U ARCHITECT OR � �� TEL. �NOTICE O APPIICANT: IF, afrer making this Certificaie of�' �-� � n � w Exemption, yov should become sobject to the-Work rs' ENGMEER NO. C1A55 NO. DWELL UNiTS y Compensation provisions of the labor Cade,you must forth- � � � � wilh Comply w�lh suCh provisions or ihis permif sholl be AD�RE55 SEWtIt MAP _ f'� TEL. deemed revoked. - � � � � - ��� COMRACTOR K-S ' NO." � � BK. PG, � VALIDAT�ON- �� LICENSED CONTRACTORS DECLARATION� - LiC. ^� � . . . . 1 hereby olfirm�hol I am licensed under provisions of Chop�er 9 .... ADDRESS ��Z('� N� NO.Z 6�Q�i VALUATION � (commencing with Seclion 7000)oi Division 3 of Ihe Business ond � ��� /�O . Proiession4 Code,and my license is in full force ond effecl. ❑TY CtA55 S � �0 4 0;.7 A � . .. SQ.FT. NO.OF NO.OF CHECK ' ' - � License Number�Z�O Z Lic,Class � � 5¢E STORIES FnMiUES ONE . . . �p . � ''(��� 5. . �,�.�.• .2.� Conlroclor��Y�S � Date � DESCRIPTION OF WORK�'�R� �� N� , , ❑ � . . � ADD - I.�.���-R.LL� I am exempt from the licensing requirements os I�om o �'R �L� licensed architect or a regisiered professional engineer _ _, _. . . . . .. a.LTER_ � FINAI .� �',�� �(i Q� . oding in my professional copacity (Sec�ion 7051, .� REPAIR � �ATE / �� p� � � B�siness ond Professions Cade. � ) USE OF � I Q 2 a, B�� -7Q,� EXISTING BLDG. . -� OEMOL FINAL Lic.or Reg.Na. `� wZ_Dote APPLICANT ' TEt. p 6 - � � � ��- �-OWNER-BUILDERDECLARAitON � '� �� � PRWT) �-'n10. �7�9-I � . � I hereby affirm Ihat I am exempt from the Contwctor's License �` A't�n-, d , . �. Law for Ihe following reoson(Section 7031.5,Business and� - AooRE55 �[J��I�F�'T�e�y.Ca _ � Professions Cade): � . F�ESEtii � � _ a - �. . .. BLIILOING . . . . . . ' . I, as owner of Ihe properry, or my employees with qooRESS wages as their sole tompensotion,will do the work and � � . � the struc�ure is no�intended or o(fered for sole�SeUion �aA��TY � : � - 7044,Business and Professions Code). MOVING TEI. ' � I,as owner of the property,am ezdusively tontraUing � CONiRaCtOR NO. . - � � . � with licensed contrac�ars to construcf the projecf(Sec- qoDQE55 - � -... tion 70d4,.Business and Vrofessions Coda). - ' � - �� � " REOUIRED TOTAL SETBACK FROM EXIST. ' � CONSTRUCTION LENDING AGENCY SET BAIX �AR� HVJY PROP.linlE WI�TH � � � � I hereby affirm that Ihere is a mnslructian lending agency for fRONi � - � � � � ' the performonte of the work far whith this permil is issued P.l. � $'0 4��4.7 A � (Sec.3097,Civ.C.).. . . . . SiDE . . _ . . . . . _ - � . . . . . � -- . . . v.i. Lender'sName ' �•� ���'� �'� lender's Address v.c cee s . �� Permir Fee �.3 � 1•• •3 1.5 p I certify thot I hove read�his applimtion and s�a�e thal the � issuance Fea Q� v� - . •�• �J�,Jr Q� above iniormation is conect.I agree to tomply with all Coon�y_ in�esrqm�on fea � � � / . - - � � - - -�ordinances ond S�ate laws relating lo building construt�ion, To�al Fee ��'`�� '� Q J 0;$;� ond hereby outhorize represeNolives of Ihis Counly to enter �-"upon�he obo�je•mentioned property(or inspec.tion purposes. - � � � - � _ � � O� 'C�'J$ � � � SEE REVERSE FOR E%PLANATORY IANGUAGE - � � Signoture of Applicoi or Agen�� fDaia _ . . . , . � ?� , i T = ` .. . O C . i �� r V� =n m A � m �. �n f!i T N O O., O �� f� 0. � O N O � . m�r, n S p o 7 p p � m n ,ic., p. 7 � r�i m p �- O S � ' . . � a O � 7 m � � 7 Cr Q, , o.. p:: ,'��'� 'm,� cZ � '�o Q n '� S _. � H � �� � a o op D �a - � . p 'n' o � m T o � .^..�c m y v �c x-3 � q' 3 N a� a. o ? � x � �- �c c� o f > > �'� t o o °� :o o ° � o o � o_., 0 3 .. ., p c a o � e� . �-, ,o � � m o. � � r o- ° g � '� « 0 � �_ . �.� �; 0 0. I. M , ��� �� � . . .. a� • � � ' � . - I � � -o m r 0. � I 7 {Z/f � ],.' _ �1 O � .� � o p. A , � w �. 70 -�c G � + � �• • C . i ' 2 a ' � ° r o Q a � « � v ' � a L9 o � ' . a '° a w y' r o o v a a o < e C , �y D m _ O. d O . 1a _ ' r j �y i, , � � ' . � : � A �-+' L . t, . � �`; `i �� �� *� �, o ; ^.. `i -.r •i� l; •• i O i�, _ i `� � � l N ; � �' :.} . �� �(+`, �,f r ��. ' Q , � •.� t• j. .?' � '� . 1 �' r ': i . . ,e Y, .j t � j�� "' ' I " �''� -1� . � � `�� . r� J _ 1 • • _ _ � ��1 _ y y � . �� � • � � '�., � i , cr�e a-'r ^ °r�'�'s f A � a-o o'o ����c c ^ � - 'r c r`�"7' . ...�.� e o '� i�� m � 4 w A,�a � `c x,� � o i! . . - � Q ���ti.:'eA�II �iOp�� � eQti'�.��';' c� ���A �.�� �'�6 � Nqm � u• '0 h � �i. R' O Q ` �b O w,c '" �t b.A'`� p M. b ry•A p Cf O : 0� � �i n L�. .`t it � n O _' ]� �'�- r'< ' � • 7 G h Q �'a �..^ _� �. � C�O.N v' C N � ei iS �..�r A �+ .Y � p � ' - � N T' � e� 2 C A O �w� ` �. 't} Q o � =.5•. .� o ��,� �N e,F� x q T� x ����'a N ry � f �z `' � , ' N V h- S x m o o -�e � o '" � w�„N�•f °v,'o C- ti '�,o� � � 0 3 M N ��, . m :;p ° r°, a a,W a ab x� E A'��� � � o p s �'�•q.�"0.,~ n"� C��'J � aa � o ":�•�'vexo so� � � -v N o � a A$ o.�,".�.� � �o ` �^� ? ^.o' � ''�° �y o fi.M C.� o °� �a .. � ov - 0 7 —t•• N � �t�+� � a o p m ^�,° z''e`r a n � Q� � p �`r b �"���'b y n o 3 d � m �$ o�.a o�^ e � s�� 8 o p 0.7 0 �k o'��`'� �.'�+ �0.f x 7� m ,�.� m N.'�•Q_�-°o �BbA� ox �� °.m tOn^�' � �~ � ~ ° a � 3 �: • O �. `o o.n o_`� �� � � A.� °o �� o�ttt`�° �".�. v C) 7� .`t A �n� � G Z K -O G .�..' T'� rn ' �p,�� o�c � � A o b � o L�.,m� �" tt V F n b �.:���-�i`� o � �'�;. � 2 ° � � co� o e� ~ eN~'� m .�.o ti �``o- �yo � •r ° 9 p ; � M_v� q,= 3 e-...���:�� n�� �' � rn� H 3 � p p ��e o 3 7.7 ,� „ c a a c .� ., o o —3 s�.Q A M �-•, a•o � q i.+ . �4';� e n x . -.`���•-Ai c�II��e'� � �"`� A.b .�. A'a 3 p'9v_ � y S�,.� . �n Q o • y n : c1.'1 w A F,Ia,?i^ � m �,�...c a n � � � o � ' �.•��`n m �, . � � ° R'e�ia�L,R �;�"� A c a R.ax�" F�'.° :' � m f1�7, m ao w �'tr � � ��o� �r q ° o M ti v� ��O�°�.N o C� � ? � - :fl s�..� �m n � o L-c .�i �,�N:�.�.o �"p w p 5° c e� �`a `o � a� `� . � � n � M c� � � � � A 3 A L`�.� � a fl � O e:'�n's F � o M ,� ��" N o � � p N a � �7-� ` O�C�� � � �„ � C'.�.a � � T C-n L'�'� ° � � A���^, � �W v'a S ::'e a � N � �0 �n n