HomeMy WebLinkAbout0057A 0058A , _. . ... ...... . .._ . .._. . . . . . ._. _. ..... ... . . .... ... .. .. . _
;%ORKERS'CO.MPfNSATION�DECLARl1TION ', . � � . ' <
. . . . . ... _..... . � �" " � �' ' .
insurebor�arc��if toir,of Worke s''Com�pensalionslnsuran�" APPLICATION FOR BUILDI NG��PERMIT
o�a certifr,)d coF��hc�cof(S�r.cx.�BoO,lyb�yf C.� /� �7 COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolityNd.afJ��tR'P4�Y ./`a.a-f.<. l.la,...rl'it
� Cerlified capy ts hr.reby furn�shed. � FOR APP ICANT TO FILL IN BUILD!NG � s �'�. ;
nooaess
� ' Cr'���f�ed copy�s i�led w��h ihe co�nf b�d�ng ins�ec- BUILD:NG�� R S - S p
ti de orimenl. . ADDRESS � /a
�-//�� . /� 1 1 . . � .. . • ""
X,Do1r. /. 1 Applico ` 1 � CI7Y � ZIP 1p('AUTY ' �
� ' ERT ICAIE OF EXEMPTION FROM WORKERS' NO.OF ptDGS. NEnRESi . .. . ... .... ... .. . ._.. ,. .. _. �
�� � COMPENSATION INSURANCE'' � � SIZE OF LOT NOW ON LOT CRO55 57. �
(Thii"sec�ion need not be comple�ed if�ho pr.rmit is for one G � - ��� n55esSCR . - ^
hundred dollors(5100)or Ir.ss.) . . TRACT ���O Bl K �LOT NO. p. MAP BOOK PAGE� PARQL,
O`NNER N'�A'L c�.I C N J7'�/?'f U.5�1 NE �.P / _ � , ' }
I crrtify that in thc performancr,of�hr,work fo�wh�ch this ,,�,p `�,,,� ��
permit is issued,I sholl not employ ony person in any monn�r ADDCF55 �� rs VCF� � ���L . - ' S.FCIAI � � � � � � a
so as to hecome subjr.cf lo Ihe Workeri Compenso��on Laws. ./ ^1 CON�ITIONS 0
. . .�. �. . CITY VW . ZIP �S /! B . ' . " . .. .. . .pC
Date ���' � � �npplicant .. ARCHitECT O I� '_1 n` i[ �1 � O
NOTICE'TO APPLICANT: If, ofler moking Ihis Cenifico�e o� ENGINFFR !� Ipr /�JP N 7����f D�51RiCi G40UP TYPE fiRE FROCESSED BY p..
E.empiion,''you'should 6ecome subject to ihe Workers' 7 y / 1r ��'`ST• Z�'�E , . . V �
Comper.sa!icn previsions c!rh�lebc�Ced�,yov musl ferlh- nDDaE55��7� ')y[/(G �a� y /� W
�) a
ith eomply with sueh provisions or this pr.rmll•sholl be! y
' deemr.d revoked. . . • . � , �pNTRACTO � � � 1?0'�90 $TATISTICAI CLA55'FICATIOY APT. ONDp. Z
LICENSED CONTRACTOR$DECLARATION . � �i�. QnSS NO. ovhu.UNITS
I he�e6y alfirm ihnt I am I�tensed undcr provis�ons af Chap!er 9 ADDaES Z�. ��� ��h.t0.
(commencing wi�h$r.a�on 70(p�of Division 3 of�he�usiness ond _ tiC. .. .__ 5�v+�R�.'aP ,
Aro�r.ssions Codr.,ond my licensc is in iull force ond effett. CiTY�V� u-S • tta55 � AK � " " VAIIDATION �
]� Ra $p.FT. NO.OF NO..OF CHECK
LicentpNumber `_�"`" L�c.C�ois � SIZE �� � SfOR!ES � FANI!UFS �� O!�E � � . ��
� 1I �'^`��/� ^t VALUATION
Conlra[1or\7NI� Ll.�fwTDo1? n � D�SfF:PTICNOFVJORK . .'�. . .... .. �" S � „2SO . . . . .
ADD �
❑I om r.zempl undr.r Sec. �
. . . , t.UER � . ���j,%�1
8.8P.C.for thls reason . pEPa�q .❑ � s � � - ' �
' a�� � +:. . •
EXIST�ING 0 CFf:.OL � C"
-' Sinnnli_�rw� � APf;i�,qNT T �/� �,/7 � e •?'l.b 3
' FRINT o• 0 FINAL �
OWNER�6UILDER DECLARATIO � �� GS � n ' .DATE r�J.:
I hereby affirm that 1 am crempr from the Co rac�or's licensc /��� • + m? !,L`;;`i
!aw for thP following'reason(Seclion 7031.5, Busine.ss and ADDRES� L2' ��n`.+/"LA7� k�u- FINAL �
�Profr.ssions Code):� ' ' " � ' � ' vwtSEtil BY J l.2� "�C;.7� �
❑ BU4D:NG
I, as owner ef Ihe preperty, or my employecs with neo2e5S
wages as the�r sole compensoiion,will do ihe work and , �
Ihe slruclure is nol iNended o�offered(or sole�Seciion ��CALITY ' . '
� 7044,Business and Prafessions Code.). ' " h•.OVtNG ' � � TEL. � � • �
� I,os ownrtr of the piopeny,am ezclusivrly contracting CCN7RACT0¢ NO. �
�wirh licensed conlr�clors to construct thr.proje.ct(Sec- "" qDDREss � ���}�� �
��on 7044,(lusiness nnd P�olessions Codc). �
� � " " CONSTRUCTION IENDING AGENCY REU�iRE�. YARD HWY t�fAi SEIBACK f x� _ . .. . . .., • • • • �
SEl BA�K PHOP.IINE Wi��H
I herrby affirm that there is a conslruttion Ir.nding agency for FUCNI � • •(�N G Q.
�he performance of Ihe werk lor which Ihis��rmil i�issur.d - P.l. � . �- �
(Soc.3097,Civ.C.). s�eE • � +�1;C iJ
o ..... ... .. . ... .. . . . . . P.L.
. ... . _ ... . _. .. . . _
� lender's Name
� 7'63 ae.m��r�� a2� LD!.1A Ref.N G�.L� '-8 7
- lendr,r's l�ddrr.ss P'��FP�S , � ;
I certify that I have read this applimtion and sfaie that fhr. Issunnce.Fee �� '•.rd LDNJ+P/C M � � ��
r obove information is correct.I agrr.r.to comply with all Caunty i��esu�„„on Fee
.'3 ordinonces and S�a1e laws rela7in�lo building tonslruclion, . . . Tobl Fee�� J a - LD:1A Pe�m.Y � � �
ond hereby nuthorize represrtn�a�ives af this County�o entr.�
� up . e obove- .n� e pr, opr.rty for inspecl�pu�
� lti� �
SEE REYERSE FOR EXPLANAiORY IANGUAGE
., � � S�gnawre of A�Kconi o.A�.�t'� Do•e . -_. . . . � . . . - . .
/�
T n= ,., „ vi �. v �,+ ^v .c� C.1 -" x z -r
o c � °c C T � � ° c ° � o � c� �c- `� a �' `' o 0 0
- � T � v � �c � p � ., � rt o• a o
o =� � �v `�° � o ° c D � c "o � �, � = o s m
� � Z x ��c — - ir7 v 7 Vp n � �
�� R O f J � po � � O ?7 (17 C � r' �n D
N
� °a � o � Q '0 1 i o °� ° � � o =� v
_ �re I _ . o N � - a ° • � ? o 'o � �.
o � m Q
�� � _� '� n n o „
> > � Q
v O -
� � �
N
�—, . - . �
.N �\ _ , �
N o '° � Z
N - �
O y
Z
• \ < �. . O . � O
:. o y
a i �
c • y �
� ' c •-
.. z 6 n
. . � ,. o ° �a 2
� ' O ' �
m . `
n ' I .� � v
� � o
N e
� 'A
, o • a e �
� � _ o � - �
�o . � <' 'o
� ae <
a o
a
,�. . ' -
f:" .
. �. " •f'� .
.. ' �� �.
. . /� \
' i' � .+� !,• ' �.
. ' . ' �i .. �.
� � � �. .
.. ' .. �• . . � ' �
' . :�I •% , N
. ':. - . J7
. L ��.. - _- , N
. � �' _ `: '. ' ' O
� .1 . N
. " ' �. ' _ •
.. l_ !� y.. }; .
. � /: _ ' �
' � '" '
�...
, � � C'i [ O 7 �G ^ C� w� C [T £ �� �C��G ��~ ' [ n —
" c � � =`'. '^v�_�] �' Li � " �'F �.a� � 1�y Ca � w " .~. e r_ �
� . � ' ^ N.M� �f .; 3`^• ��; C h � a _ �=ti �c C• �`�a � ,^�� M � �
O ; � � �\ � �� . n � � C � �t C i^�� �t' �
- , j c' z° -o :. `� � ,. � c' ° `^r '=�o`"�.^c E � : o` O
.. ,, �� �..` " n rt C �� = ^,M .in ? C f7 f O '��' � ` -N.�':'C� y f C.i
�. I"`�"i �M � � � � �� Cc ►.�. ; f ..`� ��� " ti., � =!
C C f; J N r +[ +� ;7.N 7 �n '^ 1 ~ p 3
3 n � � a� c : �.° ` ��`a o � = � 'w...•r�i � ,�� �
�� , z • v_ ? `� a . �n� ^ `�c `o'�.a ^ a'� ��,�, c n'b '� �_ ^ e � M T o �
tn � �'h C c ti� � c F}= c : �'� o �� �.:: � �'M C R � `' r. - C
.'� T _ �-' C'� 'v O q ' �C � �`J G y`�'G 3 1� � �"=� , ,'`�G�1 ti M O �..
� '� •�.`� � L•.. � w C� � V 'h�..'L�C ` O
N `e � o . , x :-t% � n v � � c a i � n 3
� � � . o � na� `ti _ `,w .. c� o o r
0 (. �' 'v'� C � r'.e� a.�X �O � ^-C r C� �.• .. � f9,N
� ^ ��n c o r, c`�a .�, c.=^ : n �m -��,c ti ,�,`i ° �: .: � n C
v� .•'.C a'� n ;� � � � `a c i .a�v� �" '�^�i C�`�"' �•t ,1,��; 3 �-
�, O � .a z c-c� o :. °'z i -, M�n�� � M s � h ���_ =� a f^,
� ♦` ' �n .. � ^ C r O� C. .�. ^ " :�4' r' �.
-+ � `E c.'" 3 ��. +? �£. � C� 'a' � " � o >
. . N �� ..n " ,�, „ �.C+\�`� o =3 c�� ��.� '� � _ � o a .T.
�_ • i �'' -� �' ���- r, cr i �•,�,.� `� a o a•� 4� � C.� �•�" �c > >
�' •:�k. �,' .� ;��SN ' � � ��� ~ ��o:� � ���'�.' n �z � � n T
� F �`
• ` 'w. ..e��ti n� < �.����� �'..`� �; ��� .�`� c a Q, � M c � c in� C
� �« � r � �F C � M p +.} C C� � n (�1
. �J .. �.`C '\ \�. ~ N �C^M'N�G K 1.� C` ~ �` ��� n �
� n ��C~ 1 n n C C' r-L = � n.n � � �O �.�f �+ �� n �4 ' 7
. �`; c � o .. � �,n`� c^ �-N C z ..1 n `�. :�C. = � O�
- O� ` w � � � � � � r' � � v C� v�� o' ` ' ��
� � . `^ �; n O \�3 ���C C�'S^ O7 £ `c.P•C'� n C � ^ �^ v`O".
• - . . �„ . C'^ M'" i �: n�7 Z a � a T �4: n M � w in �: �