HomeMy WebLinkAbout1719A WORKERS'COMPENSATION DEGLARATION � I p�U�pU � /✓I Ucl� G! `'1% G� �
6 �
I hereby affirm thot I have o certificote of�o�,e��,o=a�F �� APPLICATION �FOR -BUILDING PERMIT ��� �
insure,or a certificaie of Workers'Compensolion Insurance, . ' � �
or a cenified copy ihereof(Sec.3800,Lab.C.) '"" i
NT �F LOS GELES �� BUILDING AND SAFETY
P❑ollcyNo. Company FR�hr�' S SOl C' — • 'i
Cartified co is hereb forniihed. BUILDING
Pv r FOR APPLICANT TO FILL IN ADDRE55 � - �.
� Certified mpy is filed with the counly building inspec- � BUUD�NG 1 ,A �f �/- r1
lion deportment. . ADORE55/C�IQA� /�y` �c �y�� �Q ip�,q�ITY �
a p2 NEAREST
Date `��'a J Applicanl CITV zlp CROSSST. ' �7 ,
CERTIFICATE OF ExEMPTION OM WORKER$' � NO.OF BlDGS. n55E5sOR ,
COMPENSATION INS RANCE 512E OF lOT NOW ON LOT MAP BOOK PAGE VARCEL
(This section need not be completed if the permit is(or one - TRA�� lOi NO. l U/SE]ZO � OP D C� � i
hundred dollars($100)or less.) `� �
TEL. /�� JU. SPECIAI UQ }
1 tertify thot in the periormance of Ihe work for which ihis OWNER re le N DSoa � / CONDI710NS d
permit is issued,I shall not employ any person in any manner � . DISiRICT GROUP TYPE FIRE �D 0
So OS 10 beC� �me subjecf to ihe Worker'CampQnsa�s. ADDRf55 � �CONS 10� ��
�� � �
Date 8 Applicont �� CITY Z�P STATIS71CAl QASSIFICATION APT. CONDO.
NOTICE TO APPIICANi: It, af�er aking this Cerlificata of ARCHITECTOR TEL. �/� U
ExemptiOn, you should 6ecome 5ubjeCt fo IFIe N/orkers' ENGiNEER NO. � CW5$NO.�:�2.��WEIL.UNIT$_ W
C
Compensation provisions of Ihe Labor Code,you must farth- qDORE55 SE�NER MAP �
with comply wiih such provisions or this permit sholl ba j TE� �
deemed revoked. fONtenCrOrt L /N� NO. 3 BK. FG, -VALIDATIOH I
IICENSED CONTRACTOR$DECIARATION ii�.
I here6y affirm ihal I am licensed under provisions of Chapier 9 aooae55 3a � f� �. NO d - VALUATION
(tommencing wilh Section 7000)of Divisio�3 of ihe Business ond � ���' ROn, O�
Professions Coda,ond my license is in full force and effect. Citv �( Ke wa�d Cin55 C S $ v ►
SQ.FT. NO.OF - NO.OF CHECK�
License Number 3 3 y YQ lit.CIa55�^a 9 SIZE STORIES FAMILIES ONE
f�n ,J y� DESCRIGTIONOF WORK a, D� NEW s
Contractor VM�L���7 Date-q � 8�
❑I am exempt under Sec.
�e IAII,�✓ V �� ADD._ � �� l�.n{i
ALTER � FINAL� 'y " s . e e � i
B.SP.C.for ihis reason � � REPAIR � DATE --77 3 ++` I
Dole: u5E OF DEMOI BINAI I e `�,'S ',
E%iSTING BIOG. ❑ �/�sJ��/ �
APPIICANT TEL. Y ll ir�—
Si�nolure PRINT NO. ' ' ` � ''`�
CijIVNER-BUILDER DECLARATION ���� �
I hereby affirm rhal I am exempt from tha Contmcror's License • , �:`•-:_-r- �
Low for the following reason(Section 7031.5,Business and ADDRE55 u ^ �� �.� ,
Professions Code): ',
aBWLDING . �,
I, as owner of Ihe property, or my employees with ADPRE55
wages as their sole compensation,will do the work and ip�q��iv
ihe structure Is not ininnded or of(ered ior sale(Suction �
7044,Business nnd Professions Code�. MOVING TEL. , ,
� I,os ownor of the property,am exclusively confracting CONTRACTOR NO. . ' �
with licensed contractors to tanstruct ihe project(Sec- aDDkESS
lion 7044,Business and Prafessions Code).
REQUIRED TOTAL SETBACK FROM E%157.� '
CONSTRUCTION LENDING AGENCY SEi enCc YARD HVJY PROP.IINE wioiH
I hereby affirm that there is a construction lending ogency(or � ppONi - � ,
ihe performanca of the work for which Ihis permit is issued v.l
_ �Sec.3097,Civ.C.). i SI�E
P.L.
Lender's Nome I
$ P.C.Fee S Permi�Fee
Lender's Address ' /
� I tertify that I have read Ihis opplicalion and state�hat the '� iss�on<a Feo ! D�
Aobova iniormotion is correct.I ogree to comply with all County � Inves�iga�ion Fee ��� ��
g ordinences and Staie laws re�ating to 6uilding convmciian, I � Total Fee �
CS and hereby aulhorize repr entatives of this County to enter
� opon he a ve- nt roperly for inspaclion purposes. � � � ��-- � � �� , I
a � �3' SEEREYERSEFOREXPLANATORYLANGUAGE
�� Signawre ol Applimnl or Agent Do�e ' . .. . � . . � mi
i
... . _. . .. , �. � ��
�N V'� �+ [ [ V-� ^�„C`�'y-` L'E�' 'h``'tS-C �` C �\' O C'`_`� ' ` ' _ '- .
,O(7 �•C�� ��7�M i.h•V C ; C^ t�.•�C`F'� C 4 �`� C��+ ~ C' O . '
U 0 .�.. a � y�.`^.�H M C h C� `C '._a. q„ . C O v C �' n ... . . �'
�� � � 5 � � � �
o .: c�.c h`1` �.��'.-� o %v'r��-e, :i,•`� C >.��x �.�, i: U , . ,. , r
tr � �n .. : %: � G -, o .�d
rG.'U C: " y" ,.�„�� C �G' � r a e� �� C ,.i �����t'� � � 4L' i =' � a' . � � - .
�� V C k ��V G..� C,..� E .- �^ �: C .�,.+. y ��-�' d � �'_� Y �` �':. . ,
�.-.= . l i._t�.,y.: Lt C � t. C Y: n �� t� �r L .. � L S\�; � ' • - . "
� � c ° 4 r „4 +,,. � r�'� r-p o��c,�"�-'!- +,i x -n �,i � • !- •
" p � c ` A ec ti c�=�" c yi �� @_.,, c..i� �� _ �� �ti :,, � �� ' �^ . .
. �„ ` �C `. � � c t `��+ti. p ': i,SJ,�:�- c•_ , r F - '�: �-�c Y- �:� - . • .
r. � . �' � c •�ti_ `.•., r � U
. ' (i (_ � �11 1` i � �- c ',-•r i e'� .e �i c •c,�J r... i:. , • . , . �
l r �� � ` �„G1 ` � ` � 6 _ . � �. : b .. � �-�.�, :,,, ' �I � tn
� � : :" 'L " c c.'�+, c.' ' c ci .� s. ` � r :. . . � ��.F. - � ii ^� i' , I�!
� ° � " =�� r,``� � ° � ' c �•e: � c c ` :..'.:� '' i C� I,
, G E w � ` ~ " r ' ` ~ =~ G �i,� �'� c^':.'� � _ c i�`'i;'i: �,�- �� -�I i. � . .
G �� ,.J rc1 ti� ;. �. J F � � S:�i�.. l'.'� , G :.:��c '. L Z; �� 1 ' j
O t`� � �� Z K �``..� — (i :` C 1:.1�� • � .. 'L r :. � y . C „t I .
. .�.. U� �` � � � .. w C�Y..� - ` t' c":i- w ;, � ,- _ C �. ` _ ^ ] . ..
,_ _ . � r-,-e;,�'``1 - � � u a• . . ,�. - � ' • `� c °,� r N c 4 ':J' I
— � „t•.. � ,c o:� �. �
�• � G �' � C�Y,"` �.1' � �: U �;+� r' c. • � � C '- y c � .E - � .
•°' �-� - �-,��'. " ., ,. C � • _ �: j I.. ..
f.`� cY.� `� C r�~ ' ^ ^ 3 � v�C' .e: c` c� � � �. 5 �: �x 1� . I
� .:, � � � c,�� ., o c Z, c ` ,° - ;�' � ° c' :' �•��=• � •� " .
c ' � �. _' �.� � e � � � _. e ri_ �� • ._
� C. n_' �J a ` w`�n'�•C •`. L�� U ' j`Y.� ^ _ ` t,� C C �='� .v. r. .G
.,-� = '^-w� `_ — o ��� i.� ` �� i — f• o'� � � �— I rp._
Gb W '��� �.- -� �� �,,� � U -- .: �. a . I
C7 c r••� 1'•�`-� y c1. � v�• Q• —,••'= 7 •: i, p � •� ` :'� ^k: c '.'. r ' o _
� •C 1• v ti r�_'�� ` c `_ O G: ,j.• � i. C •�. •~• � t C1 �� �•� C'� u . �� f� _
. . � ��' l 1 Y'.0 C [. . .^'�,� �C G � K."O ' i. . y O . '.�
• �".r � C y. ..V b .. C. 3- C L:�: �y'.� � I� �T�i C��% �� , �
. ` ' ' s . ', . , . ' . . '�� . _ , ; � � �.
, - . .. , w. � .. , _ . . � . . • I
. /
I �
. "� �
' J. ' � ' �
, , „
..- i :. '-., � `� �,� ;�..
� `� � ti j: � �" %" �` - �
O '"�� ' _ , , ;
a j� . �� '^ ��. . . ,
� . . l.� �l � � . .
w ,
a } _- r-' • ,,, .
Z �t '`�
_ �.
- i '"i
- ' ��� �
. . J ,
.�� � � .`, ;r! , . .
• .
� . �1
_ � «-, •� _i ' . . ; '
".' r
�� �
�;. � ,
/ '�.
� 1.
O > O. I `
� �
a e ` I ,, , �
a � o
• a
� � a J m
, �a � N
C �
_ � p , . `_ `
.o
. � `u
0
� � O a �
a C Q � � �
V � _ � Z
, � o� � '� � �
K « I
� �
� � �° ! *y`
r � � y.
�� � I - � � 1`
. � , �. I � ° j
� o
� C
4 I . i � �
,� �
_ c 3 —
. F �. �'�� s ��
—,. _ - .-. �
u, � � � � .� .o _ a�i, o� ., I v .,� o I�
p `+ o E c ' a — �
, r_ " i .c i� E a � d, o � > ' r ° - o � �
I L' �. (1 C: G O [^, o � � o C O
C �G. U � o �U c L U [_ I a7 � 3 o a� �a u.
. � V o a c,� �'-' � �.. c.x �.� ic Z'� c
' � U L p � o — � O u O � < O O ' � >- O C W p u � G
� H 'u C �� 1] C% \_ �• `
p ; p _ ; � � u p U .D � L 0 �C �N O Q d L L 7 O 4:
1�. L ! = lL U� � d.LL'... In� � G. �� tL V7 lL W � � S U LL W