HomeMy WebLinkAbout1248A WORKERS'COMPENSATION DECLARATION . �
I hereby offirm�hot I have a�e«,,;�o,e of Cpnsent to Se�F APPLICATION FOR BUILDING PERMIT
insure,or a cerlificare of Workers'Compenstion Insurance,or
a certified topy ihe�eof($et.3800,lab.C.) - �OUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyN ��� Company ��6�r�- �U/�t17. 'l
� Certified copy is hare6y fumished. FOR APPLICANT TO FILL IN ADDRF55 �G' 3�✓ -�=-�/!��-+��f <-c
� Certified capy is filed with the ounty boilding inspeo- BUiIDING '2 1 / • l/
tion departmenr. qooRE55 �) � F � � �OCnLlrv ��+_,a�C�
� � NEAREST (- �/ � //i`
Oate�-/Z-�Applica / CITY Zi7 - CROSSST. �>. /(��LL<-G�-C�
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE � SiZE OF�Ot NOw ON tOi � MAP&OOK GAGE �ne�El -
(This section need nof be compleled if the permit is for one n 1C � /� USE ZONE MAP �
hundred dollars�5100)or less.) TRACT�// 1 eioCK lOT NO. �/� No - .�..�-=� r
� � TEL. �" SFECIAL �y
I cerliFy Ihal in the porformance of the work for which Ihis OVfNE .$ NO. � Q � /���vv CONDITIONS O
��� ^ �ISTRICT GROUP TVFE FIRE PROCESSED BY
permit is issued,I shall not employ any person in any manner — V
ADDRESS i 1 - CONST.� ZONE
so as to become subject to the Workers'Compensalion lawz. � �� G:
crtv 0 V 1 w il- zia '�� � !L a._e_r,c/ O
Dale App�icpnl `_ STAiIS11CAl ClASSIFICATION APi. CON�O. V
ARCNItECT OR TEI. � ��
NOTICE i0 APPIICANi: If, after making this Ceriificaie of EnlGweeR - NO.�- C�A55 NO..�:1_DwEu.UNi15_ � a
Exemption, you should become subject �o the Workers' y
Compensalion provizions of the tabor Code,you musl farth- ADDRESS SEWER AMP Z
wilh comply with such provisions or this permit shall be TE�. (/
deemed rewaked. CONTRaC . (, � _ { No�3�- � BKJ S PG. YALIDATION
LICENSED CONTRACTORS DECIARATION iC.
I hereby affirm that I am Lcensed under provisions of Chopter 9 AQ�RES � ���(-� _��i� 'v J NO. � ,� ypLUATION
(commencing wilh Section 7000)of Division 3 of the Business and ` t,, LIC. 1
Professions Code,ond my license is in full farce and effect. � CRY d�/)vl ry- CLA55 -1 S (p l�f0� Q"�
� c � SQ.FT. 2 NO.O NO.OF CNECK
Li[BnSe N��Jtnber/���J./�7� Li[.Class� I SIZE � J STORIES / FAMILIES � ONE
Con�r$tt�"��.�.�/��_lCl�W1� te _f-/�-�� DESCRiPTION OF WORK . NEW � S
� I om e.empi from ihe licensing requirements as I am a � �77��OM ���)�'� b v�, ADD
licensed orthi�ect or a registered professional engineer aL�ER � FfNAt y i( �
octing in my professionol copocity ($eUion 7051, REPAiR � �AiE � � �
� Business and Professions Code). � uSE OF
' � Ex157ING BlD�q- `� .�� DEMOL ❑ -FINAL,A�
Lic.or Reg.No. Date '� APPUCnN . TEL. C gY ���"����
- - OWNER-BU1lDER�ECIARATIDN. � IPRM ��-� /' � L. S(Jw-u10. �Z^ !� ��2 Q'a A
.._ . ___ . _' _ "__
. . . . .. . ....... . . . ... '_ _" �_._..
� I here6y affirm thm 1 am axempt from Ihe Comractor's License � C-- - � ---- -----"-- --���--�� - ----- - --
� law for the following reason(Settion 703L5, Business and nooaess: �W�`l-F1 l_1_ n Y?_n i S 1 � �6 �V �.� � � � ���
f ProfossionsCode): . _. . . ppE EN
aBUnOiNG 1_•_•6 1,5 0
I, as owner of the proparty, or my employee5 with ADDRE55
woges as their sole compensalion,will do the work and r r .6 1.5 0
the slructura is not iNended or of(ered for sole(Section
LOCAIITY V
� 7044,Business and Professions Code). MOViNG 7[�. ���� 2-8 2
� -� I,as awner of Ihe properhy,am exdusivaly coNrocting �ONTRACTOft NO.
with licensed cantroctors to consiruct the projecl(See � ADDRE55
tion 70a4,Business and Professions Code).
CONSTRUCTION LENDING AGENCY REOUIRED TOTAL SETBACK FROM EXiST.
SET BACK YAR� HWY p�pp_LINE WIDTH
I hereby offirm tho��hcre is a mnstruction lending agenty for FeONT
' ihe performonce of the work for which this permit is iswed v�
' . (Sec,3097,Civ.C.). SIDE
P.L.
lender's Nome ',�7
j m . P.C.Fee S Permii Fee J'�3- v V
lender's Address v
W I cerlify ihai have read this applicotion and s�ote thar the i,,,,�„Ce peP p. S U �
Qabove infor tion is correU.I ogree to wmply with all County In�esi�gaoon Fee �
ardinonc nd Slote laws relafing to building construclion, ioiol Fee ��- S�
� and her y ouihorize representotives of Ihis County to enler
aupon a6ove-rt/1entioned//ffyyu/q�,����"%}', inspet ion purposes. �
a (Llc.� ({K` l l./���1J�'�V / i
/ W SEE REVERSF FOR EXPIANATORY LANGUAGE
- Signature o�Applicont or Aqent D�e��C� � '�s
l� r�
o� �`'�: m m o v Q°'Dh a�.c-C Q�.h 0 y ti x,��^. o o ��s.'� �� _c
� � {ry, '1 O� ti�• O � O ;, ..
ooa 'ac�,U� � �� no 3 � � �` ^ � ec � ��� " " c ,o
c n «� 4 �``o N M N� � o �y o � � y� � � ° � « �'�..
� C.` ` � .h..�' h \ ?.'_�. ty V
7Uw �'bo .,o�+:� e^c ° �'�03"� � �,r � d ° o �� � a
, pm� � .��,'°� '^�'bd e � d a.c °' � a� c�'n• ' > aU • tl y w
I„'c i i �.�+�.� � c�'�"' O a� O " .�., u # �d '^ � ° �r,.�`�� � m 3
Q E o �4 a .�.r � y'C c�, i`�-.� >.'o o e 4.,p'b a� u� X 1r � c '0.
� ° o 'i.�� x` ,°, � c ati �� �--oCip��b o��,� �' � � �,o� O �
c-`aj a` c:'. r\m�` o � � x �;c.«°7.'� ° o � o c,�o � oU ° � � Z
W � �C' Q�� ..C. .�,. 'n p C'� OVi'� � � O� t~u'tS �� C � � >. V y C K• Vf
�..v y 3 � � �' � `' '�'�o tt�a p° o U� �..�ii c�+b G�'j oa� ° : tl� a �
�;a ° o « ° � c„`1 Y y ti c v o � o " e � c c� � a'y���- N O
E U ,; e c c ' a a, �U �,. , �.o� v
�] O.�O h �n �.G ts-:m C,� Z CI a-D y X�V,O .. � b�k a V�r„G V �y �
�.+ k � C h� fi �•�` � E C � b Q a•,�, O .`.. tl s O C '�•y- L b -D d
a O L ,� y ^� � � Y �C ` O N y ��.. � �. � � C�V C~ T b � Z
�S ^ V a�. V y`� �C.M w Z' tl L � m C G�..�1 p �� p �^ 0 �Z1 F � � Q �
�-�j E,o i` � o� � c° c � c ° °c �°. �o`, z °. �� N " c w ° o` c c � m
�"- 3 "0.n `v ;�� � �Q e F� � ° a� ��"v o �� �,���°, a o a�i z� =':� �'
.�`o � aa - m �� � � c � .,. � -
� A-� C C �.V N i..i O.�. ��O � v� � � '� �� X V O O �- �� l••v p �
j] y H�.1..''�".y�O i. � O U h 4 4"L1 � G� i�• _"L t,� C ti l� �
m a � u tl C� �,o �b �� � u � o: � o z p d
`m � .�'� �d�: o^� `' v'� a, N r'b '�' c, u �+ .q 3 ^ ��" u .�. o
'� u � O'4' o �t a c C•`'. �t❑ O 6i � j•� 1C. O � C� o ❑ Cf v ���C 0 ❑ � � � �,
� '' .�.�.� «. e d « n i y w o o � tp• �, v o ,
� 4 w c �U`v a c, 3 �►� o c.,-: :,,a � n�-:-c r„U p
i
N
W •
0
Z
N
C
�
f.. "
V
W
a
�
Z
� —
�o
v
o > � �
R �� O �
u
!� v q C
C: q h
G� y�
n o �o
C
,.. �
�"' p � .� i,-� �
C:
� L
C C� 0 � �
U � � y
� 7 m
a �,
a �; Q
Q m .+ K
c: m � '
O o � �� �
6
Q �' O � � !'�
C �
G. �
d
� 3
� � � v
n � ._
o � m m "i, o � �` c
� a `o E � oa '� � ^ � ` ° � yv
i'' - o` E ci � � � o °>' T r —° o .no c
C ` aai o V ct o � �t I c' � ° Ea. °
c �d a 3 0 �y � LL
U o p- � o, °`_ I. � rn 3 a- c� �o c Z'.n u, Z°C I c
m
� s o F O ' � 4u a c � C' 9.b v' m m p�� � c� v �
o � m o y°, v � c o � -� - � °� �"' a o a� r— _c � a v
o `o
h � I � S = i� (� (7 a� v�i U � a�. ��� � v� u. w � � 2 U i..w