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1748A (10)
i ,. � � ...._ ._.._ ____--,_ _ .___ _ _ , I, t5 - WORKERS'COMPENSATION DECLpRATfON � � I I . � . . . . . . ... I herebq�offirm Ihnf 1 hove�a cerlifitnte of tonsenf to�7tglf � ��-APPLICA'T{ON-�FC)R��-����UIL�DING �PERMIT ' ' �"or o certlfico�e of Workers'Compensnfion tnwranee, ������ � " Fot� ��ified copy ffieraof Sec.3 ;a6.C.) � COUNTY OF LOS ANGELES BUIlD1NG A � or u ce Np SAFETY rr�/p'`�3 9�mPo�yq��d�'� _ . _ eunoin� � �� Certifisd copy Ia heroby,fumiahe '����+C. � FOR APPIICANT 70-FILL iN �-��� � ,npoa�u •��•r"� �� ! � � . (� -Cenified eopy ia filed with�he coonry b� dlnp inspea � 6WLDING � �+ , �� d I � � � �-�1 _'L'I' �G5 �'� .7t `.,.,., �ocnun ._ G�a� -tio�nfdaap�oQrtm�e/nt, . ADDRE35�� �� � Z 4V }�`l� NEAREST . . i . Dafe ApplicpM _ .. . CIN � N� ZIP� � CROS5ST. �.�. GERTIFICATE OF EXFM�iIOIV FROM WORKERS' . . �� �No.OF BLOGS. ' .45ses50a - � ��.COMPENSATION INSURANCE : 52E OF 1Di � x'�� � ��NOW ON lOT MAP BOOK �VAGE PARCEL � (ihia uclion need nm 6e eomplefed if ihe�permit ie for ane � � USE ZONE tiuv , . ��' hundreddolCon.(ST00)or,less.) . .. .. . �� TRACr S � 840G:, ..... � _tOTNO. - �p� ' ... S�Cu` , ._} I�certify Ibol in.the�performance of�the work�forwhicb thia ��R (�W�' . NO . . .� DISTRKT�.. GKOVP�IONPE .. PIRf .ROCESSEDBY �� . -�permit ia iaaved.I eholl not employ any penort in ony manner . .. A�ORESS. � �, aC � � �CON5T.� .. 20NE � � �� V �so os to become t�bject ro the Workera'Compansotion Laws. . ' _ 2 _ ,r�. ' .�� l!�� . �. . .._....-. .._.. ' � _; Ddfe . � �. . �Ilmn! -�.. � � . . . .. �. CITY� � Yh0 �� 1�(Ak�.. ZI7 STA71S71CALCLA IFIG4710N . � APT. . CON�O, �O . �NOTI��TO APPLICANT: It,�aNer moking'fhla CerNficate of -� ENGINEER �-� `� �1 �����NO.�Stf �- O J� '/ � ���v CtASS NO.�OWE4l.UNITS__ � W 'Exemption, you should berome subjed to rhe Workero' . '� N �Compenaatiqn provlaiona of 1he Labor Code,yo�mvst fortb- . � appREu, . ... ....,.:_ ., .....�. --.�.... s�yyEg r,ye,p .Z -with comply wi�h�aveh provisions or ihfe permu��he�l be � , , �. � �� ��� �'_ � -deemed�evoked. �. � . .. � � � - ��� COwTRACTOR C . NO. � �� ,. �....gK;�._.. p� �.. ..,� . ..VALIUATION_.I� . �. � GCENSEDCONTRACTORSDECIARATION ,.� . p � ���� , LIQ .Q,�41(' � .. .. . . ... .. - . .. , y... .� . � �1 herebyaffirm Mwt f am licensed under proWsions of Chapler D � ADDRESS �l NO. v '� yALUATI6N�" � ' (comme�cing witN$eclion 7000)of Divieion 3 of the Busirross and . � � � tIC. � � � � � '� , ffed. cttt • -C1A55 - . . S�.� f B"'�� � , _ � i � ! Profesaions Code;�ond.my Iicense h in fvll fwce and e ticense Nvmber� �, Ua Class ��� . .�.. ..... , -..- ,�.._..,. .NEW � � . �.. ,i� � � � �oI� � ,._. 5(]FT. NO OF . NO.4f CHECK SRE .jL9 STORIES FAMIUES ONE . - � :�. _!"�� h,L Date� _.._ . .__.._....,.ADU.... � . �. , . �.. Contrallor .4 Z~Z ' OESCRIPf10N OF WORK /C. 0�� � . � . .. .,.. . . . . ..._ {. . .. ❑I nm-Oxempt under Sea �. ' . . . . OOVI/� 1,' �. '' . . . . ALiER � .FINAI� �n, . . . . ;. ..; ' . 8.8P.C.for�his reason . .. � ' �. �� I , . � ... , �� .� .� .. �5�o��S� . .____. . .REvniR [] ..bATE �,� d � i ; �. , . , ,. Date:� � _... . E%IST�ING&OG.�.. _. � � MOL..�] ...#INAt ..... ... ; . .. .. . .,.._� ....� .. . I ...51 naturC ... . . �. . . .. � , . � . APPIICANi ' . ..TEI. 7 r � ,. .-, . . .. .. ��j. j e � __. - � �:OWNER•BUI4DER DECUIRATION .: �' . PRiM � O C w0_. `GZ.- �7 ; � � I here.b affirm fhat I am eaem from the Con�rador`n licenae � . � � � low far the followinfl reason Sectlon 7031.5.�Business and ... A�� � �� C� t'� 4�r S :�'- .. .. . .. ... �����'�(�$A� �. � professiom Code)e--� : ,. .� '� . � pRE E . .; ,.� � � I . � O I,os�owner ot the Proparty, or my amployeas wNh . -� �ADPRES�'S. .�......... . ..�. -._-..' •`'^. . r� a�`.. � l=.;_� #�• �• •.�� � woges as tbeir sole compensatlon,will do tAe wcrk and t�m .. ..� .�"`.✓' ;,_�)� 4T�''`�,� ����.-,Y,�` I •1 } �,�rJ` , ! . tha structurc�s not in�ended or offercd for wle(Saction , � - �'+;,.�J .;�- � i .. 7044.Businett and Professiona Code�, �� . � MOVING � TE4 � . .� � ' ��Y. � � � , _� 1.�ps owner of the properfy.am.exclustvely cohlractinp .- A���� - � NO. � ..... . . . . 0 2 2 7 1�4; I _ witb ilcensed contraqors ro construa the projea(Sec• � .. . . . ;�. . i _ ..non 104a,Business qnd Wofeufom�CodeZ. .... . . .. _. .. , . . , . . . I t _f her.by affirm�lhns there iaoo co tDING n lenP ng aqericy for . R��K YARD- HWY.. roTAP�l N F�� WIOTH , . . # _. .� ., .� the performanae of the work for whlch this erml�la Issued p L � - .� . i ���. �j5ec.3097,Civ.C:J.. S�pE � � . �� . . � ' . F.t. �... . . ._,I I . � lender a Name � .'. � . . . � ��. ' �. . . . . .� .t� + ��, _._.. v __:_ . ... , , •. . . �' _. . I i P.G fee�S � PermR Fee� t..�� ..I. � Lender'a Addreu� � � - � ''�r ' - i :... . .. . _.. ._ .... ..__ . , .. . .�: � '.',. . .. .T cenify thar 1 huve�reod this applicarion and�tofe rhat�tMa � . � � . ..���../O. S� � � .. .." : abova informwlon�s corroc�.i o roe to com f wNM.pll Coun . ' �w c.F•e�. , . �,.:� � 1 fl P Y h Inveatiqaiion Fae _7� . � �' : . �ordinanees ond$tate laws relmir�g to bu�Vding eonstru�eion, ... . ...-. � � �.1 Y J. -'.... " "`..... ' ""`. . . . . �. and hereby���qqquthorize praunfatives of 16is County ta�nter Towl Pee� � ; -up tqq6�v ont ed perryforfnspealonparpose /, ., -..�... _..._... . ..,._.._ . .... . .._. ... . .�.. ...�... . ' -.; . �� � �� '�L t ... : . r.�: - , _..... ..._... _.. . . .. . , .. . .. .., ,. � i SiqnmlreofApplican�wAyen� . �rpate..� . . � . . . .. . � I� .;m+ ! vv" SEE REYERSE fOR EXPIANATORY LAHGVAGE . . . . . . . .. . . . � . � ' �_ . � .. .i'.,._. _..�,.. .. . . . ._...-... ,.._.. _._J _... . . ...,.._ .. ,...... . �.... , . . . . . . .__ .:.____._. ___..:. , . .... _. s._.. . �._____.._,--_.___. . . - --- - - _ . . _ __ {, .,.. �,��;5:, �, ,. � p ' . � f plA1iL'.SO A/PWCAHT;:� . , k�' ". '' .. ` ,.'INSPEROR'S NbTES ....-.. ��,.�'_1 t��r,e604 N�K�B�Lpm s 1)�CS.ARm hepC�'trac)or,'�s �' �t . . ,. . .. , .. . . . . .. . P QS� . ...1 .,.} ,um�d.... � -_. ,.,� ...y, .. _... .._ ,..,.,. � . Liceqse Lqw�.tor�the��•�followit'g��rea�n.�+(5aa^�i�793h5) � No. -�--Dat „ � ' No. -��Dafe . ApprOv�d .. » �. Bael�ess,anAProfssjionsCodcR�luy' ' :qr�ibprEfyw6icb ; 'fo' . ..--- _-- R� ..__. . , .. . . . � . ..... .. .. . .. ,�. - +,or repoirae��strvcctu�e n n�r}aTte h�{'oue:�dSneolish, . —-. — ,� . .�,� . � .. .;� ,, ' . � - , � � . „' — "'�=thewpplictth[foJrsucd�8t��t�oiYiisertenYe,etso'reqrciris �._ _. _._ __ ._..._ . _... . . _ . _ _... .� � f '� ' ` • . � !Av'$ � - ; .. �p .!o fllaJrs:gned stdterNeht .__ ... .-.--- — -.:.�.. �' .._.._ ..... -._ .. .._.. _.. . " to ibe'� vrsians e Cafr _.__.—...._ dhath¢Jalacewsedpurspant tirb .oftb ' .. ,.': ^ti.,.., 7� r', •' ��' :� trpctor ��irqnee��'�bapter 91(cdfnM¢ric4�ng`uS,'tfi Ser � . -.. . .� ..�• _ , . '��� . . � : . �r •• ..___-drim� �00�of ro�sJor!�`0 1beBws�ness dndPro slo�ts . ' � - 9 ) ,Fh .� - j'e s 1. , ,, .. . :: ,.:' .` ..� !�} :,,.� .. �. CodejerdbuE 5dta ere»ipd therefrommandl6e�bus&foribe 4,».y�PRrowM . `•_. Y�fuh� _ o��pPProve�d ._-j� , �"�.! - - C r' it < ."pe eltyfi�n)'or sret b x f���6u d dpd ttarn(�65�d�X : _. "`..,.. �- � . >.j.•.L•1.__ r --._ _ _. _ :� _ . ., - �::I:;a�ownmr�of�.RhearsPa�tY::qr.myem IoYees:.wi�h� ''' "`- Woter�e�tificdte 3 �'�.' , �.� �. .`� ��.�: . � � �-w as�aa�lhe�rs Io'com . " � � ,...1 ' ..... ��" , ; . /ii f 7't�rd.-1 .����;� ..� � ` a9 C _ p9nsationl'wlll'�do.ihd�work;and �. HealthDeparfiiienY.�," .��.: _ ���... ,`::. � . .�.�:_ i .. ... ... . _. .- 7 ( ... �� �t ��, �' �� ss'endProf srion�SCode�fTbeCo4ntrsctor'sLicexse . ��.?hs 61fU BUSiriF . ' . :• ; . i " " -" ��-"'.� �--.; .. _�.....� .: - Lawdoea-notapply-toahouJserofyroQertywbobrit3ds �'� ^4 F�rs Dsportme`nt �,:;�.� . . G :�. , i....; ! ... , i .. v .�� � <- 'or Fnt�iov�i�lh.reow,"bnd eob#r2-bs'iurb u,erk'biin}¢!f ur '__'_ . ..�. _... .. . +.� ! __. .�. ''4hr ., . . .. - �� Gradmg � " ... i._� � °s;..� ,..... _ .._... . _.._.... ._. _. _ .___. `�ro ¢�nAatssare nvt��riended�r�'offe�`eG f r��sae.�f .•.," .�i�.i f`�(J .:.• . ' r i ..-. �. - bwuer�Elrebu�ldngoh� prov¢mexijss�vfdwitfinax¢ Geotoflica! ... --W. ��. .. ' --.�;,� . .r;, ... .. „ ., �.: � •�. : year of campletion, t5e owpar-builder w�ll ba e ihe ', -. � ` J , . � . � � 5� k w,,.burd�� /�iromwg,lhat{�e did irot dueld orimprove�f,o.r . . ji-�t��• � I)� �,;�i ��. 4 .. ! Pedestrion Protection �.. ` .�. �� . , . ,y - e u!pase�orsaleJ.,��,1 a. :_.,_ r r . � _ „ _ ia � (Fence)(CanoPY) .�;. `:..•.. .... �. , ,. i� .-...... /'�J1ltl,i ,�..,. ,:.[ji�I..m�owA6rof�rhe.proPcrf}ndrnexclv�aiYsfq�coMrac- i , . .. . ._ __. '' ' � � tlng �m/iY5litensed coniractor to, �SG�ct the pro�ect(Sac. � r _:.'.;_. L_ ' -�. ' � • < � ' _�a+�z�r�uaimeas;and.Pr.ofera�ons�Code;Thi Corieractoi� ; Special Inspaction .._.._ _ ....__. _... . . � (Cont.)(MasonrY)(Yyelding) .:. ` : , ., ., , �. . ,. . �L,cesyarl,a�dnesxota�p! t an��nerIo,(flroPeriywbo .< � ....1_ ._.. \'-".1 � :' —... , : .�:. _..`; �..�byela's nr ir.rf"�routslhe.a��a�a_rrl elheSni�try+�ts'/or�rucb ��� lo�Drainage ."-:�' �� ...'�., .� ` '��- r c..?c � projects witb a co�tractor(s)licensed ursuant to�StS'e , � ,. _ y.__� F ; ,.,..�,,�, ,,. ;�: ._.._ ._—___. .. . ..__a� __._Enxeractnr'.ei.krnse7.awj. � L_t i _ � Parking x. � � - . � ., . .� .� �� _....._' - - - �� ' + SP C �, ;. �. .. .,,_._,. . , .. � :,.� . ... . :.._..__ _ ...�. .: ,_S,a.. l '� n er ihi . , .. .., � �i.,i: .„ .( . � ,` „.,,,. � I am e'emPt'u��d-Sec B � for s� ,_ „ .., ... . -� ,_....,__ :._... 3. _.__._. __....._._ .___._._... '. 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