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HomeMy WebLinkAbout1099A r-_ __..�____ --- i _ , __.__,._. � � � .WORKERS'COMPENSATION DEC44RATION �' � � �- - � � - �� - � � � . I hereby affirm that I have a���f;�a,a o,�o����;o,e�, .� .. ��� �.;.APPLICATI0-1vI�..�F�C)R���BU�LDING�P�EltMIT�.� , inavre,or a certifkat�of Workers'Compenaation Insurance, � or o'certified co y thereof�Sea 98 I.a6.C.). � COl1NTY OF LOS ANGElES � , BUILDING AND SAFETY Poli� �_,�L._Company. . :. _. � . . . � �.-. . . , . .,.� � . �Cenified co Fs here6 furNshed.-- + ' � � BUItDING � � � �. - PY r -. POR APPLICANT TO flll IN ` aooaess , � eenified copy!s f�led wi�h the co� y ofiding inspec- BWt�wG' .�ion de artment. . .. �. .. qDDRESS� . . . .. tOCAlrtv . . . pote(���~� A IiCOnf ...... CIN ) �/j� �L,r � '. NEAREST � . . . PG - �.t . �-*'n - T•�- ZIP � � CROSS SL� . � � .�CERTIFICATE OF EXEMPTION FR � ORKERS'�� � � � � � NO.OF e�oCS. � �� �� � �. nS5E55pR � . '�COMPENSAiION INSURANCE -� � . SIZE OF lOT - NOw ON LOT � � MAP BOOK � PAGE � PAR�L �(This section need noi be compleled if the permif�is fw one � � - � - � USE 20NE MAP � � A _� " b��d�ed dolton(S�oo)o.less.} TeacT e�ocK wT No. �� , No. _� 1 ttni fhat in Ihe . . . . _. . OWNER A� �` K.�.�'f.. ..�� NO. ��OO Jl.r+ CONDRIONS . � . . . d fy performOnce of fhe work fpr which thin � � ,, „ , DI TRICT GROUP.ON57. Z� PR��D BY �U . permN Is issued,I ahall not employ any person in any manner �� qppRE55� � ao aslo become sv6jecr ro ihe Wwkers'Compenwtian Lawa. � - . �. . -.� � - � ZIP; / . ...�.. � .. . . Q Da1e �� --'� App licn�t� � . . CItY �Q - � ` . S7A ISTIGALClq551F1 TION APT, ONDO. NOT�CE�TO APPLICANY If,after makrng th�s Certificqfe of � �RCHITECT OR � .TEI.. ; . �(��A� � � Exemptloo, you.ahould-become-xob�ect;to the Workers' N INE�R� . Nq . :�t1iq55�•p,��pyyELL..UMTS� � �� .� CompensRtion proviaians of the lqbor COde;you must foHh- .. ADDRESS- ' ��� SEWER MqP � ��y with comply with-.aech provisions or this.permit ihell be ��' ''� � � � � ��.Z . . deerned revoked..� . : � �. � �.�� • :'�L. �� � . .. . - � . . � . ' . �- COMRACfO '� , n�I� �BK. PG,�- � . ���VALIDATION � LICENSED CONTRACTORS DECIARATION ,/� � / tIC.p/�/ - 1�hereBy affirm thot I am licenaed under proviaions oF Chepter 9� ADDRESS�r��CGVMhp4f,W�( ��NO:.L!(. � .YAtUATION .. . . . . .... . �...�.� . . (commencing with Sec�ion 7000)of pivision 3 of Ihe 8osineu ond ... LIC. - . '. Professions Code,ard mry�licensa is in fu11 force and affocl. OTv� � � � "r`3� a�� �� ' � � � � � ., .' . �.. `_s Q� �. ' ,. /�' " �" SO.FL. ._ . NO.OF � NO.OF � .GHEIX - � � . _ cwss S I licenae�Number �� o - lk.Ctass�-h � � . 512E - � STORIES FAMIUES � ONE � . � � - . �Conirac�� � '�: .��� �4 � Oate. ��� . ... .... DESCRIPTION OF WORK . � . NEW Q ; .' � . . .. . �. . . ..� :. _ .._ qpp .,� � _.. � �1 am exempt under Sec._�� � � � ... ... .. .. . . . .. . ..� .. nt7ER��� fINAt . . . .. � . ' . . . B.BP.C,for thia o �r. DATE _ _ � . . . . _ b5E OF .. '.. REPAIR Q ._.�. , � e: � .. �.�.. ExiSiiNGBLDG..�..�_. .. .... .. . .PEMOL.Q FINAL .� . . . _. .. . . ey ��-SlgnatuY � . � . . A�PRIN �'+^'�n1'l ...1!' NO.� E�SI yp.. . .._ . .. ._...,_, � . _. . i .. .,� � �-�OWNER- ILDER OECIARATiON �-� - ��- " ��� �� � � 1 hereby affirm thaf 1 am exempt from ihe Conbacror's Wcenu �. � � � . � � � Law for fhe following rceson(Section�7031,5,Busfness and .. AODRE55 � .. .. ._., . . �, . ,_ . � x �'� ' � P P NY, or my�employees-wlth . ... ADDRIE5�3 ._ � , �. . #�,�0�9,�n�.. -❑ slOnf GOde � - � �Profes{.�owner of the ro e � ..- . .. � . � �,�• •�;� weges as thev aole compen:ation,wlll do ihe work and � � . . ��� � .....' , . . . ,�.s��4�Q� � .. the sirutture is not intended w offered for wle(Seetion . ����T�' - � „ � 70d4,Business and Profession$Code), � � � MOVING 7EL. (�, � � .� , : � . . �. I,aa owner of ihe property,em exctusively coNractinp .. i��T� ��NO. �� �� �•• •,(j�,O O T��,.. .with Iicenaed contratlors 90 tonntrod the project(Sec-� ADDRE55 � � � � � � � � � � � �. . .Yion 7044,B�siness and Professlona Code). - .- � � � � � ,Q,,�:�9 r 8(� .. . . . . .. ` � R�pUIRED TOTAL SETBACK FROM �. EXISL ... ... . . . . � GONSTRUCTION LENDING ACaENCY � ' � � SET BACK � YARD HWY pgOP.LIN WIOTH � � �, � � 1 hereby offirm fhat ehere iy p'conaMudion lending agency for. ..pgpp�T, _, _. ., . _ ,, , ., _ �, , ` the performante of the wo.k for which fhia permN is issued�� '�p:i. � � •. : � � ` �See.3097,Civ.C.)• SIOE . . . . .. � .... . . . .;�.. . . . ' .�P.t... . . . , :� � -.�.,, . . ,.. .... . . . .. _. _. . , . . . .. LendePs Name� � E _.._ . ... -. .. . .. . . �. � .... „�:. .� '.. � ._:.. . .. .:�� ,- ..�. ... .�. . �. _ . � ��� . . Lenders Address ' � � . P.C.Fee S - � Vsrmlr Pse � � � , � � `I cenify�ihat 1 ha4e read this npplicotlon and state that the � . ' ' . ;:.." . .�" . . . `O � . .. . ......-... . � . ... -. . . �. � � .��� . luuann F�e . � obove i rmmio e t.I agree to comply with.oll Co�nty .. .., �nwatlpatian f�e y�O .. . .. .... .... .. . . . .... . . .. . -ordl a and tat la �mlaNnp fo buflding tonstructlon, -.... . � ... � -... eaboe�r rnedpr�orfinspec�onpu�s[p�sr � ' . tEEREVERSEFORE7[PUINATORYLANGUAGE ... � ..�. . ..... . .... .. . . . �. .� .. . � ��, II �� . . .. , . , . .. . . .. , , . . .. .. . . � - �_ iprwtura of AppliwM orApent � � p�. . � �. � � ' �� � , , . . .. . . . . . . , ..0t .. _ -- . .: .__,._.. _ _ _._..______.. _ _ _ . ,..__..r._.....___._.__.._____------____.... ----._. � __ __ . � � >�:, . �. " s + 4)ti : TOII'i �ES • � . n4 t ��QWN�33ua�.D�{RDSC�.*xA�'IC1N..a_.,.- � � , -w " , . . ., ,�... , ..I�here6y pffNan,jhPi I pnm skea.pr frant atie Contractor,'s 7e: �. � , .� jt�urn�d . . . � .�, � . � Licekn'se Law 6.� tYt9"hoNoWing..,reasort �Se2,��7031.b) F '��� c ;�. : ��.�' APProwd �..�• ��f. BuswesSsadPro„( ons.Cod An�t�a Qr �t�+wbic,b .. _ ....,. ; ... � _. ._ . _ _... .. . .._ ,._ . Ne: Dufe ..'��No. r� DaH r, -,e' ... �•�==� ,.. .. '.:��.. •. ���.,� _.....r�gutr¢t�- '¢r�<it�J�'s[r t�stoer`;t»�rnue�denio�'b� .. , � ..,, . .,, �- �_... ,..�- :��,.,,. ._.r:. . . -.- ..A,, ...,._ .._ , � . ar repair�structui��;'p�ior!n`3xS u:idante,alSa'ieqw'ires . .. .._.... .. __ _ . _....-� -- ..__......_ __.. .. . ...,. : ,-�-;_ ' �, . �---�ni n :��.'�� =.�Dye pp¢leeaJ�x for.sucb yinnntt-td jrla u segr�ed�.ttotem¢n? , . •\— k ;s 3 . . . ,., . : �. ___.__ .__.:� _ .._.... . .- .._. . . ' _ ,...... ..:.- _.._ . _ .. Ohat 6e a ens d u ana to t o�Yh ox � 1ac' g rsu bv pntv,ssrrts f e C ; �j `�� ., �` �,,�,, ��:,� _ trattorF- �}�`�ti��fiap6er9J�'em"�5swti�±igtlNtbSec* ! ,1,�.<l�5-�r3.�,�srf�� , ,:`:� - f �� �P.af'ea's�oru � � z,,:.f _ ..•�! '• ,�� ,. , ., , � .. „iy ,�� ...-Code�����e°iaexen4pb[heref�amaddt�ieSruuJortbe 'j L t.'S �, %f'Roqulnd pdfelF�edy�A; �•'.•+� '.� i�'. �G I -:� r "�"ai�a�lfidnC��f�oerdpe'r'ni�t.iub�ects��e�fipl���oo''ir�vsi�',! � �...�...'�RPrbv6�s '_.._. . . ._- . • - o mu .e u re o �: Y�s Nq. � ��iAP�rov ; ..a,. ! �,. y�..i� .�....- '� �'��. penaltyofn t rxtban�r b d dd llers�(3�DOJI t � � �.,, . _�'_ , � �.- � .: . .. �C.- , .._. f rI f --_ . , . . . ' ,: `,_� � � . _ _ - . � ._. . , . ., r � _,.. , �_�.,..� ... . _ �. V�ater terfyhc�fP. f..,;�:-: � -., . . .> .� , t ...;�,, r �..., r ��,;. .,:i�p�,'PW��erWfdieptopertyrormyentpoy49b..wit �rormgqs.es•ih¢ii�sal�q�o��penae�ion;will db thewoek;���erid � ,, - ��- ,.. ___,..— _..._._ _. .�._-. _ .._. . ._;t. -." ���tMect�'aciwrt�ts.rwl�tra+�n8edo.e4lsrsdf�oraola�(Set.�4�t) , '- . . .. ,.. ., � . f �rb '�'me� f . `'-..: �„��J. ,�.,,i� _ , ,-- _. t-� Business and ProJesseoxs Code:Tbe Coatracdor's Llcense . FaeDe artment �{[ � .. ...��: .i �1-;�, l�_._ " � ._`4. -.���.. � � �' �Axptoyes'lh4rpro�axJwl�iodoess 6$uNir�ibi 6uiids . . P ; ' . *-- .- `F -'- ,5 ro emenks a�¢ nar idtend¢d or 6%`jerrB ar mselfnl� ' ... 9 .. `v it' ..: ::.' ;.., , `.r ..1. ..l .�.: .'�.,. ._.. .,:' }rt',boue�r,tl�eXuxl�sn,q'�r:nrprdve�rrxe„taso w5rub 4m �� Gselo �cal x� . .. ... ..._ .;.4._. . .. .. __!� _� ��,�. `'...'� �.: ^..� . yearuof h{3x ��Fo7 lbt quperl6u����j,�uP¢ g �� Gradin t�;{� . ,. . � tBsq`pe ..:.:_._... ev e � � �� + � � - ���' � ' t :•:^ ya ; �a`��. fr,..'�' ',:�: � burp� o���n�t2ai�e�J:iq t�Luttdr�br��n�iro}e�or PedastNan Proiectian . ". F �! .��., � .y 7'. �, i t�re ur,P4,�ei tsa aJ.,;;,. r,..n,,�,. E.��'�.' ���_) � � � (Fence)(CanoPY) . . ��' t..7�:�^' .y'� � � ..�. ..�'....'--...,.�_�.___.._.1 :�.`1 v ;. �:c�oi.asewri4refthePToR+rt�yry��amrexe3uaiLhhyr:coe�raE- . .,. ..__.,. . ...... . ` _.. . ,, c�...�, i .;. -Plri�j wfthylicenscd contraAtors or�onsl�p�cl thm roject(Sec. , Speciallnspecfioa � . _ .�. I ._..i.._-- •..i.�_ .'`c -__. _ . ��7.b441.IfSsieas£�aosdPr_n.Iesa�br.s`_�v4'1f.Tfis';£oritractar4 (Conc.)(MasanrY)(Welding) �: -' ;^ _ .. . ..�.... }.`' . ,� . Lic us L¢w doea no�appfY sa an owaer oJpsoperty wbo �J! . j .... � f . �, , __.. _. _., � ��t s_$r�xprrova�sie_'rebnt_'i!+1+d.2i�n�Aen't�Cst�fon�t�cb %' �� � -'��- -$ � '` projects u�itb a rertt)actas(sJ lgce�{se�fie�rsuent to�"tbe Lof Drainage . a.. �...�. � . , . ,, .�., , ,,�-,.:, �,.c,�:.J � � .. i. _._._..._._. .__._..._...__._.__._ ._ _._..._._. ._ , ._.-.Y.�tttranaYs-tiransc'taaul• � -' � Parking P. ... 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