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HomeMy WebLinkAbout0767A 1633A �^�-{ �WORKERS'COMFENSATION DECLARATIOIV � � � �'� � ^ ' Y-hereoy uffirm ,ha,I have a tertifiwte of�o�=e��,o 5e�f�..: � � � qPPLICATION FOR BUILDING PERMI~I'--�� � s insure,or a certificate of Workers'Compensation Insorance, � or o cerlified topy ihe�eof(Sec.3800,lo -C.) � 4�' � ' �,�3�j_� COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy Company - . .. � � � . O; Cerlified topy,is hereby.furn shed.` �� '.. . � , .. . ' - . . - BUILDWG � �-� FOR APPLICANT TO FILL IN nooaess ' � Certified copy;fs filed wi16 tha tounty buJdmcj.inspec BUIL�IryG �� �• . � �- � � . , tion deparfinent ADDRE55-� �.'. . �. �� � � ' ' ��'� IOCALITY� ��c71II'L'3$dY' .: �L NEAREST p S �o�Q.� AppLccnr .. � ': - ��'V�l.�� c�n� �. .�2iv�' � Ceoss ST. .. ' � � � � � ERTIFICATE OF EXEMP710N FROM WORKERS" � . � �� �� NO.OF BlDGS. � ASSESSOR COMPENSATION INSURANCE � � � . � S2e oF iOT '- - Now ON LOr � � n�w.v BooK� ' PaGE - caRceL (This sec�ion need not 6e completad if the perm8 is for one � � ' USE 20NE M".P hundred dollars(E100)or less.) . . TRACT � BtOCK - � tOT NO. �� K�r NO. ��Q �3� . TEL G SPECIAL I certify�hat in the performance of Ihe work for which this OwNER Iv�, - jvgg NO 1 0'�(� CONDITIONS � d permit is issued,I shall not employ any parson in any manner DiSiaiCT GROuv 7yFE . FiRE PROCESSED BY Q so as to be[ome subjed to the Workers'Compensation Laws. �. ADDRESS 1763 ]� � CONrS,S/.,, ZONE � ' � ' � �� �Y�— DGIe AppliCOnt CITY Z�P . STATISTICAL CLASSIFICATION APT. CONDO. O NOiICE TO APPLICANT: If, after making this Certificote of�� ENGWEER�R$3Q�iYp N . �_ � U �Exemplion, you shouid become subject to fhe Workers' ClASS NO. � DWELL.UNITS �++ .Compensotion provislons of ihe labor Code,yau musf forth•` qDDRE55 SEWER MAP � with comply'with s�ch provisions or this permit shall 6e . Z deemed revokad. COMRACfOR �QaYD Q3�1L�'1C]1 N 71�] rj9$].�Q gK PG,� �VALIDATION � LICENSED CONiRACiORS DECLARATION � , LIC � I hereby affirm Iho1 I om licensed under provisions of Chapler 9• ADDRESS 7�$� ]�9C� O. VqLUATION , � � (commencing wiih Section 7000)af Division 3 of the Busines;and� � UC. Q C� Professions Code,and my license ie in full force and effect. CiTv � Cts�55 E �,��� . � License Number '�r7J7O uc.Class B 1 s�e�� � sioa�s � Faili�Es 1 �oNeK � ► f 0 7 d 7 p - . COnira[rof�D�1Q1Dale H�11�1 DESCRIPfION OF WORK NEW � 5 � , t�• o • •'�j� . . . � �I am.exempt under Sec. � ' ��i�� ADD �s � � o e 5 9.5 0 • • ALTER � FINAL � B.BP.C.for this reason � - � DATE Z�� • ° ^��.�i Y � REPAIR � Oole: u5E OF . FINAI ' ' � E%ISTING BLDG. DEMOL ❑ By /7 O B � E—G 6 (! Signatare � APPLICAM � EL y / O _�� OWNER-BUILDER OECLARATION vRw - i � , �, , • I here6yaHirm that 1 am exemp�from the Comracror's License� qDDRESS � � � /rl�ic� �, / �� Low for the following reason(Section 703I.5,Business and� � � Professions Code): � g N � � - � �, as Owner of fhe ro ert y P y BUILDING , p p y,"or m em lo ees with ADDRESS wagas as their sole compensation,will do the work and . �� . � �� 6 3.�J F the strucmre i:not Intended or offered for wla(SecHon ��`��T�" �� � � 7044,Business and Profe:sions Code). � h�OvwG 7EL. ' �• • • • •� ' � i,as owner of the proparty,am exclusively con�racting NTRACfOR NO. �� . - ' � • •8 G 5 0 with lice�sad contractors to construct fhe projetf(Sac- qD�RESS ' ' � ��on 7044,Businass and Professions Code). ' '�. � - REOUIRED TOTAL SETBAIX FROM EXIST. � . • � °�O,5 O� - CONSTRUCTION LENDING AGENCY sei BACK YARD IiwY puov.twE wioiH , � ;,{ I here6y affirm 16at there is a construction lending ogency fw FRONT ' �� � � � ' ' � � 0 4,0 5—8 6 the performanca of the work for which ihis permit Is issued p.�. � tSec.3097.Civ.C.). SIDE . t�, � m P.L. � ' �. . . . � � Lender'sNome - � r�7 '�. i , \'.:',',:. ; $ P.C.Fee E S r S V Permit Fea D•�� ' � j��`� = Lender's Address '� � �., �, � I certiiy that I have reod�his applicaiion and'state that the � � - is:o <eFae �Q"5� � � � above information Is mrren.I agrea to compiy with all Coumy . � �nveanga�ion Fee �� - �' - - or inonces and State laws relaiing to boliding construction, - � � . Tmal Fee - SD•SU � � YJ hereby authorize represenfatives of ihis Counry to enter � � . � po 1ha aho mentioned property for inspection purposes. . . . � � � �� � � � .,,c.�-o�.�� CTII"CJLr � SEE REVERSE fOR E)f�UNAiORY LANGUAGE � Signmure of AppGcani or Agent Daie- � � � m� � - -... . .- _ -._ _ -� _�._ _. _ ..._._ _.. _. . . . _ .��- _.. i u;;:�c r�e.uct r.� . i r ,. � ot �5 i u��n r i �t�a »tc� '� r ' � �rl hcrc i c 1 i� 1 c c� ,.. i(.cm�hc.0 ntrado's To: �I- �;.Icrncd . (� . � ,��.:L. , Lic.i L�f� i L �f o n� rcc. (5 c 7031 5) ��. :� 1�._.c 1i . � -" � l��r��,�l� - • C.pprcvcd � • -' ��— !: . I F . ( a rr�n by xrhrtL+ No. . __...Gcta. _ _ Na. U c. - � �I���( .��; r� ���.��.�� � (/�� t o �c I r!•, _=---_�— .�_ �� � . __ �.! . . E ' . . - ----- f-— n r v � t . c+r i n clso rcquores _ __ _. .... .. . ., . � . .. .. �. . . i i . . y . .. ��`[ r��� � _�., � �';�cl��.p t/ n 1�cr.t l y d.(r � t f f:c�sr�r.ed s!u cmm�t ' ��. ...- . . � ��^�l 1 i� �J � �/ t lcfm sewiio�thrCorr- _. ._..... .. - ---- .... . . . _... . . . . . . , � � rJ l r.kn r ,. t t. <r � �_.. . I �n I'--1� �. L"11 ..v ,:r.��Q�I:.C, C.�l'2.11� ;r r ! 1 a.(l{ p r �l(c r _arcir:g u it!Scc- �� � � �i �JD'1j !)7 �rf O F-L . u 1 Professiotts i � �� � i\ � � �.� . �� , �r- �� C ) ��.,t] r et�„it ��r irdtlr7r.sis nrtGc _ ' �V c �rcunr�� l,R,m. `�o`"o r�,.� a .�..t1r1 1 --r, r.t J c , r t t, 1 r i � f ee rz 7031.5 6y. �� ..���O�•O� ..�L�at (- �vcd� ��'� ' � �`�t � n.y c � ;Y �. ts � -t�t�. c.nl int7naciril -1. r..:�! .._ �.��=21U�'� �-CJ�'I�.}`lCti _ L1/�`s.�� �i-4'� `` �0 11 �t� l. J.: P, / t t J ! e..a�lt.ers �SDD J �_... Yc t e ' arA�prwcd . . _ ����- � �' - I —I..,n'J .� ��.i - � 4'••.,r-.('C -�!'E� �r�Z� �a�Lt.���� . 1 c.�o IFe��op rty or.my employeas with Woler CurliFicote . - � � '-_ -..��, � .--'_ � I... _. . ..__ - - . _ -' -_( \ �t I t;' . ,t ca 1 I. c mpen. o will do tho work,and ���., s,�.�p�� �s.ucti �al d nt�.,d c e .ed fcr sote(See 7D44J Health Departm.onf _ , . _ . . .. .,� .. _ . �7. �/y . . P, s c. 1) (�. . _ ( IJ C trnclnriLicanso . . ���d�/��O,��G��f/J --L �� !/! i n � fi �lcrtYwG bu�,k Firo Dcportment _. . ._. � . .. . .:� .:.� . .. _ '�»1 t r l_ i ! -� s r a. ie ord{� r sc!nr t1 r 1 Lrs� �i e.rl yr � frne f 3-1f a!sae! im- Gradin ... . . d•2;. �i��G G���'� . .. _ . ._ . ��:r an�.,.,fs'r c ,?�o (�•r.�d for'sila-lf� 7 I I ' . . . r, r . ... . . , ,, „ . .` . � Z, � t'. , :_ .-cl-��c�rt�n �rr: Gcolopieal . . . �f._-- ___ . .. j � � . __ .-_ �� . f. ,r.v 1.r t(� .: t<ff L e U>e .. �� . , , �I,a : �ryr��. , .c..,., � o i:c,^,rorr�r Pedestrian Fro•ecl'en �. � . . . . . . .11 / r(esr J �l . ' � � . _ -....-� (Fence)(CcnoPY) . .,.,�� � �:'.� � ,- ' "� . l . I;nso��nr.ro; h:: �., ly,cinreclusive!/.contrac- � . .. .. .. . ' . ' �.. _ . _ _ ..' . "� . .- . . . � . .�i , Y��. � �. . n i e fh=�ro�ect(Sec. Specioi In:pection � I -. . --. .. � � . --- .. ..�-. . __Z011) s a J t -. r �it La.� I�n Contractor's (Conc-)(M,asonrY)(Weldin�j) ' - !r r. 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