HomeMy WebLinkAbout0898A (4) WORKERS'COMPENSATION DECLARATION � � � - �. .
here6y affirm that I hove o cerfificate of,consent to se�f � APPLICATION FQR BUIL�DItVG PERMIT �
sure,or o certificote of Workers'Compenwtion Insuronce,
r o cenitied copy rhereof(Set.3800,lob:C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
olicY No. ComP�^Y . BVILDING
Ce�t�fied copy�s he�eby.4um�sl�ed....., .. _ . . FOR APPLICANT TO fILL IN qpo�� � /
Certified copy�s fited wNh ihe caunfy 6uilding inspea BUILouvG � � ��-- -�- -"- - . - �
tiondepartmem. : . . .. ADottess �d�ld�..GOC.It��+ Q..D
_ _ .
Oate � Appliccnt CiT� D1An,+oAtO�P ZIP IODUTY
�'' -CfRAFICATE OF EXEMPTION��FROM WQRKERS' � � - � '�-�"'������-----�-''�-����+5. � • NEARE+1.._- � .
��` - -6QMPENSATION-IN$URANCE:... .. ...
SIZE OF LOT NOW ON lOT - C1205S ST. .. -... . ..
(This Setlion need not be comp�eted if.ihe.permit is for one TRAGT � BLOCK LO7 NO. ��R�,� . - . ....
hyndrsd do4lors(SI00)or leas.) . . ��BOOK�`' .RAGE ARCEI
. . ,�. TH ��ONE P '
. owr�e pti GoitP. . No. �'trj �(
I certify�hat in the performance of the work�for whicF�this � w0. " � �
permit is issued,I shall nof employ any pe�son in ony manner ADORE55 �l��� �(J �l d'- � �Q �� i �,� � �� 9 ,Q
so as to become subjecf io Iha Workers'tampansafion laws.
....."� CONDITION
_.. � � _. . . �......- ._,. . . . .._ , ^r�/ a �, . . -
.:�. Gi.Y....O ��AJ ZIP �C18{O O ..' .- ..: ��: _. '' .� '
Ome � • `_ . . .APGlicant . .. .. . .. .. . . � ._.. ..�
ARCNITEC7 TEt �`.O
NOTICE TO APPLICANi: If, ohx making tbia Certitieate of �C,NLt � - � .,DISTRI�T GROua. 7YPE_. �. ., :FtRF ..,��ED.gy __�
Exemption,-you ahould batome-subjeet-to�Ihe Workers' ����--- E INEER WRl�sr�0. _ �1 �p�T: 'ZONE
Gompensotion prov�sions of the la6or Code,you must forth- �R� r�p ��� �A �. ^ pL. .-. � � 'Q
with comply with such proyisions or fhis permit sholl be ...,.,_..__. .., . , .... .. . � y
deemed revoked. .. . �... .... . . ...... ... � .� . .. . �� '. 5lATISTICAL LLA5$�FjCp�ON ' �: APT. WNW. '-a
' . �� CONTRHCTOR VAN UU�f3� U}ILIIRlalO � J )_ - �
, LICENSEA CONTRACTORS DECLARATION_ ��.. . �- . ���CV SS�NO. �f0 OWEIL UNITS �
� I hereby affirm ihet 1 om lic0nsed�nder provisions o4 CFwpter 9 Ap�RESS��O� ���11(-1/���.Np.�a7.1���.
- (commenting with Seclioa7000)of Dibision 3 of lhe Business pnd . 1iC. ���� �
i Professions Code,and my{icense is in fu�l force and effect. CITY V/SA! ' �! �4OlQp,55 C'Co r� - �
� � - � 50.Ff. NO.OF NO.OF CHECK � �� , Vµ�DATION
li[ense Number� � � � �-lic:CIOss�`' � � SIZE - �- S70RIE5 fAMltlES ONE �0 8 9.8 A�
. . . . � . . .. . _ . __. NEW � _VAI.UATION . #� �• •Z.3
. . ... DESCRIPT�OIJ OF WORK.�_ ._...._ . ... �.
Coatrattor � - ......Date . -
�I am ezempt ondar Sec. . .. .. ' � �p L��� �- �/h A� � s , ` � •1 4 G.5��
AlIER
B.&P.C.for ihis reoson REpq�Q_..� - Z/] rt /� •�� �L Qr 5�c�i�
DOte: EX STING BLDG.R-�.S A�\Z.6.l.�T . DEMOL � oGS V�CJ
� 211 -&6
Signature � -' aaPtiG4N7 •�. . .. ...--. _.iEL � .. FINAI
PRINT �[�tOTY Q- . NO. �QO
. OWNER-BUIlOER DECIARATION ,._ _.pq=g.-__.._._ .
�I heraby-offkm tho�i am exempt 4romlhe Confractoi s License . . . . -...._-. .-.-..._ _.. - _......... .
Law for the following.reasoa{Section 7031.5,Business and AOORE55 � ( �C1 EA1 T..I Cf"� < 'T R L/ ./3' FWAt� - � '-�-- " � �
. _�.... . ...... ..
Profassions Code): _.. .. R . . _ ..__._......---.._. ::. yY .... � . . .. . �. ._ . ....... ......._...
� BUILDING '� -
1, as owner of ihe property, or my employees with qppRESS G'•'• '..
woges as thair sote compenso�ioa,wilt do the work and � �� � ��� � �/1�/�� '
fhe sirudure ia not in�ended or offered for sole(Sectian IOCAtRV � 7/�� . ,..�
� ��7044;$vsiness and Professions Code). � MOVttJG��-� -���� �-���' � �� TEL � lyYE�l},
� I,as owner of fhe properry,am e:clusively coniracting CON7RACTOR NO. � a�l /�,i�-�iG,/_ � ,
with licensed contracton to consvuct�he project(Seo- - -- --� � �- � '� � '� �� f�
ADDRf55
tion 7W�,Business and Professions Code). � _p/ i �
. ....._ . REQUIRFD._ . TO7JLL SEiBA K . __... �r� � �
�CONSTRUCTION LENDING AGENCY $E7 gq�K "(ARD MwY fy2pp��NE WIDTH � � � �
I hereby affiim tho�ihere is o construction lending ogency for FRONT r^�{t �� �
the performonce of the work for which-this�permit is issued -p.t. -- /� �� //�
(Sec.3W7.Civ.C.). SI�E L p ��/� .
m ._ .., .. . ._ . P.L. . . �I
e Lender's Name � � �
Q L�MA Ref.N �� �
� .... ..� -_... P.C:fee S� - Permii fa� - . .
lender's Address � � � �
� J certify lhat I have raod this application and state thot the ....... ._ . �ssuance Fee � �� ---- LDMA ViC 1f � � � � ���
¢ above informatinn is conect.I agree to compiy wilh all County Inrestiqa�ion Fce .
� ordinances cnd Stata Iaws reloting to 6uilding conatrudion, __..._.._.__,..___ 7otal Fee - - �-� ! tDMq.Porm.Y � �
and hereby authorize represento�ives of this County to enrer ,
� upon the above-mentioned property for inspecfion purpoaes. � ,
� _ .. _. . . . � . . �
a -.......__ .
n Gt,/�j �GG�e� ��/ SEE REVEiSE FOi E7f�lAHATORY LA!{GUAGE .
.--..._ Sigewrure oi AppNwn�or Agenr - Gole . .-.-_-- . .. � � ���O� '
�'^ �'t d X � � ie."a.n`i �c c �b `o .� m w h a„e m � _
�,�, m � E`'�G„�� L u-N,� �� '
�� .e... � �U�i'° �„\'�0 3 °o �' �' o..� oV � x
p O '] 0 p.y d� y O..,. tl O .N y�..�-0 d^O�T.r` G � C O y i. � .� ,
C^ w d t S .�a �O-:G M ..Ci� d O y� C � .Y M .�„ C� � d « 7.�.1� . .
O � R a C ti '� 1. � \ T 3 v.'�i';� ti " 1� G. >-'_r 0� y k U .
pm,n � acsd ° K'ei� = �d asg � a,'� e`�� � ' aV ° � y aa
�s � � v.�O.� x n w•.+:? y o � « a�'i 3 "y ° �3 ° '.c„'t,�= m m c
0.�' o � � � � a a � m Kh °Zt E�•° o ?"Q m`�.M�;a � ?F. � �� � y '
� ry � e n.�v ` —�Uya-�p e. � � oi o � u+
,�'� m T�� c.°• � evv `o3m �,ti� 'b °i �� E �� �� K �'
m
V a x �`1m� � Q x y e -�.e o m s. w �.c � o c � � �, Z
W E ��`v w-wa�`�.y c,,� = o F" y,y° y° � oti � ^oV �b:,, .
Qm ; m � �� $ mro�i.3�-b`a a-° ovro3-°t, m'CtC�b a.„',c .°, nH � �
W ° � � ° � 4`�"�= y`� ° �v ° � 9 >;x E ° v ° o y.T..x� �n O I
A o V '" ,[ u� o a F aayV e ,V c, ' m-c n m ° «t��
� .Y7 .O c�i �i� �U � a�i �.�v L O N,� ,,�, d �4 C' 0 "' C � O�Q y «'J C tdn
w� � � y
d
•'�"^- r� „ y � � C d° d C .^�� � v � � �,� m o x x'�� o 0 4' o � y � Z
�,. � "roJ'�.� x a � � � ti� d x ��.w �o� �z � c��i 4 � a �
a.� � � �, d � � m o 0 0 ��, a m d�o a �; d �
Z,�'� a` � y'�x �=•o�,y�� 3 .� `a 'y � ���,���; ; � h� � °a x
r�.oa � 0.xa',: :�-�tlamax �r °'xecy, rw � �N � °%.� � �y-� E
O >..� n n v � vc h.�`ti o ` 5 n h a a �`�c o= �� � � �s
� y�' •x h O �: m'^ o H m c c� i e :.c �r�.i
m u� � d c 0.a'�o oZs '�w — � ` n � +�"� E ='o e � C1 a o a � —
d c .X� tY�A,4 :� o�i m �"' � K Z1 Q'�m d c� x 3 ,-. z V� w .�.. O
L � y 'y l [Z! a tl '� �v�• �� p � 1.'ZS Q� �Y Ol v'^C � w �
— � � oai i,y.Q �.,�� �•' t c�i � d« � C �.� ► O a�i .Y� C p w Y 1�. � y O
� � w ^. .,U n n C, 3 W a o 0.-4 �,•o � n►��c ra,V o
N
W ' �
F
Q . .
Z
N .
aC .
0 ' '
F .
W ' ,
d
Z . . . . '. ' . .
o " � '
--a :.. _�o. . ,`
6 0 0 � �, .
Q � n ;� �
� oa _ m
' O 0 ~
V '
Z ' ' � . . . .M ' . e
a C Q 0 C �.
u � Z ,
r « �
�
♦'
� .' � p � � t ' . . . � . ` ' .
Z o
N . '
� �. O� Q ,.
d .. �
. � -
c 3 -
m � o �
�
� °> m a� �> ;o '' ~ ° I v
0 0 o E ` �/ 07a c M v ° �
_ n � ^ �, ne � o a o o i m�, `c
a d � E . a � ' m > r o g � o
o. 'a c u �cf ' o P �a a . ' 3 0 � �� LL�`.
u � a'. � u o-- c " a cY ' � T� K Z c
� � � � ,� U Q � W
� � L '� � O � v R�C ' a � 'C a O� C � T � C , � � i O
p p N O � "6 � W O '�: O � �' � `y L L � O N
0 0 � � m �' a o` °i o ° o � ooLL c
F: Z � 3 x � c'�J C� a'�. �n v o � o t� in ii u, ° ° x U ' i.,