HomeMy WebLinkAbout1442A 1491A (8) i
WORKER$'COMPENSqTION DECL.ARATION � -. -- �--- J'�
� �he*eby offirm thot 1 hove o cenificow of�Q���"o,��f _ ��aPLiEATiON F�R BUILDING PERMIT �
.� msure,or a certificate of Workers'Compensalion Insuronce, -
or o certffied copy}hereof(Sea 3800,to6.�C.f - �
COUNTY pP LOS ANGELES BUILOING AND SAFETV
Polity No.__.. Company � ._ _. _
. � Certified mpy is hereby furnished. . -.�QR.AP�i�ANT TQ.F�u��.. . Bl1�l.RING ��.{ . \ . ..___("���,��...
__.- ADDRE55-. - � Ut
OCertified copy is filed with ihe tounty building inspeo- g�qp�rrC. �,/ �
Fiondepwtmant. A�DRE55 � 3� ���- �Ss�ry ! [.V
Dote .... AppliwM . . � Citt I'��Q�D � ZIP ! �� r/� �
LOCALITY W��
CERF1FIflUE Of E%EMPTION FROM N'ORKERS' - ���8��++`- NEAREST
- C(JMPENSATION-INSURANCE - SIZE OF lOT NOW ON LOT CRO55 ST.
(This seCfion need nof 6a completed if-Fhe-pesmit is�fw o�e - TRACf BLOCK LDT NO. ,Hqp gppKR..� PAGE PARCEt
hundred dollars�Z106�w less.)
owr�R E2T Q2/L/fS�: l►f�li 7 use zor� Mnr �
I certify lhat in the performance af the work fat which this (}�I �� j 1
parmit is iu�ad,I sholl not employ ony persnn in ony monner �9 � SVECU1l
so os to kietome subjecf 10 fhe Workeri Compensotion lnws. ADDRE55�J.�� ��� -G�-Q�S�� � g Q� [�p�T�pNS �Q
A CITYU 6�� ��� ZIP �f/��.. -.. . � GJ
�Dute • �-�� Applimnt���� ARCHI7ECf OR -TEl � �
NOTfCE T4 APPLICANT: If, nNer mcking�thid CertifirAle of �GINEER � O�STRIR GROUP TYPE FlRf PROC�SSED BY Q
Exemption:-you shov{d batome wbjxl to fha Workars' . ���- Z� �
Campensotion provisiorts of fhe�lnbor Cede,you.must-forth- ppoREu V
with compiy with such prorizicns or tA�s permil shpll 6e - �� - �O .' � . � . �� �:
daemed.evok�d. STATISTICAL CIASSIFICAiION nFT. COrvDO. f/�
[aViRACTOR t�. Z
tICEN�Q CONTRACTORS QECLARASIQt+4 . u�. �55 h70.�OWELL.UN�TS
F hereby cHirm ftwt t am licensed under provisions ot Choptes P ADDf�55 Np. .��R� _ . . . . . .
{commenci�with5ecfron7000)�otD�vision3-ofthe�Businessand . ��. .
Professions Cade;and my-licenx is in-fuil#oree a�offect. CITY CtA55 _ �. �. � Ypi�ppTlOp�
. . ..' . , �. ..- . -... . _ SQ.R NO.OF NO.OF EHEIX
Licanse Numbet �- ".Lic.Class-' .•- SRE 5T0&IES - 6e.lniue5 --.-.—f3NE--- �
YAIUATWN
Contrxfar � � - Do1e � DES[RIFTION OF WORK r v F� A� o � �s�� . - � �
❑I�am eaempt vnder Sec. - � �£r� �C�� � ,�
ncro� z i 4 G.2 f1
8.&P.C.far ihis reaton �PA1R --� . #� �• ��3
. ____ ��. USE OF -
. �- - :- . FXISTING BL�C'a. �a � � -
fl : -_ . : �f�1 . _ . ... .t a �.Q.� �._..
-$inCtqrc� - ..__._ ...:.�. APPLi�CANT. . .Qr ffl[f+.lss D�p.. � � - �K�fAI. .. . .� _
OWNER-BWIDER DECtARAT10N �7 ��e� , - DAT �f � •s sµ,,. ;- .
�.t hero6y afficm thaf 1 am exempt from the Controclor'3 ticeme qOottE55 O-.a � ���� C..K-B-s:�1��1 �-
Low for ihe followirg reawn jSettion 7035.5,$usiness and - - NNAL �G���_�R
Profess'ronsGode). _., .. . .._ _,. .. . .. _. _.._...--- -_-_._ .__---------..___ ..__, �:-y�r`�_- --
..tt''''77tt ._ � � - BUItOitJC
�_� 1,os owner of the p�operty,or my employees with AppRE55 .. ' - �-
woges m their sote mmpensaeion.vriil do rhe work nnd� -- -�--.-..-._... ._ .
the structure is not immded or offercd for wla(Section ��`��Tr �
. . 704A.Business nnd Professiais Gcds� . . .. -- MOVING � �L ..
� 1,aa owner nf Ihe property,am exdusively contmcting TRAC70R NO. - .
witH IiCEftSGd[ontractws�to cOnSFrVe1 tFfe pfOjE[t(Se[- ADDRE55 - � �
tion 704I,Busineu and Professions Code). - � - - - �
REQUlRED TOTqt T K �� --�`- - � � -
. - . .. -EONSTRUCTION IENDING AGEMCY_. . -�SET en�c . .y�. _byyy.. _—_PROP.-lll�-------� -W107H- � -._ _ . z`} �i Y,1 h
!hereby affirm thai there is o consk�ction lendin9�^�Y f� FROrvT . .
.__tha.parformance uE the.wnrk for which fk�is permit is issued v.t. . #•+ • • • �
(Sec 3097,-.Civ.C.J, SiDE
r.�. 1 „6 l 7 5
...lender'a Nama . . ..... . . . ... . . . . r ! iDMn Raf.A
P.C.F��S Permit ha �J ��-�1 • • •� �.j 5�
m lendar's Address � �
� I carfify that 1 have rwd this opplicalion and stata that ihe issuance Fae 1Q•`$� �on,w r�c x . 0 9.0 4—L�?
obove iniwmntion is correct.1 a9ree to comply with ol�Couaty invsni�ptfort h� � �/
� ordinances arrd State laws relofinQ l0 6ui�dinp consvuctlon. . iotal Fee �+ 1 � _ � .
and hereby authwiza rapresenta�ives of this Counry to�anter � ���Px"`.�
� upon�he bovo-montionod poptrty for Inspection purposss. - . . . .... ... . . .
g ��^�/ fif NiViRSf i0Y iXMANATatY IANWAOi - .
� -�S notw�of.App�fmn�m�Apant . � Ooh � ..
_ . �
{ � � � t � �2r �� 3�o z'� � �` ��� � i�-1�� -Y - _ .
., _ a - .
-� �: . A' � �,v. •�C �� � ��� ` � t u% :. a �, . _ . .
'L � c ti � � �s C •� �-C�� W ' .. � r,�, �
G� .�.'C �-71" _�`� .`.Ni -� Y � 2�� � y �� � i u �` � F'\., - - i
� e e L' � •`; � i ��^ � ^ 3.cn'`_'c.: ''_S C �- o ` �„ r. C. ' . .
a
� �_,i. a �^J y ;+s t C C � d� L r +"���_�.?�,': � -j Gv i. j � .: MS � -- : . .. �
� r x ' e g � E - o c� : w - y � c�. �: ai "_'
'�.t � '- � i m. A " +.C.c � c n'_y 4.� a � y � =�-C 1� ` __ .. - .
e� t � �' 1�` 5 � � � ��� C"�.Y-_'�.. � C 4�5 G-.`' `Y- v _;� i = C � � O�;- .
! '
� C ., C ,� �i C ,� _. �b_� _�,� j, �'�:_�ti ".. Y ` ., ! : W - � �
� e > ,. .,: `y c fi c�� 0 3 c,�� � � r.� � _'� � f" i
c c ^ ' � �.c ^ cc � � O
� c�'� : ;^^:` F L'� � a�� � o r.` � G a � v�' �„z•.. Z :
.. x � -� � " .. z y � � sti�i c o a e? �c s. _:� a � % � �� � �
z �' c � � c � �:Q a ` e -°Q� `� �� y�� c `•y � � a p -
`• �•� � ��„ n`` �ma:. �`. � o r' fi _ 1 `n � �
y ' v C
c r ` �,z�� � � cEfis �� � � a =� �� � L � s�. �� �� 'a d _ �
r,� - � c, a :, - °y� d-c, `�' c� c. � �•` .. � � .
r v � � �, n e'w ° r �' ° �' � "o o ° r ' � I
� a.� 7� .� E � d � a`�� G �� =V ;�rti '' c a
. „ ` � y` � y 'v . [� -� C ,7� � 't O � ^ id. •�`•� . C .�i� 3 n ^• tl•" y '
L -- � . m a�--�f C y-� o `. H 4 -C� � a-z C=� ; c ``s G-: '"' � . .
� c3'� �.�'r ' � � a � r �'� e � '�s � -"i•„ H � � s ==-i; c �
^v >.-% - a -.�`- `;: �S �� � 5 F ," � " �� < � a c
L � �:, ���: c °i' c'� � -, v �` - � -.s ,R� ; � �- ° l
` "' ` `�` ^�j� �1' � 3 F'� v x G - .r` s �^ r � � i � .
L � ' ' � �c v � �' „ g . a �' a� c- v • ?•�z �°, m -
— E a��,-�C �.r " e'a ._ L � g ^� a. a `', c°'o ` � t - `_ � a "
-� y �. � .y .".�J O 7 '� 3- �'.. �+� . �. = h�:.[ C.�V p' � . -
� :� � '_ .: .: : . :'� .- r+ - . . .. - - � � -
f
€
_`. Yl� �� ' � ' � .
+.a� .. - . . _ . .. - �
W . ' , . _ � _ � � ... - .
0
Z
N .
� � � . .. . .-. -
N
V - - - . - . .. .
W -
d
N
Z � -
f
� ' � ' . - � � . � . . . ...'
kt
_m (. . �9 ._. . " .
_O .a � � ;, _ .
p � � f O �
y �
Q - - �! O.: , G !
K Q' Qy �
�.a � �
� p a ; I � 3 f i
� � � a � i ' � � � I
` � � .. i � . � (((((( � �
Q L 4 � i � � - � C � t �
� ( 'O Z ,f � � � � �
V � I � � t# � � 4 � � �
Q � .O �� � 1 « >,.(.._ , � � . � �- � �� � � � . . �
F Z I � I ~ ' � � I � I I �
N ,
Q � ' . . - m 0 � � � � � i f � I
d- � i {_ . (_ � j � � _J �� � ( '
I : � � � � f { I l
� M ��-. � � � �� - �� ��_ �
m �. ,
0 � � � o_ I a � a ` � = a � � °` I � o � �v� (
� Q : _ - � v o � � � ; 01 _ a it—
I Q i -.. � c` I � � a � a c a, � o � Y; � ° o _ �� Q,
j i � ¢ � � ai c c t. ' c� � I i �i a _ 3° � E �+-� �
� I a � n , " -° � a ._ c '' �Z oa
' ,. I _ � .G j Q. �` -C � a, ` _ _ O C � Q i O d � � T p C 4J , �� . �..
i I .` Q ^ Y Qi �U'
1 1 G C. C ^ � C'� j � E- � L` L �_ C G-�
O O ( .. z � _ � G � �' LGe 1' i O.�j G •��•� �p O O W O O 2 lJ .�w
p. Z � . _ _ � it li C� a _. ' � n. N