Loading...
HomeMy WebLinkAbout1338A 1529A 1530A \ ' WORKFRS'COMPENSATION DECLARATION � , � � h�re6Y aff�,m �ha, � �,a��a certifica�e of�o�s��, ,a se�f APPLICATION FOR BUILDING PERMIT insure;or a certificate of Workers'Compenstion Insurance,or a certified mp thereof ec.3800,La6.C.) r � � - Pol�yN��"�"!�'r''�t�Compony 1�,��..C�-+«.v� (ir:zt,ttt�' `f=0UN5Y OF LO$ANGELES BUILDING AND SAFETY Certified co s herob furnished. ADORESS �/ �� !H1 �fJ�j J-%l �1 ❑ PY' Y �� FOR APPLICANT TO FILL IN ewiuiNc � Certified wpy is filed with the county 6uilding inspec- yUIIDING � - tion deparlment. ADDRESS y. '��' - IOCALITv� i .�,(i,� "� ;'�%j,,. NEAREST Daie Applicant CITY ,�% ,�C.�U� � l/L zia� cRosss�/y�D,v�f���l '�6CD•� f�R�l+v�C1 ��`£ CERTIfICATE OF EXEMPTION FROM WORKERS' NO.OF eLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permif is for one �USE ZONE MAP . h�ndred dollars($100)or less.) TRAa s�ocK lOT NO. NO: � � � ,� TEL.y+J� C�� SPECIAL 'ey I cartify ihat in the performance of the work for which this OWNER j� . ' NO, � �(;�Z. CONDITIONS � ermit is issued,I shall not em lo an DISTRICT 6ROUP TVPE FIRE . PROC SSEO BY p p y y per5on in any manner qDDRESS L, �[,l�U�df( �j/ � CONST. ZONE � so as to become subject ta the Workers'Compensation Lpws. 1 py ciTv L�L3I�UY} .q, zia c%7 t/0 �G� � -� ll .,,L.•.zc.c�;�-- � Date A licant �"' PP ..� STATISTICALCLASSIFICATION APT. CONDO. g�y NO110E TO APPLICANT: If, offer making this Certificote of AR�HIIECT OR . / � TEL.. f' J� � ENGINEEft - �� ~ NO.J��`'}�y� CLASS NO. �I✓ DWELL.UNIiS Exemption, yo� should 6ecame su6ject to Ihe Workers' �^ � � Campensation provisions of ihe Labor Code,you must forfh- ppDRESS/�LZ`��UC�h S� �I��S•/�.✓L•d%�1:.5 SEWER MAP � .wi}h comply wiih such provisions or tnis permit shall be Tf.l.'e)j � deemed revoked. �- 1 VALIDATION CONTRAQOR - ;7',_.S C'��!U-3� NO. BK. FG, . LICENSED CONTRACTORS DECLARATION �IC. �+ I hereby affirm thal I am licensed under provisions of Chapter 9 ADDRES J�� ' LL�tL"�tJ�L�• NO.J�Q;i�C',�. VALUATION (commencing with Section 700D)o(Division 3 of ihe Business and " LIC. `�� Professions Code,and my Ifcense is in�full force and effed. CiTY}Sf,,,��,� ��,$'�k'/.L���:S C1A55 $ �]L��� �-.� 54.FT,- NO.OF NO.OF CHECK �j `�3'��A ��' Li[enSeNum6P�2L��LC2.._ LiC,C�ass� SIZE/��,j STORIES FAMILIES ONE • ' #me.ee�� ��� �ContracforC�✓�S �:.Er � Dpte �) r DESCRIPTION OF WORK ,NC:9J ,(�fi1/p/,L��— NEW s 7>+ (p i/L� p 97i �•�•!L'J�I'2m ❑ � I o � /1(J,�O S. 4 � I am exempt from the licensing requiremenis ps I am a ,y yj'jj/�,y - �y`� � .�;t � � litensed archi�ect or a registered professional engineer �.L7ER � FINAL .,/ ��e �� • o j ��.�.8��� v. . acting in my professional capacity (Section 7051, aEVAie � DATE �f' � , Business and Professions Code). � USE OF � F�Np� � � f�%(��-8.z � EXISiING BLDG. DEMOI • Lic.or Reg.No. �ate APPLICANT TEL.�/j BY ��7`�'. OWNER-BUIL�ER DECLARATION IPRwi� � �S NO. � �.r a I here6y affirm that I am exempt from the Contractor's Licenso . � Law for the following reason (Section 7�31.5, Business and P.DDRES .(J � f/-G'p 0 1• 5•�;�" � z Professions Code): PRESENT P 1 5 2.9 A � ❑ BUILDING � G I, ❑s owner of the property, or my employees with ApDRESS ages as their sole compensa�ion,will do the work and }�o o�n o.2 3 the structure is not intended or offered for sale(Section LOCALITV 7044,Business ond Protessions Code). MOVING 7EL � y �6 4.0 0 � I,os owner of fhe proper�y,am exdusively coN�aUing �CONTRHCTOR NO. with licensed cantractars to consiruct the project(Seo - ADDRESS m f9 °�U.��U tion 7044;Bosiness ond Professions Code). . � REqUIRED iOIAL SEIBACK FROM EXIST. O��� O�H�.2 CONSiRUCTION LENDING AGENCY ser nneK YARU Hwv PRpt�.i_we wi�>Tr� � I hereby nffirm that ihere is o mnstrucrion lending agency for FRONT � the perfonnanm of the work for which this permlr is issued a i � . (Sec.3097,Civ.C.�. SipE . �.�. �1 5 3 Q A _ �e�aors Non,e � . �o'o.a e Lender's Address y� P�.�ee s I a Pe.m��,Fee �r��, ��� •�� I certify ihat I have read ihis application and strte ihat ihe "�(,��U !✓ jl� . � m 2 74,5.p above infonnotion is correct.I o ee ta com I wi�h pll Count Issuance Pee � 9� P Y V Invcs�lga�ion Fce �ry e m 2](�,5�`�� ordinances and State laws relating to bullding mnst�uction, ioral Fee �,,,'���:��' � � and hereby outhor�e representatives o+this County to enter � upon�he obove- � � ned�properry for inspecrion purposes. ��� �'8 2 " �l� SEE REVERSE fOR EXPLANATORY LANGUAGE Siynufure f plic �r yeni Uale . :Pis =f _f_"'.�.`_s�.�fS� r' �r m -r. �! � -n r� j-0. - � `n ��T' b t� C�� = � '�` �__..�.__.___,_'�_--}��.}� --�-y � _3 __ o _Q_ N o_ _ Q __l,�^L..-�-� _..�--� g i I ° , �� , o � ��.�-._ � � _.�._,I,_� o � I � Q �. � ,� � ( o , 3 � 4c� o l- c. s-- s a- e � � � i � o - M � p Y �u w..� � �_� ;� � -3 �ts-�� ��.� vr_. L n co � a � , i � �� i E ����o � i y m.. ;n s p ,( �. `.� �'p 1�.;�,a �� °, fl L"� � = i ;�, i � .� 1 s 1 � :�� �cb Z. �, .'N� % J _ �X 3�.� � ..,_ '_'� n i tfl � d V � m,� � � � � �, � n� c � � .� �' � t �s ca- �� fl' ° a i = i � � � ...� ,9O 5�-O . _ 'N -G 4 cP.... �� ..,J � � fl _ 'G � i a ��-c � o V 'o c ; � � �-. -�.. � � _ ; � 4 '- : , I m � � � ' t�l � � F Q I . } ,.. , a �� 6: � � �� �;; G � � � `� � < � �� � $ � � � �I o � � I I _.. ' i k _ � � _.. �i � � - � � � � � � � g � _�{.__�_ � ' � � ` _� s — � i_ i � � � i � i ' ii � � �I I ' � �� - I � V- —�--��-�� I � �� � f iD -�- i^ i � �. � a g � � i � � ��� �� ;,� �� _ � '- —s — _ � , ; � '� �I� P . � � � � � ! _- "_'_""�..._�_. .� � �� 1 � —� � I Q E � � � ! �� j � ! I ' � � i � � � �. s. i ;: I � � � a � �' f � ; � � � �' � ���_ ; �i ,� a. �. i i ' � ;y § i—I� �, p � I , I � 3 � 3 � I � �- � , i I I fl � � � , i , � I, � i � I � � � � i �� ��� � , � v� .� , � � � ; ; � n � ; i � � � ► � i � � �. ! � � ; ; � � � � i i � `��, � 2 , f i� � I �! �s.:. i _ �_ I � !� 1 l� � --;— -- �— ---,-- �---;�— — �— � .;�—. �.� � �____ I � � � I � � e � , � � � i . :.� i , . � ; :� � �:� r � i ; � � . , i I ' E � ; I !I � � � f � - I � i � � f I I � a � � ! I —� � . : ; � � , ; , � �, �� I � , � � - � � � � � � ' F� � � �; � ..: � ( ' ;.. I • I �.+ . . . . . I � �� � ; � � .� _ � , � Q� ! � ! , � � � I + ! � � i P � � � � � ; � � � f � � � I , i : � ' , � � ; � � , � � � . � ! , f . , _ � f `7 N (�'SY �p"�N- 1., ' Sh m � ':? A A ti eF w p 't 'tiy �- � ' t � � � Q _ � e � n a co ea � '.°a ° o � ' �' � �� �� �� c�q,° � K " '�'a r m s � � o J � m.yy e A [�� �.'� ,�, � � ,��a �.� y �._. �a aa ,� K �� �a � . � c� ' y � ' � � ���`^ � F. ti ri,p e iq':r ��1.A � '� `�,il,�'V 4 ro'i!� �'� '" p A �.. � � y � S � �'Y o o b. m �, m m ¢. � _ n h.O `� s- ^,e, � � e� u J � �, n O ,- Q .v"',to • O ' �. M y''^ n � � � � ° ° � :,.�. :' -9 0�,� � a,� n c � O �+,A � �Qh a'N � s o'� Q :I � E 3 �„�.... � �'� � �,",s � �N �,•° a a,`�. m� � n, �a � o M ^��� a. � °.� � � x �y..� �y � � .�y��� o '� ��� � � ��� ��^ N � '� b =y I y � N �l i � � �-a o � m � � � m � '�. "' � � a � .� �1 m � o � o 0 3 i � � � � �, � �; a � - � �j�p.�,o o �u o a x w'c �ty N � ^:��- �'1 � -6 N p ti � n f�'%'a a Q c� a "�t� _. N �e m w'{�` M, oi. s I � c � s � o A°� �, ��� �,'�., co �� a � n -��. �A k C'� � n y C :: �-fl � � � � j � 2 a Q �� �Q � � �o �b � � o � 3 � A �� s wh��� � w � � � ti, A b.'r,� � '� ^'�.� " a"o ' x °<', �a e,'�' � o° C1 . I I � � y `° ° " °�° a � 'e � o n�-� �° �y N "`�.°,°� K s o''� o 0 3 �' � I � � m ��� o•N v a.�b c y `r g 0.° a°c �-� � w ti;� n 0. � X �." � I ! � sc �'': o'� o `� �:� o �_. � y ;c . � °�•: "TA'� ° �. o'� `•° �� C; i . E �' n•&� " ^ � -`°s v � 'c� o� ^j�� < ��. °���7 i�?� •a.�ca 3 r' I 4 ` } � � u o� o ° c• � N � a �-cc n � �,,��,,,� �c� '� c�^ ! � I � y .,.� A,�', � Q„„ c� w,`ri'' cu � � v,,"S�` a O .� �;y'� N m -,. �'�. . � � �. � . � R,^ � �? c'.� {�+..',h��n� '� e�_� a.� `'� � � c � � � � � � i � �IL � � ; � � ��� �e i„��. _ �:° �'^s A.�� � � n.�G �'b �k�,� � C''^ x�• Q � � � i x � s� _ �, ca � n ;� �, o :c o'r �" a x o'oa � -s .� N i � m -�i�:��'`� c�H � � °.R'S° � � ° 3 �'�o �`S n x x :° ? n Se�: � � ,�� a'� o p� m �""�R'o K �� � � � � � � V A b W�R"�:' � � ;�Z � � (1 �.�,,� S Cu n �' �� a � `��ti n � �0 �xf o S�a��V.a �A, "% �� .� � i � I " ^� `_: o o C S�, n � . . �c4 �" ��,c� ri� ca.q � v Q . . � q � � O O y � �N 3 y;� r� ��a�'� ���Vo Q�F �M �,,�� n �n� N �� W n ay ' V„o m o '�.. ° •�,..:� aa � . `C o„v o � o m .:y n o' o � � � i I � � '" �u ., y`•`i " �v e'�c�a -�� �^�s H'm �°.' o..7' ' ^`e fJ � r �i :. r�:, � v�ui � � �