The URL can be used to link to this page

Home My WebLink About1759A 1760A (17) ; � WORKERS'COMPENSATION DECLARATION ' � � insureboraafcertifca'teofWorkes'iCompens lioolnsurancelf ' �P!'LICATION -F�OR- BUILDING �PERMIT or o certified copy thereof(Sec:3800,lab.C.) COUNTY OF LOS ANGELES _. BUILDING AND SAFETY : P❑ol�icyNo. Company . . . . . __ __' .. . BUILDING � Cer�itied copy�s hereby furnished. FOR APPLICANT TO FILL IN - nooaess �� 3 t�. .�� Certified copy is filed with the counly buildin9 inspec- BUaDiNG �+ � tion department. � ADORESS -J• LOULItY� Ls's>c �� . � NEAREST ; � Date Applicant � Citv AJD � Ziv � �S CR055 ST. CERTIF�CATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. a55E550R� COMPENSATION INSURANCE � SRE OF lOT NOW ON lOT MAP BOON � PAGE 7ARCEl (This section need not be compleied if Ihe permit is(or one USE ZONE� MAP hundred dollars(5100)or less.) � TRACT BLOCK LOT NO. � . .�. NO. /��.� � . . . . ___.TEL.' � . SPECIAI � .Y OWNER ',u5c - El. O. —� �ONDITIONS - a I cartify Ihot in the performance of ihe work for which this ., DISiRICT GRouP rvPE FlRE PROCESSEDBY 0 , . ...'._'...__.__ ___ . ..._.._.. permit is i55�ed,1 sholl not employ ony person in any manner CONST. ZONE so as to become subject to�he Wo�kers'C mpensation Laws. ADDtie55 �C• _ `� � � O � �I� CIiY (L� b GrF ZIP Date Applican «��'� � �,/J STATISTICAL¢ASSIFlfAT10N ,. . APT. CONDO. � / ARCHIiECf OR � TE�• W . NOTICE TO APPIICANT: If, after making this Cartificofe of fN�iNccq �' R n ��LASk i'�-ND. � � �-�- CIASS NO.�DWELL.UNITS_ �Exemption, you should become subjecr to the Workers' - N Compensation provisions of the Labor Code,yo�musl forlh- qpppEu . ..-_ . .. .._- .. - � SEWER h1AP �, wilh comply with such provisions or this permil shall be TEt. . deafllBd fBYOkC[J. ' ' CONTRAROR � NO. - -�BK. PG, - VALIDATION IICENSED CONTRACTORS DECIARATION IIC. 1 hereby affirm that I am licensad under provisians o(Chapter 9 a�oRESS NO. yqIUATION � (commencing wiih Setlion 7000)of Division 3 of the Business ond LiC. � � . Professions Code,ond my license is in full force and eHect. CiTY Cv 55 S � � . � $p.R, NO.OF � �� NO.OF CHECK � � �� Licensa Number � lia Closs � SIZE � STORiES I FAMNES ONE . . � / a �175.9R OESCRIPTION OF WORK O N NEW ' Contra[tor Dala . . .. .. . . ... .. . _._ ApD - � �• • •-•2 3 � ❑I am azempf under Sac. qiTEg � FINAL-. ,` .._. I • �z�� . ... . .. _._ ... . .. DATE'T�'.�'�M`�1 . B.&P.C.�of this feP50n (J p REPAIR ❑ � � � � �2�O O� , Date: . .. -. EX Si�G BIDG.� �\CCTA1�- -V EH�T � DEMOI ❑ BINAL1 \\ � • p p APPLICANT T L Y �1�''.� 1\ � O Z 2 V—V� . Signatura PRINT -LC � -� -.. - . . OWNER•BUIIDER DEClAR.4TION ^�, � , 1 hereby affirm ihat I am eaempi from tha CoNractor's License qDDaE55 � 1!!�I� F-�C.�r �� "" � - ''��'�� -� � � Law for the following reoson(SeUion 70.31.5,B�siness and . . . Professions Codef. � - PRE N -' - � ' , ❑ B�ILDING _ . . . . ... . I, us owner of Iha property, or my employees wilh qpDRE55 wcges as Iheir sole compensation,will do the work and ��A��TY . �1.7 C,0 A� .- �he strucwra is not imended or offered far sale(Section � �- ' - � 7044,Busineu and Professions CodeJ. MOVING TEL. Yi.� • • • •i� � I,as owner of the property,am ezclusively toNwUing CONTRACTOR NO. _ , _ . _ .. wilh licensed wntroctors to construct the project(Sec- qDDREss � �,• •L 2 5 Q� �tion 7044,Business and Professions Cada). � - -� �� - - � 2�2 5 Q x . � - REQUIRED TOTAI SETBACK FROM E%I57. • • • � . YARD HWY , CONSTRUCTION IENDING AGENCY - SET BACK PROP.LIN W�DTH � � I hereby affirm ihat Ihera is a conslrottion leodin9 cgency fot � FROM� - . , � �- �- - -- �- � - � Q'L 2$-$[� . . tha performance of�he work.(or which this permit is issoed ' v.l.�' - � . . � • ' iSec.3097,Civ.C.)... . . , • _ . .. ..SIDE�. . � , . . � . � .. . . . - . . � � . . . .�P.L . - . . . . . : lender's Name - ' -. . . �: .'. . . � � � y ._ . ._-..� ' /,y• � ----� --.... � ._ . � ' . .. . ..� . � ' - . P.C.Fee S �' �'� Permi�Fea ' if ' . — Lender's Address . � . - , ...... :✓�U _ -._ . ... --- � � _ . . . .. .._ ..... .. . . . ... a I ter�ify thot I have reod this opplitalion and state Ihat ihe Isa�ance Fee� ' � a6ove information is correcl.I agree lo comply with all County Investigalion Fee _ . .. . .. . - � ordinances and State laws relating to building construciion, Taial Fae ✓!��✓D Y'i dnd haroby aulhorize reprosamalives of this County to emer _ . . � -u/pon the above me tione properry for inspettion purposes. (� - - � - --� � --� �- �"" �" � - . < x ��/ . SEE REVERSE FOR EXPLAHATORY LANGUAGE._,,_, ... . . � � � - - . � /�iq owre o}Appliw ar Agent Dale . � �.�s I ' � , . . . ... _ ... . . . _. __ ... . . � � i: .. . . .... ..,...;�O 'O� '� � Cl/� j,' 1n \' �' � � �-.CrC,y:p��0�'•`•'\ L� afi� CL`�C��- '��Cd:C� Y� ' S �1 I� '. " .._ - V� - � Z v .M l h•l�C 3 O G ��•~: y. � r y ��- - :` . �_ I . ; p O ` C�•O�4 V, � �n O,r �2 O y n..�'.�L,' „��`.t.G � C �+ - p- O . _ _. _�.C n ��`i y��y C N M�V 71 O C r C�'.".-ti:ti b l O � r��. i.'�~- . � ' '_ ', . ' �i: 7�iu a�� "o�G`,'c�^.c` o3v�-��.�:., �'�'� w� . >. o�. � • � ' a ' �'• _ �r � C �� c `-" e� :.�►!`' ^ c � � m� � �� c`;�'� " �� a�: � `' a. �:n7 � � . •- . .. 1-'= ' ' i:��,;.� � y,�'°�` a ^ o � +�+.:�'�•�.'� o ��``: �L �� : �'� I , c 1 ' -- - � . � . .. - . � E o ' s^`:c N•w' G �'7 � 'c� �'v,«o tt �.�b�i� o,� - u �[S�, � c C,' - � I 3 . __ . _ � " _ ", r � p �- ; b � G:�Gr;..e b E_ 6 \ y 27� �"' �. ! ` .. � ��-• � i� yl " " i . Q'~ d `_' 'a � £ c�_, ;c` a. 3-c U c'� ' �'::� --'c` i--�. h. i j _ f�,'„ . . _ ,�f�� 'C t, �.c . _ .'4 c �' c'1 ., c .C�r. . f u F �� . . i , � tU-. L c�c.'h : ._m^.�`a..F..`:� T o o�'c�,'�'�� V "^ >. °V C—I..y J �- . z _ - , - �"' x c: :. � �� .�`�c, �y` e; C, -c. .,'S i v-;. �. p Z C'� . I i �n _ � , . ' I .. '�• � ; �. ��i ti ��'� c V ��o'L• i,��-r: `.i� . c. n c � M � .,u _ c' ..i � � . � E� V .''.:i � K �r."o: � ,`G•. e�i�'U °�'` �'y.� �._�e. - : i,��, �. =�� N . O . - � . � G1 0° = �,� °"';n �.� m a v e'�,� .. °'�' - L `r„� � - :a`� u - � y C .��'i„ `` ` s•�v � V •�c�'y � _"^ G+-.r �_i � i 5 ci. y� 'G ; . - Q± �; _ i . � .. r�7 O r � '� :: � " � � � � � � ...'_ � c. [ :. ��, �� fi .� i �� ' ' ��.. U C [.• � O �" R- '�-� ' i; � ��e _ .::C • v �::•c r`� ��c.:� ° �`' : c � 'a- - . _ - � i ' .. , ; ... `Y ti�:�. . � '�r c, r� �• c7 � • _��L E 0 l -� ��„ C � �� C'�'C : C. v�i C L•'�a�, ` ` �`'^, y, c� .� C = r� 4 . . . - J • �+ +C�. eti, :'~y c C'��C'~ O • r� v C e'� C c p� �p c �� L��' ' ' . . . � ' C ' -C T� N q C,tC•M ti C� i�i.� .. ^' `- �...� C;��.�` tC.1 O C'u• ,� ' " G �O i � � � ' • .. 4 C l' ` � I . W r C. y C C.Ci�i C'C,�'l..�,.' — O u ` C.i 4 + `C'�"� � L q N C y V _ i " , . : � 1�� G,� � � '�. �� 'S C! �• l �~ t, _� � � C �` C N•� -� '-� t� � � �. ? Q G� 4 .L. � � O I �' • 1 �1 „ " ir� m o .- � c�;' = c � � " � � c = c�.c`. �=1 c�a� '.�•c� l] o � ' .' .. _ � . � � �� . ,G'c ._.' a e i � c c, co � = ! o `, - � c C;e 5 c. • S�q r ,c� Z: .-,-`c� � r��-c c,C: i p � _,_ . i i _ . . , " S ' : �.... � � � � � ; ... _ ,. : . � . { � ` . ' • ' � r.� �� ' i � !. _ `� . ' - :.i. ' , ; ` � . __ . � -- . - . W, , I � � . , ; i O _ � ' -' Ir I� � - f � y l" � Q � . � �/ � . ,� ; ..�'� �� I � I � l� � `. N 1.. • � , ; I - , I . � I:1 _ � i _—I" ' ._ '• ;'_ �_ _ Z ' � . 1- � � .. � II , _ - �. • — i , . -' �: � f . t• � ' :ri , `� ,. , ; , i� � i - `_ � i , � � !' i � ! ' _, �. - � ' `I �^ . ' � � � .. __ � �, ri ; ; _ � i f . - ' �� ' i - '9 ' . � � � i, . •�� _ . . . � . � , � � ,� - � a � . , � � � '' . � � < , •.a i ec n c eQ --- e' l" � D i � � � . . j ' � : _ R V �C Q ' .O' � �. I ' C r 7 ` . � i ` � _� I ? -� i 6 � � P : a � . . .. • . . • o � o � T ' � 4ry � - - ,` a t • i i /� . � n � L � C I . ' '_ � ' I - i � i � , i � ' ' '"' '« S I : C � V- .I __ M O " " _ j . C� � �� r- � � � ❑ I � U G ' .." T O ]' ./1 � -L o E_ `c °' a � � 'n ° 'o �v , � u ...� . i o o uro r� n .p . .. � �?� ' ' � :� U � G c � o, � > `_U c � � �'• '- a o a a o, •• c�� •�' r� �; � o � E a° ° ; � C V Cl p .O C U C� O.. •- I� O . O N u. I . ' i U p a c. .� O� .-. � L C-Y = 'i �c >� x Z°d c � I I r o • � o =� o�� ';o� �rn- Q a.o a �. , T o c u, � I o I ,o � a : a �o -�p o ��a �r ;Y �V.a c � � . p �— „ ' � ' o o d t r �`' o� � ° �---- - ----- --1-- o o ° ° E c z -3.. ._ . u.' (� ['J a� ✓aiU ° a �� u°. in �i w xU LLw