HomeMy WebLinkAbout1249A 1449A 1450A (6) WORKERS'COMPENSATION DECLARATION � �
.... ..... . . ..
insureboracertifcateofWorkersrtCompensatwnlnsurane�f APPLICATION FOR BUI1.� ING �p��ERMI
o e�tifi d copy thereof(Sec.3800,Lab.C.)
-� �� �- /,._. � COUNTY OF LOS ANGELES BU �D� AND SAFETY
�y ".� "`�Yompany—�� �� .. . - ,
BUILDING
Certified copy is hereby fumished. / FOR APPLICANT TO FILL IN qoDeE55 � ��'s'��"`'�' -�`��'"'`"�r-�-
� Certified topy is filed with the county building irlspec- BUILDING // ) ��,fi � , vi-�a: � -� ��,`�,�
tiOndeparfinent. � j (��� ADDRE55 / /�/r'✓'�� � f_. �ov.un !L� arF_.es�r=c
^��.,-� ��L'L� � � i ZIP CROSSST. �'�.t-�-«��-
oa,a f"d �Applicant ���- arv 1�'.°%"���L t�.Q-.�
CERTIFICATE OF EXEMPTION FROM WORKERS' No.oF siocs. A55ESsoa
COMPENSATION INSURANCE SIZE OF LOT NOW ON lOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one USE ZONE MAP {
hundred dollars($100)or less.) TRACT BLOCIC LOT NO. NO. fl��-<��(
/ '. TEL /'���; SPECIAL >
I certif that in the erformance of the wark for which ihis OWNE ; �1G'Gi v:T.f{ NO. ` CONDITIONS �
Y P '� �,� DISTRICT GROUP TYPE FIRE PROCESSED BY �
permil is iss�ed,I shall no1 employ any person in any manner f�� � f�:�yN�ti,��]�. �/��' CONST. ZONE �'
so as to become subject to the Workers'Compensqtion Laws. ADDRE55:C. � ;i. . �-J I �
Date Applicant . CITY -�,A'/d?;L'�j�/f!� �,(f�z ziv �- '�"�"`� �� �
�+RCHITECT OR � 7Et STATISTICAL CLASSIF A710N APT. CONDO.
NOTICE TO APPLI�ANT: If, after making this Certifimte�ot . FNGINEER � ' ' � N.O. �
Exemption, �yoo should become subject jo the Workers' .. , CIASSNO. ��"r' DWEIL.UN175
Compensafion provisions of the Labor Code,yo�must forth- qDDRE55 � � SEWER MAP �
wifh comply with such provisions or this permit shall 6e � � � 7E�.1!3f �/�C-+ gK pG VALIDATION �
deemed revoked. CON7RACT0 � ,- �' . �'/� NO. a5-�-"rri/-J R
LICENSEDCONTRACTORSDECLARATION //.f d��g �n,y� UC .�7 n�
I hereby affirm ihaf I am licensed under provisions of Chapter 9 ADDRE55 // ru!/,,. ^r j(�'d}�-� N < .� . yqlUAT10N
(commencing with Section 7000)of Division 3 of the Business and j ,(� /+� _ _.(�,��-�
Professions Code,and my license is in full force and effett CITY G'�J /✓�"}C� �'� C A55( J��7�� -�v•'�v �7 2�i,9{i
/�} � /._�^"� $Q.FT. NO. NO.OF CHECK ► �• e e •C v
/_��' � / , � SIZE STORIES FAMILIE ONE �y/
Litense Numbe� J���(,�Lic.Class � § N�+3�•�" � � a C 5,C�Q
���.,-�j-��1,� 5� �ESCRIPTION OF WORK I S;�L t t� N� H
Con}racfor Date �1 G�il� .
�I am exempf under Set. �� '�'����^' ^���'�'� ���'� �� q�R ❑ FINAL a n re���,Q j}�
B.BP.C.for ihis reason �1i� '�''�5 - REPAIR � DATE - G L L E�-�,�1
USE OF4 G' DEMOL FII�➢AL
Dote: EXISTINZ',BLDG. }_.r� 1�'.�.i-� � gY -
9 APPLICANT TEL. /_
Si nature OWNER-BUILDER DECLARATION PRIN7)-. ��-J��1={'G5' NO. , -GsSW� �1 4 C,9 A
I hereby affirm ihat I am exempt from ihe CoMracfor's Li[ense ppORESS%�'/'^ �fi' � �����/�� ���� ►
Law for the following reason(Section 7031.5,Business and �° e e •2 v
Professions Code): PRE �
aBUILDING � m e •2,6�
I, as owner of the property, or my employees wifh A�DRE55
wages as iheir sole compensation,will do the work and a o e �
ihe siructure is not intended or offered for sale(Setiion �aA���� m 2 6 3�
7044,8usiness and Professions Code). MOVING tE�.
� I,as owner of the property,am ezclusively controcting CONTRACTOR NO. �2 Cj�Y'��U-
with licensed contra[tors to construct ihe project(Seo- qDDRESS
lion 7044,Business and Professions Code).
REQUIRED yqRD HWY TOTAL SETBACK FROM F%IST.
CONSTRl1CTION LENDING AGENCY SEi BACK PROP.LINE WIDTH ,
I heraby affirm�hat there is a construction lending agency for FRONT
the performance of the work for which this permit is issued P.L.
(Sec.3097,Civ.C.). SIDE �� �'-�'•Q A
- P.L.
Lender's Name #'� � � s � �
$ �P.0 Fee$ � (�Ls Permii Fee /�.�. Sr�? p � (`
Lender's Address I 4 J,�D
� I ceriify that I have read ihis application and sta�e thai the �•4' � Issuance Fee %C-S°� o v �(a.�Q���_,,
¢ above"nformation is correct_I ogree to comply with all Counry Investigm�on Fee '/
� ordinc�i ces ancccJJJ tate laws BI g to building cansiruction, Totol Fee T'� . �� �L,Q 9�-�(j
�i ond he�eby a�/th�rize re�' t tives of this County to enier _
m upon iF�e abo�e entio,ped`r erfy for inspection purposes.
� � �� ���'�� ��J����� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture of Applicant 1�Agent Date �s
�,,.,,,,,�...,m.�.R.,�,.. ��.,�. .. � _....._....� - -...�.e.,,�..�.�..w....n._.._.....� C`.."�7 f: � Li�S.t 1�Ca.A.T2n f I3V .
.....-.:.;,:�.-�.�^a" ciP.�iC:�l3T �.. 6L&u?�',Ct^+5t"$'�IC�FaS _.,.-,�� .
�-�----..-, ..„ �-..w.,-.-i.�.�....ai.,,,,..,.,--....«4-..m..�.:.a�e,r�-.:,�„,�,..__-.,- ..� 1 Lereuy e rrs'1 ihs. �s n o�c�nrP �vm 1F.�Con�rc,:'or's
IYB: � h�3mrvsc�d, Lice . i or ihe foloWi y rc.son {Sec. 7�315j
��_-�.� .RnGreve:l !— " .---.__-_ �'sse ,ra �'snj -. c, a.x� ';yc:�.:u;s��tuaich
�f"-, Cc�?s� �t� .� F3¢:Po . ` � . " _ � ;��: - . ,y t- . . r � :n:pr>.•z,6'�n:;:ic/,
� ;- '- --- - nr�-,h r t ^r R - ...<'r.cr,zlsc reguire=
�-._�w.-_,_..____.�-- I . . . ... . .- . th pf � �� .ct�r�r t f d a ss�nrd stctc,:aeni
----i. . - - —� _. . - . .. . - . ' - r„ c-^s..e_�..,>a.:.. tn in..;^raaisso�ts j[Fe Cnn-
.� - , -�u n..r � �ra n z�+ , � r�.
�'�___._�-_.�. ' —_(_ — �-'. . "`. - ��-- F.. 6� a s x r .e i reess�:!'Yroj'e.s .<
� � D f � a 3 C s ons
I I � � .' � . . � C<f � 9�F r.a cz.n- a 7arefr� x cnd[Hc das's far t 5�
L�,,.e,.�_.-._...._i_...,.._.._..:_...... a-�.._,.._ ..._.._.e..-..._ .:-_� �-._ �.- �_ -._ _ l:. r � 3o As�� �r ti^o �f Se �s .�'l.�Sy
�a?c�'wc d 1
� � -� 7:.4U::e� �...._ , . �� .��8t If. �s r �i�h� _ orrris;iJ
_].O'.r.,. S:F�'�'rp:FQ @�' ___ _ . I:�, ..-� .� h �_ Y..7.•�r�.`.
�J 'W_ A90 I � �
�..-;---- . _ ___.,.__�.__ .. '� . . � . -. . . . .., ,.!,�.�w� e,or.M�prop�r y.o y e np;oyoas ev�h
Wo!,.r.. t� at: ... �_ � ~._i -�i ,,,, . � c � o �cnse,:on,�v il uo tiz�eerlc,end
^ l � � �� � .. ' ` •��. . -. .' � �-� . -. . . .. . a� . ed o efferca for scle l5ec 7044c
w
. ' ' � ' ;n s iu d �
Heoltn D . .. �ient .� '' I i--. . ` . . ` ;�v _s ,I /- s�s .o✓'.,2 i^Co.strztt::'.=7+cens
.� ,� . . i� - . �� . . _ .. _.. � .._. ..._ .cu -i r s r- � 5n bur?ds
_ 7
, �Fra Dppo :�c-ar i o--"--�-----�-----__- ' .� . , �, - .-'i ie � .ut�s�. . >x r4 f:3ssej nr
I„ I � _._.-^ drfi
`
�. _. . . . - f3r � � x..- nyl J � a,Z fi s ��
:G'cd�-� " .. ��• ' ., . �____-_ _- - __ . -. . . Gr s - - �u rot zn£c3 d f o -��3f e ja sel �.
�--. ., . '..- I �� ' " - ' . . r t f 1 t e e T f a i ��re�.-
�Gcnle cal.� .. . i , —Y- � _ ,_ .. � , -_ � _-•-�- . - - , - _�_-. �. . .! r. . e c..�, i 3,a xd s r
i�
j ' g I �-� � � � . . � � ;ixi ,nf rr<�.�o :.r ,_..n. .� e �.
' �-q- i _,. . � . � .,,
!P cl�strien Pre}c-e'.:n i ; : .� .. . r( s�f �1e1 � ..
I(F�r.ce?(Ccnor%) ��I . ; .,... . - � � . . 1 I o e ncr<f �n p�i -m e d s I conir;rc
:h
_._y�.� �, . ... . . ... c._ e t c iro t ,� ., i.c lSec
. f X
-apraal Iqspec'on ��: � . .. . : 7C-C �x..v r e , i -- -�� Lad . . C. 'r¢ctnr'<
.(Cone)(fSesonryj(-h��din9)! � I �-�_ . � . . . .: e�r �d -.r e } �s ¢ er �1 r p,r7i'u.L;o
i�._____..__ 7 . i � ... . . .. .. - . � � . n���a, .>n;r a ms ?a;�,e . <,pcqo canS o..rsfnr;¢cr�
� o.��4 ��� �_J � � — — — —----- ti: .. ..�_ . _. s., -. . . � ,,�
.�, ` _��
:9 _..5..i
' I u
�Fc•k ng � C . ,. . � � �
.. .. ._. . _ . ....
i�. �_.T��.� �� 1 . _ ' - _._. _. .. m=e. �_un.,r.r5 __._ .a .. .or his
I a -�x Srn•�P t '
` I �-_ ._-_.-. r—_- _- ' aG
�..__ --_ -.._^_i� . I ' -�� _-_�— - � . , . . � Da ._. . . .. 4wner__'__�„-
,..�.�.��,..-,.,1-�......em_..,....�...�,.�.+ . . .
i-..o..-v.,,._ �. , . . .. - . .,. ,
�,�,.t..,..., w^:e5a � �e:enav':^.'s Se�:-�@vre .. . .. . . . . . . ' ' ,..,. .-.,....n � -t'ee., c .: .
4.-.� _ ' __- I i e s i�a:'�...
- _r.m-�..-.��.�...,��:r-•:=..-�.-._- .._....,._._ '- -- ---- --- ...s.. " - a..r,.
!ioca�ion� ---�'----t-i . . . . . .._. .. ... . . . . __.
�cserb�c( s�•cr�'s), _��_ L — _ , ' ._ _
���_.��� ; .� L_,"-
�'oun�aficrs � � � . . . .... . .. . . "
`^.___ � _ � _ __
�n� �._ ��- . . ' . ._ , -_ - � "_-
� r :
E..—._,_._.._�,�... �__-- '. � . , .. — , . .
f`�Ene.�r��gY In�swct on ' 'i _ _ . .. . .. . .. .. . . , ,. . . . .
Lc4h� /D� ali Y-1 I - � - - � ..
y:.� ,�,.�z: �. .�.;. ..� ..
� in�er or- �____.�_.J.�_-._..v �I.. ,�. : :. .- .: --., . �.._. , -.. -�: _.. . , _ . _.._ . _ . . ,._. ._.
.�_____,.»T� . --' - -
�La n .Extcr or � � ' . �� . �. _ . . _ . . . ...
a..
i . _ T _��E ��� � � ; � . . . . _ _. _ . . .
�N -se Nu-nber �'�--- i . . . . . �' • . — , .. . .> ,. ,. . ,.
� o rect 3°es:::d � - - � �
.___._.....4_� '_�rJ'_—
1 F�rol . . i �-r.-_ -_- _ � - . . . ,. , .. . . . �
i
�t(itc*G:l� ^ : _.. '-. . .... .... .:..:. . .. . . .. . - i-, . .
,"�__--��-_�_�, ____�v.�" ____ �
� ,
; < i
� . ,,,:.
.._ . ,.
° ` ,_. . ----=
I- �—�—
- — -� -._ _ ._ _.., .;...: —.F-
- �-
i ,
�^-----_._.-._��_ - - ------ --- — ---- — ----