HomeMy WebLinkAbout1578A 1579A WORKERS'COMPENSATION DECIARATiDN . �
I hereby affirm that I hove a mrlificale of consent lo,e�f � APPLICATION FQR BUILDING �PERMIT
. insure,or a certi(imte of Workeri Compensation Insuronce, - �
or a certified copy thereof(Sec.38IX1,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
P�o17cyNo. Company BUILDING n
Certified copy is hereby furnished. FOR APPLICANT TO FIIL IN AD�RESS Id �+ YI� �'n �
� Certified copy is filed with tha coun�y building Inspec- BuaDiNG D��y�.� �� �C�' C..�A�r
tion deparlment. AD�RE55 r iors.urv
NEARES7
Data ApplimM CITV 1 J'. ZiP � � CRO555T. Qq U
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS. /+SSESSOR .
� � COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be tompleted if tha permit is for ane lf O 9 � s USE ZONE n�nP
hundred dollon(5700)or less.) . TRnCT 7 BLOCK LOT NO. �J � NO. �������
� � TEL 1..� � SPECIAL y
I terfify thaf fn Ihe perfofmance of Ihe wark for which this - OWNEIF� NO� CON�ITIONS fL
permft Is issued,I shall nol employ on person In any manner " 1 �r DiSTRICT GROU7 TYCE FIRE PROCESSED BY Q
so as to become subjecl to 1he Wor Compen fi lows. �'. Ao�RE55 d /O � CONST.� ZON� V
/��y � �
Date��Applicanl � . .. CiTv � I - ZIP. 7// .II STATISTICALCLASSIFICATION APT. NDO. O
NOTICE TO APPLICANT: If, aRer making fbis Ce�fificofe�df � ARCHiTECi Oe •�.:TEI, ..... . _ . ��. ,
ENG�NEER�: .� NO � --CL455N0. DWELLUNITS u1
�Exemplion,_�you shovld.�become�-subject�.fo�the Workers' � � _ . ... . _ - p,
Compensofion provisions of the Lobor Code,you moet forth- �. ADORE55�� � SEwER MAV °A
wilh comply with such provisions or this permit shall be � ./ � ?
� 7EL � ,�/� . - VALIDATION
deemedievoked. � CONTRACTOR � NO. ' BK.' PG,�
LICENSED CONTRACTORS DECLARATION ���,
I hereby offirm that I am litensed vnder provisions of Chapter 9 AODRE55 �NO. VALUATION �
(tommencing wirh Section 7000)of Division 3 of the Business and - ���• � ODO. �`
Professions Code,and my Iicense is In full force and eFfect. CiiY CW55 S / . . . .
� � - -�� � � - � - � SQ.FT. �f NO.OF NO.OF CMECK '
License Number Lic.Class - SIZE b�d0 S70RIE5 FAMItIES ONE i
_. . . . � . N� ❑ 5 . � �
ConlfaClor ��� DESCRIPTION OF WORK �
TE,.�q�,v�/MP2ovE���cl Aoo �
❑1 am exempl under Sec. � j �
ARER � FINAL.�\r y f (': .
B.BP,C.for this reason ' � - - � - � � DA7E ���'� �
REPAIR
Date: USEOF �E�L}/L`-'�LOTtIl�I�y DEMOL FINAL�,\n -
EXIS7ING BIDG. � BY ��,``t!�,.. .
$Ignafure� A7PlICANT C TEI. u��� .
OWNER•BUIIDER DECLARATION PRIM ,G r 6 NO.7 - -
I hereby affirm thof I am eaempl from ihe Contracfor's License qDDRE55 �G� S/ 9� ► - � '� �
Low for the following reason(Sedion 7031.5„Business and - ' �'� - � -
'PIOf055i0n5�OdB�: � - PRESENT ' ��'S 7 8 A
� � . BUILOING .. . . _. . . . ._ . . .
I, of owner af the properly, or my emplayees wifh ADDRE55 j
wages es their sale rompensation,will do�he wark and - � #� � ''�2 3.
the structura is not intended or offered far sale(Section «`�'��TY � -� :I • �.Z S O O
70I4,Boziness ond Professfons Code). MOVING TEI. .
OI,m owner of the property,am exclosively coMrocting WMRAROR NO. . __..... . � � •�� �2�0��
wfth licensed conlractors to consfrod tha projecf(Seo- ADDRESS � '
fion 7044,Business and Professions Code). � � � � � � ' O Z� b'S�l �
' � REQUIREO TOTAL SETBAIX FROM E%IST.
CONSTRUCTION LENDING AGENCY - SET BACK YARD HwY PROP.uNE wIDTH
I hereby offirm thaf there is o tonstr�ction lending ogency fo� . pRONi / . � . '��$'],9 A -�
the performance of the work for whith this permil is iss�ed P.t. . . .
i5ec.3097.Civ.e.). � . sioE . . #• •'• • •�.,��
- P.L. .
� lender's Name � ^c � • •3 Q,rj Q
a' . . . . . P.C.Fee E C�J.�d Permil Fee �.0� . . 3 Q 5 0=
tender'sAddress � "�� • c�
I certi(y that I have read ihis opplication ond s�ate�that fhe - hsuance Fee ��'S�
obove informo�ion is correct.1 a ree to com I wirh oll Coun 0 21 6-8 4
� 9 PY �Y Inres+�goiion Fee �
ordinoncee ond Sfate laws reloting fo building constr�cfion, Towl Fee U.S V
and h y �thorixe rep esenf ves of this Counry to enler
{ upo ve;me f'on perty for inspaction urpo es. � � � -� �- - -
} SEE REVERSE FOR EXPIANATORY IANGUACE
Signmure of A ant or AgeM Date � � ����
r , •9 r Uf T'a .n (,� ?! 2 �. -. _ .'_ _'_ ,O O
r m T N T
> > O o �O O � O O.: � N�n p � O f�C j 0. p � C+ p C � �
1 p c �S S � � 7-' C�P 3. �' � t�i n ^ N p a 0 �- n : � i
o � � i� -� � o � N l : °_ o ° �' � e V o �' ao � � f1 f�
»-� x c'� ic'7 � o n'I o � c7 + j r ;.
� w� '' �N. o:_. ��I S„ r. �� n� o, .o = tii I
-n �l o <� o c ' � j n 'r o v j v i 3 � -^' 'e� . - i ;
� o m °' •— `o _ �� nY ���� � � v° ° I ° 3 � � i / I ip
"�k ` � �o' o- �� o' '< n '� ° u I��
a c c c 7 • * �� �.� i. � 1 - `� � � V;
� .
� ' �' _' "
"' ^
O ��
. �. o � " �=:'-- � 7 - -..-; i / �ii Y r�t
� q a : _j ' � � '. ci
o _. _
{-- = i7_ a
j ° . � ��° O
� I M i ' .?^ ;.-� �
c ' u
i.. � 'r��'�� ; C r't-',
. �- /� � � �1 G' �7 .A
. . • p` �_ I p p, `.
i , � � � . .y.I� r ..�
v ' `� �
� M � . � � p�,�0� 'I
� I H . . ..�� •/• �' 1
r ' . . '° �r � D
V a
7 � i . O � O
C ' b
' � C I ' . � !� K' . .. �
n
; O _ �I ` .. . 0.9.: � O.
i �
' ' . . . ��` t - ' . _.
. . ' ' i I _ _ i ! i .._ '.. �_ ; ;I i :'' '�i '� � ;
I ( _ 1 i iI,r � /! �
. . ;; ,, , i _ ' �� .- . �- � ` .I� f/" � r i'
� � � . '�: , � � � �'.
. � � '/'� � � , � {'� ' - � _
, I �. ' ' � � I �. . e r � �
� . , I• � i� ' ' �' �' i:;
, � ' . '� . . . " 'a
�: . � � � m
. � � �, .�.�
� - � _ � � ��Y� ; 'I 1' { '", . t ;i. O
� • � . . ./' L. "� � `� vi
� �_ i_ - � 'I t �' - � O
. � � . .. � i ; .,� ~//
. ' ,^- ' I ; �� `/ � ,
. '.- ._ ` j '% /� � '. _ •. .. �. '^ i.
. � � r ' . l' l e J '
! ' �• - i � f . '`' !�" • ' . . ^�,
. 1 • . „ . i , ..� , .
. . . , � - � , . i.
II
' ` I ' _ . .' _.. i ' j j � �_ '. .__ _�� ' :�`� J __ . I ., i -
, �� - . '. p� i �`a 'J-r I� _ =� � �'�r .., s-,C:�f : �,'1, �� =.n�•� ��i • � �— �
,� _p o ? �o � �.� � r, �-oi `.F �.��'� f ` -•�G,� � � " 'e � ns
. R' � �`'� n v L ❑� ',.., � O C tn N � `+r."7 `V C ."+L.YJ � O
�i ' _ . _• ,. . � ' � �« `< .. � � � -�_i�^` p 7!� � `;: .�C C N.'�`E . ^. c c. .
. . . i :I . . G'i� 1 � . ^ ' ` n �';- _. +'.. ",n_:, ``C �:N..n n ^ �;a '� C l�. i [r..
. � . � ' .. _ i • C o '� f^N p�` ~-� w C- C - p `, . � �.��...C � �� � C� �-
, � � y _ . 3. � ;''� ' ^ � n'` ° �N �.c'`'-. ^.L�' �� � �; � � ��'ti'�� c`� '` c -"
' � - i k ~ �� 4 F C � .`..�.�=. �i c �'i y = � � ��`^� `C� �C e _ � L _•f i�
.. � , ��1 c. C N r. l � �� �-r' ' �,r � O [i c� ; � �M 'r,C~ N �', "
, , � ,. = i . . . . ! `,,3� � � �'=� � -�•t� :i M- s i� ^ � �y � � C
, i ' - 1 I "'• �o �"' � �� O. `� `: r��•� �7 n n. ° e. �^ '= U ^ `�t. C :
�/+ , r I �- ." ,I I ji .� ^ '' �' '.° :;, ? C 'v j U j- �`�'�x `-i-2 '� �•' - f t'`_
< < � . _ i [:. t� i�b� �' ;? :• ~ti �'� r'w 0.L �7 � �' '�W�� 'y � p � T.
j f.` I i �: . � r ` �, o �' H o " %,v+ � � �p C�a� � ti a � �N� 3 ^ ��� o ;-1"7 •
` ��� ; - � �: � � 7 -'�c`•• �, o I�.� � ^�,n _ � �° Q a + i'`',� `� � t x �
. , / � - I _ . ,.: I n. -`q O �. i0 �`�` .:�`�H � " .: _,� ' ^•. !� i � � ^ ' •. 7 4*�.�'..�
J �. . . - . " c� _ ^ A U r. �- r r, �.O =H p:,� `C Q ,� r`�w� '
- /ii .. �' I ' � : .. �..� � 0^< � ..G'.�.� 'M1 L,�,.p] •� = w �p Z�o�in �Y 't., �.
. s. I :r c o� O - `�'r �� � ��=.a Q .c 0.�'o�� _.o� i�- � .
,� � � '' (: , ''� 1 _. _ �.� st= 3 0 .F'a. a� o ` = �'
_i �-^�n ` � ` -.� ° n ''
l ' �- m - .� � �' c „ ;! 'c m C::.ty .�`,�� C:� =� =.'vi-� h � � p �.� ,e '0 3 ,~ '
_ �e _ �. 1 `�:- - -' y,�- --- b,� -. .ti.'^ � ��-'.`-' n �,t��i. •.-^i C.. �'^..,. �a�i ��.^�i ^`�� ` u•�'%��-� ° ? '.�'.�•
. - - '� r - � ' .fi � � �'�-c .� ��1 , R,ti a't� o ¢ �,,.^ �.. ` o -. p ;, ti �-
� r' " ' " - � - � ,. . �! F ,.�\!M1 n u . -� X C i`••�'D'y'� O S3 n`i C i.. n R+ ^.. j V+G 'O
�� • � _ „
,, f� ��� , <�� _ _ , � c' � � N'�v �o „• :,a..^..��i w �trM�u'�o �+o� �F�.a p �'^ � ,!:
' n V m 0.� G '� .; j/_ "
._ . /' - � _ - i fl.' ^p.� �s N O '^ r �P ^ �C�ti n �m �w p..w„Q e�'.� �n e W � Q Q:
K 11_ _ i. � .. c. . O- 'p M� !, N 7 �� y,.j,n.�:�C; p O S. `F �n� O.n O� �'�'^ "O '.
'.J � .. ' . ' f _i � f' "' . T �'v r O c�`� O _' .y....`� p `�^ p 7 _' �r,�-C+ � w � L� N'
m�n � �'a �i =:�e � w ^, a : �
, _ N