Loading...
HomeMy WebLinkAbout1578A 1579A (15) 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