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HomeMy WebLinkAbout1828A (19) . . ---------. _ �__�_�::._ .. _ _.. -_ .... _.. .._..._ __ . . ry.______.__ .. --- I�hereby aff�m�thot I ho e a cerNDECLARATION APPLI_CATION�FOR-:BUILDIN WORKERS'COMPENSATIO y _ tificate.of.conseni�,toseli � /�. bC�A�'� �: insure,or a tertifitate of Workers'Compensation Insuranca, V r C �Y� .. - -'- ' ' ' " or a cejified copylhereof Sec.3800.Lob.C.J .. ..`.: - ...-_". -' - -' 1 • • �� COUNTY OF LOS ANGELES ; BUILDING AND SAFETY � ;.. PolrcyNo.wPR(Z�JJCo ��Y_Au.a� ,�t.co� � � � � � - - . . .__-- _ . � Cer�itied copy is hereby fvrnished _�•. � FOR APPLICANT TO FILL W eu��oiNG �/� � ADDRE55 V O�,��Ce�lilied copy is filed with'the counfy bwlding inspeo- -�--� BWLDING A1�� - `�'tion deparfinent.�� ' AD�RE55 Q /UK/ • Da ' �...� . , .. �,, _„ ,..� �,, .. . . . , __._' _ _ _ _ _. .___. _._._ . . te�. .'.� ���APPlitant�.�� Cltt �141ti'1. 2iP LOCALItt " .CERTIFICATE OF EXEMPTION FROM WORKERS'�"� ---�-----"�---�------ -----�---NO.OF BioGS.�. .. .... ...... NFAREST_..- ..'-'.....-.--_-�-.- -:. .._..___.__..-..,-.--'.. ; •� � � �-� COMPENSATION INSl1RANCE'�" ��- SiZE OF LOT NOW ON�OT CROSS ST. (This'section'need no�be completed-if tha permit�is for one .- .... ..._......._... ..........-----'.--.._.._. _._..-. -.-'_---__... ASSESSOR � . ,'- �- , ' ...- . . -hundred dollars($100)or less.) . , , TRAR BIOCK LO7 NO. /Nqp BOOK � FAGE PARCEL� ,Y , � - - t, fEL. L • USE ZONE MAP . ' . 1[ertif ihat� . �.P . .. . �.. . ... __..._ OWNER�'l � ._._ .�L..G ..�.P..._-NO. S7 ' . �which this NO. � ' � -.- '� - � 0 os to becoma sub'ett fo�FIe Worke SPCOmkenSa Y manner ....._' ADDRESS-�I � .."-'...'-- SPECIAL.. . � ...• -.. . _ . . .... ;y`� I ermit,is issued,1 shall not em lo an erson in a _ ___ __..._ _.. CONDITIONS ,. .. ,.:. p tion Laws. ' � �� � �u NOiICE TO APPLICANT:�I(, affer �� an L A EL -- _. ___ _ - -- - __. _.____ZIP_..' ____-- . . . . .... _.._ . ...__"'. . . ,d' Dofe Applimnr �� qaCHITECT oa TEL. : � � Q I making-Ibis'Certifimfe of DISTRICi„_ GROUP NPE .. FIRE,_ __ PROCESSEDBY.. ENGINEER NO "-1- Exemplion,�yaJ�should become subject�fo�the Workeri -�-- CO T ZONE ��V Compensatlon piovislons af the Lobor Code,you mus�forth• ADDRESS �G/ --I�__ � -.� 'y viith.comply wi�h�.such provisions or�.this permit shall be"----�� , ' ' � - � y -- TE. .� STATISTICAI C7A551 ATION APT. CO DQ. - deemed revoked:��.: � ..- - . . �� . -...; , ,.,.��� CONTRACTOR � L NO. - � f'� (� � � IICENSED CONTRACTORS DECLARATION- �- �h ---�-- - -� � �� � � ��� � � - � �- � - __._.___. -..__ ._ '_ _IIC:....... -. . ..QASSNO.�^DWELL.l1NITS . . .� 1 hereby aHirm Ihot I om licensed�nder provisions of Chapler 9 � ADDRE55� �S 7I� NO. - (mmmentirg with 5ection 7000)of Division 3 of 1he Busineu and ..,_._._. __��� ___. SFWER MAP � �, � . �. � .. ._ ' ....__._._..... , , Professions Code,ond my license is in full force ond effed.� C�TY�F- ��` C1A55 GIO-G .. -----------�---- ---'---.._.._.-VALIDATION--....-".-1 . � .. . .. ��f. ^. . . ,� � . .. � r S�.FT.__.._ NO.OF NO.OF_ _ CHECK BK. PG. � �icenSBNumber 3���/d'� Lic CIa55C �O�-C�YS � SRE $TORIES FAMIlIES ONE � . � .. , 1� . . . . . . nr�' . VAIUATION. . . ... ,�^. �. , Contraclor�'IQI.�Q1Q. �,l�S��{-1M7G Date�C{i.� . ��iPTtONOFWO ., N�-- O �OO . " .., ..._ A�D S 1 • � � �1 am exempt under Sec: - _.... .- _.. .... ❑ . _ .._. . - " --•-�. . , . ALTER . ,' . . � -� _. . .. . _ .. . � .... � B.BP.C.forthisreoson ,-- V{.lC� REPAIR_� - f�"-�'-"'. �. _.-.._..'. . ' ....._. ... ." '_ "" ,' ,.,...._. . . . . ._ . . _ . . .. . . ._ . ..�afe: -_... .� � E%��- Y D DEMOL ❑ . � _..._.. . . .. .. . .._. . ... _ �.�. '_..___ � $Ignafure ..� . . "' "" '. .. ...'-'- -' APPIICANT TEL. . ' . OWNER-BUIIDER DECLARATION PRINT S /�/0- No.4 � F'NAJ 2�S4 � � , �I here6y otfirm�hot I am exempt from�he Confmctor's litense ���� � � � � �` ��� � � DATE�t�- 7�' ��.� -� ... .--... ,. . . Low for the following ieoson(Sectlon 7031.5,Business and ADDRESS �� S� $ �CL'/! S�-.5�.�'!� ' �� �''� ` �� ' - � ' _ ,.,.. . ...._.."-_' .. �1 . ... .. ...... _. .!... _.. : . � ProfessionsC6de): ��-'-' " �""' �-" pRE Ni --gY` � f`� ' � ... BUILDING � _ -: , � 1, as owner of the property, or my employeez with qDDRE55 • ��, : •.� � • � � wagesas7Feirsoletompensotion,wilidotheworkond �� �-- - -�-- `"- � -�� �' ' - " the structore is not intended or offered for sale(Section ��"��Tr /1 �t pl I , .. --�--7044,Business and Professlans Code).-- - --- '' � MOV�NG�'""-'- � ' '� ' TFL � � - -- ---� -- - - �S , �`% � . � I,as owner ai the property,am ezclusivaly coMratling ODNTRACTOR NO. 1 a��� - .. ..-- ' .. ...... . .� .... . . _ .__. _ .__.__ .- -- --.. . - -�-- -- ---_-f-'. .. :._ . wilh licensed mnhacrors to-mnstrucl Ihe proiect($eo- ��-""-� ADDftE55 � � � � tion 7044,Bosiness and Professions Code). ' ; $ � � � � e., _.- ._.._. . _ . kEOUIREO .-TOIALSETBACK fR M... . %1 . ...._.._...__._ .. .. . . ' '_�'.. __ . .__,...._J _. CONSTRUQION"LENDING AGENCY"---- -��-�-- �gT BnCK �"YARO� HWY p{tpp,�INE WIDTH --� - - �� I hereby affirm fhal there is a construction lending agency for FaONi � ' � � �e-i��'�'j�'�", -�Ihe per/ormance of the wor4 for whichihis permil ie issued --- -P.L ._-_ ....... . , _ ._..'..'.__.'"'..._.." ' ..._..._. ___.__.._ . ._'_. .__ ___.__' ____. _.._.�__..... . ..... . .. .. �Sec.3097,Civ.C.). StDE ' •.� n.'.:6.7 J csi�� P.L __ .. _..._. . _'_ . ' ._..._. _.._'.'__ _"'__ 1 ' "'"_._"_..__._. _.. ___.. _ . .__ .. . .. .. ...... ..... ... ... ... ._ _. Lender's�vame ; 0 p C�9_$6 � � IDMA Re{.N � �• ... . _ . .__ .'. ___._. . ... _ _ _. _.._'. P.C.Fee E_._ . ' '. . . . VermitFee "' ' _ _ . _. . _._.. lender's Addreas � �- .. � -1 certify�ho�I.have reod.this application and state tha�.�he . ... . - ' ._ ' ----__--_'. �ssva�ce Fee - �-�O.� ' IDMA P/C M.-.. ..... ... ._. ,--� . �,��.' . � � i abova information iz correcl.I agree lo comply with all County Inves��galion Fee • � ...ordinances and Stare laws relaling lo building_conslroction, _.._. . _. TotalFee---- ' � - � �- � . . .__... _'.,.._.. . ___' . lDMA Perm:N.... _...... ._. . . .'��� ; and hereby aurhorize represematives of rhis Coonry to enter �� -�� � . , u�he o6ove•menlioned pro erly for inspection pvrposes. _ . _ _ � _ _ _ _ .... .... . .. . .--- - -- . . . _.. _. .__._ _... .. ._... .. . " � � Q G SEE REYERSE iOR FX►IANATORY LANGUAGE � i ' _.. .. SlgnaNr �APPlicantorAgent. _. . .. _ �e_ '.. _.__"_ .__... ._.. .__ .' .'_ "__" "'__' _' ' "_' "' ._"'...__._ _. � .._._ '__.___ . ._ ._._!QQi _ x o - _._.,- - _ - � g �T•' �S" �^ c9 O . T,v ..�- ^�" � Q � ...: . .p .p n'9 �O.. 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