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HomeMy WebLinkAbout1830A (21) . ,, ..._.__...._._.. �... . ....___._�_.--- _.. . .._ . ._..- --.._ ..- ---� -- --._.. . _ WORKERS',COMPENSATION DECU+RATION _ � ' � "" . ' .'�' : '� ' ,-'. . ' . . -. . ._ .- . , -� � . � � --'----".--- -- ' - -- _ _ . .. ._. I.hereby affrm tha�I have a;certficate�of conseMJo self APPLICATI�ON� FOR�BUILDI-NG� PERMIT- -- � insure,or o terfiLcate oi Workers'Compensofion Insurante, .:.� -"- ---.. _.. _. ... --- - �-- _ ' - . . -- --- �� � oi o ce�titied mpy t ereo �Sec.3800,Lob.C.) �_` COUNTY OF LOS ANGELES BUILDING AND SAFETY � � •�;: Policy No.wti�'37ti���pany Au��#rWoO - _ .-.....- ---..-. ._._ . - -- -�-- - _ . � Cer�ified copy'i3 hereby furnished .'• � FOR APPLICANT TO FILL IN evaoiN� sO� .��\�� ❑ . , .. . � . �. � . . . --_� ADDRE55 � Cehified'copy is'fi�ed wit6 the couniy bvilding inspeo � BuaDiNG n �tioddeparfinenl.'�� ' AD�RESS S�� pL1/Q .. ..�... ..n:i . ., ,. ��._ . i . . __._ . _ _. _ .. ..._.. . . Dote -.:..,qPPlic6nt � .`.. . �..` Cltt � �/ ZiP LOGUTY . ' � C TIFICATE OF E7(EMPTION FROM N/ORKERS �`�` � ��-�'� `"-�-�-'-- - -�---------- -��-NO.OF BlDGS.�- ---- � niEAREST�-�. , ' � �� . . .. .. . ..._. ..__ ..__ _. i ' � "COMPENSATION INSURANCE-'� �� SRE OF LOT NOW ON lOi CRO55 ST.,.�V-. Cl�1S�� (This�set�ion�need not be comple�ed if Ihe parmit is for�ona -��-� , nS5ES50R.�. ,., �-�'- � ' '-�. � . _...--.............._.__.. __..__. . ....-"'.. . .. . • '� hvndred dollars(E100)or less.) � .�� . . , TRACT BLOCK lOT NO. Mqp BOOK �� PAGE PARCEI .. �� ,�„ ,.... ..."_ • " '" TE ZONE �P . '. L. . .:.... ........ OWNFR. . . . .- USE I cerfi(y that in the performance of the work for which,thiz a �-� G � r,o. P3 . ' : � �. � ,} I permit is iswed,I sholl not employ any persan in any manner �- -�---- SPECinL �-- � �y ' 'a .. .�3 O '� - .0 so ds to becoma'subject to the Workers'Compensatlon Laws. - �..- ADDRESS- -- -----� '-�- --..-.. CONDITIONS �� . ... . , , , .. .� _-_ �. .. � •._ . . .. .�, .;: -__._ CITY � __"'_'_ZIP_._._._______ . .'.__ . ___ .._ ... . .. __. . � Date � � Applicanl"" � ARCHREQ R 7EL '� I NOTICE TO APPLICANT: If, oher making 1Fiis'Cerlificote of ENGwEER SA NO. • a .DISTRICT__ .GROUP roPE- ZpNE PROCESSEDBY_ .V Exemption, yov shou�d become subject�to'the`-Workers "��� � �N�����/ • . W Gompensalion provisions of�he Lobor Gode,you must for�h- qDDRE55 K A) �Q. � � ��-�4 � � �� �/�' �� -d wi l h comp ly.wi t h suc h�provisions or t his-permi t s ha l l be ----� �� � deemed revoked.. -' � TE�• � STATISTIGAI QHSSIF ATION � APT. CONDp.�� Z � `� . ". -�. . .. .-': .-".• CONTRACfOR n ; NO. � S � - _...._'_._ ._ . . ... . .. .. ....... . '... _ . LICENSED CONTRACTORS DECLARATION �:`- - � �-�---- - -�� -�iC. '� a.4S5 NO. � - lL UNITS � I here6y affirm that I om licensed under pravisions o(Chapler 9 ADDRE � N0.33 � � (commencing wi�h 5ection 7000)of Division 3 of�he Bosineu and � ���_....G�a . .. ��R�P ' ......__. �+ ._.. ._..- '— ' Professions Code,"and my litense is in iull force ond effect. Ciiv 5�f� �Q.� � M55 ---BK,—�-'� '— '---""'yALI�ATION'�"-���-" ' ., . . , ..,. .,, .. � .� . � , ' . . . . . . . SQ.iT._'__"'."NO.OF_.'__'_ NO.OF"'" .._CHECK . . �yG ,. �.;.... �. � , licensa Number�7 77�� "'�' Li[.CIa55`��V'4� . SIZE STORIE$ FAMILIES ONE _ ... ' .�.. .. . . . . . .� . � . ., . � . VALUATION .. ..... . .... . ' �/ '� "- ' DESCRIPTION OF WORK"' I. . . ....... ... ._ �n/. CoMr6ctor�Ndk ����.Dale��t_ ADD � _ . . .__ _ . _.. �I am exempl under Sec. � - - - - S f�- - ---� ,:-- - � ALTER ' , _ . . ., . � l00 ' B.BP.C.forthisreason � --- - pevntR-Q _ S r . .�.. . - .:- -�-- - �-- � --- -� . ___.__. ._ __ _. . .. . ._. .Dale•.... .. . , �� i i � , _.. .__ E7M6iM19blDG. DEMOL ❑ � _. . ......_. . .._'. ' __ . � � ......._ ' �' . ' '_' ' ..Signafun �,���+ AP�PR Tl Q ' NO. �� FINAI /1 R.D� ....;. .�.', OWNER- DER DECLARATION ,_,.. . _ . �-�OATE1����-G �---•�� � - ��� --� �-���-�� -I hereby aifirm that I am exempt from the Contrador's titense . � , . � Law for the following'�eosdn�(Settion 7031.5,Busmess ond A�DRE55 ( S 04� ( �•FS�1 FI A`L'�����' �'"� � � __.__. . .__.._... ,. ,. I .. .,;. ... . '�Professio}ns CodaJ: "-�' �'� " � ' �--"" paE Ni -bY� �E'O , - , . � I, aa owner of�the ro er y P Y BUUDiNG :� �. . - _ P P b, or m em lo ees with _ --- qoorte55 ' . .. .--'-. -- ._. _._.. ._ ._ � .... .. wa9es az tnei�sole campensaiion,w�li do�he work ond i�im � � q � _ �he s�ruclure is nol intended or offered for sale Section \ ' � - -7044,Business and Professions Code).-- �-`�-" " ` MOVING'� '� � '— '` � � - " - TEL: � �� � - � � -- `�(-�� ����-� . - 3 /� !; CONTRACTOR NO. �' `" � � , A � I,as owner of the properry,am exclusively contracting . . ��• .�. �O. � �with licensed�contractors ro construct the project(Sec ._. ... . _..._ ._-'-'-- --._.. _._ ._. _._. _._ ....._ _..._.. ...-� - ' - . - . _-_ , ADDRESS fion 7044,Bvsiness and Professions Coda). : � • °(��Q O � .� "..-.. ...- CONSTRUCTION LENDING AGENCY ....."-" ..._.... --�QgAC�.. YARD- Hwv ..TOIAPROe,uNE WIDTH --- � - -'...--'..... .. . -'�- -"'-.. -.. ..-. .-'- . I hereby affi�m ihat�he�e is a conshuUion Iending a9enty for feONi - � ° " •b�'+���u �i ��he�Per(ormonce of the work for which lhis perm(t�is Issued '- '-- - P.L�.'--... .-------'-�-'- -" '-�---'. ...._.._.__._.... � '-.. _ ..... _._......._--_-••_-'_-_-._. i,.__ . . . . .._..- (Sec.3097,Civ.C.�. SIDE 0�.G 9�8 6' � '_"". .... _"....... ... ..... . . . ... . __...__. ...... P.L .. . � . ... � ... ._._. ... . . ._ _ ...._ ..__ ._ . _.. _._ __ � .�,. lender's Nama � � � _ . IDMA Ref.M � ' � ...._. _.. ....... ...... . _.. ....,,..... ._ .. . " ...'__ ._ . . P.C.�Fee S ..." '_._.. . Prrmif Fee - _. _ _' _ _.._ . . __� Lender'sAddress �• '� ' � , . 1 certify thal I have read fhis application and state.that.lha _.._-.'- - .--- -..._ _ . .. Issuance Fee�-' �-- -� -lDM4 P/[It - --... ..'_- �--- 1 .- .-� ..--.�- i obove informatlon Is conect.I agree 10 tomply with all County inves+iqarion Fee ordinances ond Stata laws relating.lo.building consiruction, ._____ � ! ' '""��'-� .__.'_..____... ____._'_.. To�alFee. __' . . -LDMAPerm:.M____-.____ .. .._._ : ond hereby outhorize representatives of thls County to enter �� � � � : vpon the obove-me,ioned property for inzpectian purpases. �, � _. .� . .---- ---- --- . _'.—._ . . .____. ....._ _ _._.—� ---. .' � ' �SEE REVERSE FOR El{►IANATOIIY LANGUAGE� � ..... Signa r of AppllcontorAgen� . . ...-_. .._ Date ' . ... .. . . ."". --_"'__. _-_. .._'_' I'_'.'_ - '_.-'. _.. _..' "__._ .. . __._ ' _ . .:OO� �' -�' V� _T. .�. ,p. -��-- - "._ � 'O '� r- �'6 N N t9�� p ID �� .� �.� ,� r 0 � O W 7-N O .p� '0 ,7 tn �' r � m -n v+ p �o F O � p �., r�o � .'t7 O � '. m�n (l 2 0 � N � � � 6� � O .� - . O cy � �K. :1 _ � 7 � � S ` � �� C- a O 9 � � 7.� (17 fl. p�. _ � b�,�. � .. � O f0 Q I � O '� � F� � � p��. j'� ' _ m ,p �O :' O oI = K c�.� � c oo� o `° on .. oo - a 3� ,� '. ��. ... m -� �Z N O p � �' p � K p, �[ n . � - m . .4 -- ? �� p i O a a ...7 � y? ; , � '`� � � � a i � � .. ' ,`\ N S. • ,� ' � o � O � ,.' 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