Loading...
HomeMy WebLinkAbout1046A 1628A (5) WORKERS'COMPENSAtION DECLARATION � �" "- ��� � �. !nsorehoaofteiifca'+eofWoken'�Compensa,o�s��,��a��e` APPLICATIDN FOR BUILDING PERMIT � � o�o cer�ified copy thereof(SeS.3Boo,lob.C.) � - - GOUNTY DF LOS ANGELES BU1lDING AND SAFETY � + Po�l'�cyNo Jyi�yY�y�m��Y r2E� ..r�r . BUIIDING Ce�r(�ed copy�s here6y fumisfied. FOR APPLICANT 70 FILL IN qppREu JA,S`� .�,t�.,�,.�,�{ J aCerlified[opy is filed wifh the toonty building inspec- BUUDING�� /�/�rn���/7�'/7 ' �j ' fion deporfineni. � ADDRESS ` v �Tw oa�e - Z�� APPlicam W�!�Y/iF �'i/%�1p�v/,�4 arr ��� �-z�P 8 iocnutr � . CERTIFICATE OF EXEMPTION fROM WORKERS' � -. NO.OF BlDGS. NEAREST , - I � � COMPENSATION INSURANCE SRE OF�lOT� NOW ON lOi CRO55 ST. �(This seuion need no�be completed if�he permif is fo�one n /y(��� p� n55E550R � hundred dollars(5100)or less.� TRA�T L"'� B��CK lOT NO. 0 MqP OpOK VAGE 7ARCEL ./ TE�' p- 2 7j USE ZONE �P y . I certify Ihat in fhe performance of the wark for which this OwNER /�[� NO.O -✓ A� NO. .0 - tl permif is issued,I shall no1 employ any perSOn in ony manner qDDRE55��"���'""-'� � ��� � ! CONDITIONS � � a so as to become subjec�to the Workers'Compensotian laws. /� V . . . . CITY D � ZIP ,(Q � "a: Date Appl�cant - � ARCHITEC70R TF�• DISSRICT GROUP tYPE FIRE PROCESSEDBY O NOTICE TO APPLICANT: IS, oiter moking tfiis Certifimte of En7GNEER ����L� �� �1' v CONST�- ZO,.,y�, F�' Ezemption, you sho�ld 6ecoma subjecl lo �he Workeri ,�y�, A f /�/ y`�,'�` U Compensatlon provisions of the Labor Code,you mus�forth- ADDRESS�� �ti�/r/' � ��� /v �y � =� -"` W with comply wiih s�ch provisions or this permil shall be - STATISTIC4L CWSSIFICATION APT. CONDO. Z deemed revoked. corrtRnttoR �' h�S�'m� 410ENSED CONTRACTORS DECIARATION. ��v /�,�,� ii�, �r MSS NO. zZoµTLt.UNirs ^ I hereby oH�rm that I om licensed under provlsions of Chopter 9 AD�RE55 G✓�-�-c0 ��x•N/� N0. O � ��R�P �commencing wi�h Section 7000)o�Divislon 9 of the Businezs and In,� �,,, LIC. Prafessions Code,and my licensa is in full force and effetl. CiN Y1'lip/G ��✓ CU55 BK � VALIDATION * [! j' f� $O,FT. NO.OF NO.OF CHECK UCenseNumber,J�� I 7-��3 v l�c•C�o55 /y SRE � STORIES� FAMILIES ONE ( �f� VAL/UA-rTION ti✓lI �) � Dofe � ^ �/°� DESCRIPTION OF WORK L-6N N� � S (�,,.J�Di � COMrONor n p,r.�L�w��j/ ADD � u! , �I om esampt under Sec. / � v " "'�,�! q�7�R p �1 0 4.6 A B.RP.C.ior Ihis reason' � �U REPAtR ❑ _ . � u5E O �� � � �2 J �ate: Q G(� �EMOI ❑ ¢xisTiN�e�oc. � . .4 8 8 8 Signa}Uro � APttICANT � y�,l� EL. �///?J 27 FINAI OWNER-BUII�ER DECIARATION PRIM yn U NO.d�O/' ��� . DATE O-� , I herab affirm�hat I om e.em 1 from the Contracter's litenee � ,1.�� t,r' `^ • • •4 S 3 8 c=.o taw(or the(ollowi�g reasonPSection 7031.5, Business and A�DRE55 �S� �OI��7�N� �l�Y flNA Professlons Code): -- ��- aae eNT � . . sy 0&2 3-8 8 ❑ 6UIlDING I,as owner a(tha property, ar my employeee wilh ADDRE55 wages as fheir sole compensation,will do fhe work and - �- � fhe srr�cluie is na�Intended o�o(fered for sale(Section � ��`��TY 7044,Bosiness ond Professions Coda). �� h�OviNG - TE�. � � I,os owner aI the prope�fy,om ecc�usively confracting CONTRACTOR NO. _ witA licensed coMroUors to co�slruCf the project(Se[- ADDRESS -^-- \.� 'l� tion 70d4,Bosiness ond Professions Code�. —���-�.;: ��- �� 1�`:�1 CONSTRIJCTION tENDING AGENCY - SE1 BACK YARD HWY 10iA�ROP.LMEFR W��TM - �',,�' � I hereby aHirm thaf Ihere is a constrvdion lending ogenty for FuoNi 2� 6 2 8 A .the pertormance oF tha work(or which this permit is issved v 1. . (See.3097,Civ.C.). 9DE � ��'� • . . � P.L Lende�s Nome ` �pMq Qa{,p � •°�J��� $ . V.C.Fee S � � . Permi�Fee , � Lender's Address � � • •6 8.G 0 u �� I certify Ihal I bava reod this opplimtion and stale thot the leevonce Fee �D�uM P/C M . g above informarion is corrcct.I ogree to comply with all Counry Inve��igviion Fee ��� �/' 0 9.1 6�-8 8 q � ordinantee o�d Stale laws relating to building constr ction, to�al Fee r�""�"' IDMA Pe.m.N . ond hereby aulhor7ze represantolivas of thi�Cou o enler � �pon fhe a ve- ntion d prop inspa ' n p�rpoeee. �'O C . � A' L i•b�Y SEF REVERSE FOR EXPLANATORY UNGUAGF � - qno�ur o4 Applicant o Do�e ... . � , � a 1 \Z o 0 T s' C . � ,\` . � � . C � 0 l "O CJ \�n Q S C 9 ' . O " . t; �N 6 O ��j q O .. q p ' .' � � �n` Js �. '� �� p � �`, . O �O a ^ 3 . o \ � r O � p o ?� �.� � � � c q r ' 7 C J ^ � C � •� 7 � ,` ~ , � ' m�• � C p�' O Q - ' - � .� `% � pa y � 'o ^. •< ; \ p . � ° � p o� °. f�\ o - �� '• J .°� , �� �, � Z o � s, � o w � � � . 1 '. , � . ^ C`� 7 7 0 O S 7 0 -< �, � � � . , \� � • ,� w G :p O i� � fo,� C � ? • `'r G . ¢ y .4 �i Q°2 `9 � a ° J � � o � .,, -o" o . �o . Z 0 0 '�6� � o a� , o � � . \ t m \ ad % '� ...�..� � - \ y p • � . I '. , 9 0 � n a � 4� � � ' , . . , ,' ' .. 6�. + �'(� :� p_�,\ . �, . , , ,�, ' . M t 4 % � . • �� .. r.� 1�''� ,�� i' '� . ��' , ` .,^ :' r,� ,;; .i" _ . �/ .�� � , ' �. ..�, / � i. � - �� _C^ .. �• ,. � . 1. , . ��. �\�/• / !� �, • � ,, '(. t 1 �� � . �i • - �r '�O \. t! �' :l .; .\-"`Y' �� ':� •, . . � . � . ' !! ,,�S �' � ' �. : !�t� ' . , ' •� . ..� `� � `� .;• •S� � �/ A ', ' •• ?�/ % /� •;; ✓ , ' , ' � ' '. ' ' i , �� , ;r , ., 'y; S t'; , ).. �� � . � • � � �. � •,L ',i� •� /, ��J^ 'V ' � - � /� . �, r' �� . .. ��,� ��•` ��t �i• .1_. '�(_ � ' � - . . ' ��/, ;,�� '.1 :J ,� � �.t � 'jl •^1 . ', •'. / � f ;'. ` i� i f `, . \\.. . � � +� '��( 1 '!• �} '�` �•�. /1/ .��v �i `I f ./,� ,,�' `�`. •'/ �rv[ -`�, � ;�� �.i ' i/' i , i � •/� '1` � .\1 �/ ' �•�; + 1 . � . . • �� 'v � � y '.� \. � / ��; i1. ��j �� .�, � �s i � �. ;` -/�� ,/, ,',i - �/ �o .i} . : � ' �'�' i ir. . - '. V/ n �. '•l, �}� � � �� � � `Y I/ �i �( ,y � I� ' �' ,�f �.% , � . '� ,. �/'� . ✓ /, y� � , . '�� 'lj j�r .� '.i. �`iL...�.(r. , i.. � . � . ' �L. ��� �� ��, � . , � l � , . ��, ; •� i , �r� ' . � `t . � \� '1-` � ,ri� ', ,` � , i n S , . . . . . , � �=� .c. .7 � . • � � s f:_ � 4 F„s� ti � r^ . . . � �� � � ^�.. _ ��c�� ':. r.r .J . � � 1 . ' �£ ���J4 �,;..�]� � w 9�F � 4 n � • � � , .:-� -`'�+�K' v��' ��c.. ^`s: o �- - f �, : ,^v..Z 7 ^ _.: �',., r ^f ^t�'n»��, ^ �' r � � � � .. • �•, '; '. . '.C �, t ,� _"'L`m �O � -.'_' � :�'^' .�.,�� � "� . ' �^ ^f �'S � �� � C C N '3 �'"� •C•^ � '1 n �. ��i " � . � • `� /,�7�.= D`�+ .�`� � r e, .. q � O .. - - '..-L" �w t� �t �, � - � �L L 3 �.�+�{ L+.N .. '4 - .�" �,r v G K ^ r' ' O i � f' '. �- '� „' ...v �i� • ' ' ,1.60 `\� � +'e:-`~����'C� �, •�^'' `C �'G,O .�. ^f.y �C. 3�i+C�-= �.: r•�,O� �i N �. '�\ •;o �,,,��_�v: ��s. C O �r_ —c " _��.:j� O =_ � _w�:0. � _ ^ "L rt � v � ,F r 7 f ..""',.. � :,� lD:C `t, ..-{ ^._.,"�7 '� " r•.� r; . \ �'-'M c:. a � 's".7'_c_.+� -�c - �? � � ^ �.:.. .. - s :-'c � • '' . � . .- ` \ � ...t. :. M' � r O,� --�} ?� '7 C-�'C".G-� O c T L. n " y '� r ,+�� �7^p r ,. . . , '., � `'._ v�'� w�'% . ^ �.F'� C F C„�' C p- Y '� C n'��- ,+, �,,��0 �', ' • . "G 'i�'i. .��t, � O � � h' 3 F r � ^� O�,O .L J3 ..^.. ..,r .. G F 7 fS � �� ' . r.`.��t' ,,; � �.,..-..,F, . ^ n.v : r _ � p . . � '�3 t.;c ^` p D� ' L=,��...�~ �'^'4 d n ; t/��.�r _ 5,�-' � � � N (l� � . � ,, . � n� L'� ;x�v ,r� .L.� f „ t ,i,f' G � s"� s' �. N ' G•%> F �, O. Z '. . �..- `,= = � � - ^ : '" � r `1 s..-- �_ • N.���,.� • - • � .J`q � �L � :+ n'_c �C';y ��N .. _ O f _ - r. A3 � .a•� �1�G '� � �. ' , f�` �' 'l�t-3 (�;� C .S"'^ i! .�'.'? ^ N � } ��%. �.�+Y� —c. � � ,� . . \. . . � , ' .�r 7� ;, �'..-; t"t � cr Q-`9 v �'v H - �� i _ O � . . . , � � , F��F s...c��' • H .. _ _��, c� �c;: �" - . . � ' � ' .. _ 7G . � - ,n' % t ' c-� = C""' . � �' �n� ^r" C�':� 't ., ^ N ��Iv , .. N r.�^ L . L..='� ...A•OF N ^� v�� �� 1 ...� • . .i . , - 't ` :�^,�{p �.. ' r� r C : �' --�' (� � • ' � i . ''`'. . . O • \ ^tS 'O � 9 �C �1= �y`'-' ,. " .. . � � .. . N . �,1� -'� . �,�^��� o .. � „��a'- y�3 n G-` ._ � '`. . . . . '� �:. .,,, _ ;�� i'�� �`^y','n�-.. . R �\ ' O " � Ty n . , 1 t�� Yc . � � ' �r