Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
HomeMy WebLinkAbout0825A 1649A WORKERS'COMPENSATION DECLARATION � ., .I � • - - � ��
I heieby_affirm that I have a certificote of consent fo se�F. .. �:� � APPLIC�TION F4R BUILDING PERMIT
insore,or a cerlifitote of Workers'Compenstion Insurance,or I ,
�a certflied topy thereof(Set.3800,Lob.C.� _ � ' � , _ - �
PolicyNo����S�ny ,.�. � ��D,U Y �LOS ANGELES� BUILDING AND SAFETY .
� Certified copy�s hereby fumished. + ° FOR APPLICAN7 TO FILL IN Bunoirvc < ,/�4��*�J� ��
� ADDRESS .U ��. fiY ,
Certified capy is filed with the�county 6oilding inspeo BU4owG � � � -1 /7�'�yG /r ,��
lion deparfinenf. - � ADDRE55 l� ����TY .Ly ,(�!' .
� ' � - � /`. �'1 NEAREST /J�
. -Do�e-� � � �Applitonl � � � CITY V V . iIP CRo555T. � � �/L.ti-�-�'� � -
� ��CERTIFICATE OF EXEMPTION FROM WORKER$' � NO.OF BLDGS. /'� .455ESSOR
� COMPENSATION INSURANCE� - � '� 512E OF LOT. . NOW ON LO7 �((/. � MAP BOOK ' PAGE PAR[EL
�� �,/�, /��,{ USE ZONE MAP
"(This section need no�be'campleted if the permil is for one TRACT.l) (/J BIOCK - LOT NO. �� , NO. �,��.3��V�
hond�ed dollors($100)or less.) � �� . � . � � ' r { �f 57eUni . � a '
. ' I ,/ /� �-� � � � ��Q. . `�� CONDI710NS
l terfify that in ihe performance oF the work for which ihis ,.. � �-
�permit is issued,1 shall not empioy ony person In any manner ' Z �2J G, l 1 CG � p �yE DISTRICT� GROUP TYGE fIRE PROCESSED BV (� '
ADDRESS I�l�✓ ly ✓
so as to became subjecl fo the Warkers'Compensation Laws. I `D � CONST.� ZONE �„
p`/ � Ciet.t-t/ O
�o1e 'App�i[anf ' . . CITY �I`y / � Z�P I� /,� 5lATISTICALClA551FICATION� � APT. CONDp. V
NOTICE�TO APPLICAN7: If, o(ler making this Cerfifitate of ' ENGMEERTOR�NIM/i � N�Z�� �VJ�'� � W �
Exemplion, yoo should become wbjetl Io the Workers' CLA55 NO.�DWELL.UNITS n.
Compensation provisions of Ihe labor Code,you must forih- AD�RESS v • J SEWER MAP Z
wi�h comply wiih such provisions-or this permit shall be " � /2 , �
. deemed revoked. . � �ONtRnCTOR p��.� �¢I�s�,/3� sK. PG, VALIDATION
• J UCENSED CONTRACTORS DECLARATION � LIC_ '
I hereby offirm ihm I am licensed under provisions of Chapier 9..._... .S qDDRE55 . �. 'v�n. NO. VALUATION �Q 8 2.5 A '
tommentin with$ection 7000 oi Division 3 of the Business and /1p^��� n J� /�1� .
:Professions Code,ond my license is in fu�l force ond elfecf. OTY VI`y-+I�ICi�i Cj\• C1A55 E �-CJ�•(�/ � #�.• •�• •2 3
SQ.FT�/� NO.OF NO.OF CMEIX � ' - '
�ticenSe Numbe�22�2 �i�,�Ip55' SIZE /i(/ STORIES � FAMILIE$ ONE ��� 1 p g,-6 0
�, �/���� • ❑ S
Conbactor 1 GM'1R�f�Ya'{G�7�c� Da�e ! DESCRIPTION OP WORK N� � e �Q 9 6�S
� I om eeempt from the licensing require nts s I am o � IV� �M �y M ADD ��C � �
licensed archilecl or a regislered professional engineer . _ .. _ . . __. . .. ALTER '� FiNn� / / y � I 1,Z 5,�8�
.. acting in �my profe:sional capaciiy (Section 7051, � DATE (O �W p� . , � �
� � Business and Professions Code). � . USE OF �-y �!Q REPAIR
' E%ISTING 9lDG.�1/LL Or f 1� DEMOL � FINAL
li[.or Reg.No. Date � APPtiCANT'�/�� iE.�� B �� � � � �. �
� -� ��OWNER-BUILOER DECLARATION� � � �-��� (PRiNT11Vi� � N .
I hereby affirm thm I am exempt from the Gontractor's License I7I� 1 �R O 5 VE.5 � � � � -
.�, Law for,the lollowing reosan(Section 7031.5, Business and AOORE55
Professions Code): . ,. v�t5eni � � ' '
. ❑ . .. . . BUIL�ING . . . .
I, as owner o(Ihe properly, or my employees with AODRE55
wn�>s os the�r sele cen+pe.^.ta!i:n,will do ihc work crd �� 6�.9 A
� � . - the srructure is not imended or offered for sale(Seuion - lOcnuTv� - - � , .
' 70<4,Business ond Professions Code). haOwNG TEi. , '#��� � � �1
• � I,os owner af the property,am exclusively conlracling fONiRAC70R NO. � � � � .
wirh litensed contrac�ors fo construct the projeci(Seo AODaESS ' � 'I;' 1 4 a 5 0
. � tion 7044,Business and Professions Code�:� � � � �
REUUiRED TOTAL SETBACK fROM E%IST. ' . _�
CONSTRUCTION LENDING AGENCY SE1 BnCK YARD Nwv PROR LWE WIDTH . ,�• 1 4 5 5 0 c�
- I hereby offirm rhot fhere is a construcnon lend�ng ogency for � � pRONi � ' - � � - ' '
�he performonce oi Ihe work for which Ihis pe�mit is issued P L. 0 2 2',3�8.`�
. . (Sec.3097,Civ.C.�. . . �� � SIDE � - � - - . � � � � - � �� �
- , P.L. - . _- .
lender's Name � + ��J "" '" �' � � - � �
Lender's Add�ess P.C.Fee 5 � Perm�r Fee . rU -� � �
. 1 ceriify iha�I have read�his opplication ond slote tho��he � iss� ce Fee + ✓ ' �
_, above informotion is torrect.I ogree to comply wi�h all Counly ; m�esi�ga��on Fee . - . a� �I� � � - � �
ordinonces ond Stafe laws�eloling to building construclion,� To�ol fee � � �
and hereby ao�horize repr sentotives of this Counfy�o ente� ; -
��.up bove-me io�e p perty fpr inspecl' n p rposes.�- �i � . . . �
� � � � ' - SEE REVERSE FOR EXPLANATORY LANGUAGE � - � �
no�ure o( PPlic. r , m �r I . . . . . . �s
.o .
' '. . .. ... _. .. . . . . . . .. . .� ... .. . .. . ._ .. .. . . . .. . .
� �
� � � c� � � � . o 0
. i�T1 l!1 0 tf�O � O O�iE .� 4•- O � A O �: �
* m�? nS o o � '.a o _� �p '-`: ' d � ^• ,y;;' ° � -�oo 0 0.
� 3 ' °c �' �- '�mp �a -t1' d o - D t�' °•� �� . �'. n'. o m -, a � .
jt p i �p I � 1 O K. (� 'L� .O. 7�c"� 4 � �N cO�,, O 'Q � ti . .
�W � Z X '� � � w� o m �� � � 3 p . � o
.� flO C c� O f �L �N � t o � ..� 0 . m 0 , p O
� p o 3 0 ° .o . � • a � �.o .� m '"
N � ��. a. N ,�� _,o ,
� � � _o ~ y �
m .> > �s
� G'I `; s � � , r
\ 0 I N
d
7
� � � � �
Z � ° `
o " y ,o t
� � �• c C
n
.� °y, p o D
o` o . a �
� _ _ • -
� M � ' •
t
� ~ _ O � �
O 1
� � � D° Y
N � 7 �
N 'O R �
n
�;j O O
` 7 O S e
0 O O
C 0'O- G'
�
� Z
- _ b
. ' - n
. ..d
� �
' t � . A
' . N
� Q
. ' � - _ .. ..�
.. m
N
. � ��,., . C,tt C`'O' ^ O C" '1...^S� � 3 "`O.O�P «�,~j b�� 'CJ S
' � � � b a-r'-"t�a. c- n o ti �`t.a N m o ��t n c,,,a '+ p n � • � m -
' - p o � � �.:.'m',h�`.Ob �' h � � '� 0.,s -�� ❑,,;� �o0�_Q'ob•N „ C� °�
ry� n �...-i� R � O C �Ob o r�. � �, `t O°' L',•=� r`C
_ - � � Mo`°�bS_'� p`'': Y �"r '^ a � � o `°,A �,�.`�:�p =4rn Po,O
- , o .ry �.�.c��� ° m'v° c'^ �'^ oQ.m.ao ��.� "3'+� a•�: sb � �[7.^�.
-- � m '^'�,.j� ;; � ° � ob o.,� o �'A �3 N � `°".�.b�m o i � :��° ° 3 �y
x t` r o'^ � � ��.,n"'` e � F ti b o 0 o m o � o M.C C�H .^. « �'C1
� m •;n � � ap � aa gmb�� � Yn � � z•�'trez oh So �
• 3 .� N a �C o'�� �o�G � o a'o- ' k a� t n � � o 0
' . � N ^p M � Q.p O `G. •'! •y'w .�'. � •m o � `,� .Y �.oa �� �-� C"'
j � C '� .`i O �7 F pG � A p O 7 3 S Q?�G W n��O�O rn N O p d
t^� 'v a p �
' � ' � n. A a �"a�o o c s e �y �'o L�L s � m o v ,�,N w �°b �� o'�-° ° o �
� -v � ���.n.p C� ...eatt na� �.♦ C
� " n 'N `o.��� ° o �0 � ` F.� a-� CQov �v°':��i' 6•� ° �- o: :; �'oC1
� .. p . ,� �� o,o��'o � �,;o c °':" q� =' �'�-� fi h �~p-��.`r°`���i°� r
�° � ° �< x 7 � �b o Cy-� a . ° � ^'b '�':� m
1 , , N ��� 0.O �� O�� � �X 1 O N`.t�,� £ O �l.^\n 3 Z O � � ..•"• fl � `A
Z • ,-Z•� � w Q..fi..� O � �b (�S?-� � W y m C�Q P `�t O:�
� �.oa'�a3 p ���ta:noo -3 tLfl � �� - �.� � o.� ✓
�' . . „y � � � c % � �p � C.,,o- 7�O a`c �� � a n .�•� r ti �.�
m � � ,�. . S M 7 0. p o m o.F�. � � x =° C .�- �
� " N O � x � �T C . O ' O � O � f� p S 3 A n .`t A A'��^ 0.A .v' � 'O.fl Z
� ' ' .. f .. C `.W m.N. �f � C'Y�t m O'O A Q� O �' .n p
7 Q1 uy�G � 'C�w�'.F7!' D � � �v�.bOG`u. 00L'� 7
�G
, ' � � L f' '� (7'� D 3 •• O �' �t N�L K "� O O � p 1 m{�.
y �,"'
�n � .�,.`,�.3 ie�n a A C O n �, C r.n ir a O p .w..0 M�,� :�.o ��w n
i i� A � � � A n�-ma., �t' f `= �~ ��p1° '' � ^ �
, � . O .. O F ti N._ N O " •�� � �, ? �. `C b�A:t n .Y � �G �A�C N N
- Q C-o�^ n ^°� ,�A='�3 � �� =a s ' :�tt o �.
� . N