Loading...
HomeMy WebLinkAbout1282A 1570A 1679A (6) WORKERS'CDMPENSATION DECLARATION ... . _ . . ' � I hereby affirm ihot I hove a ce�tifimte o��e�,e�,�o se�f . . - - APPLICATION FOR BUILDING PERMIT. -insure,o�o terlifi[ale o(Workers'Compenslion Insurance,or a ceni(ied copy ehereof(Sec.3800,Lab.C.) . COUNTY OF LO$ANGELES BUILDING AND SAFETY �`Qa PolicyNo. Company �y �. Ces�iiied copy is hereby fumished FOR APPLICANT TO FILL I Q noosEss 154 ,LS�M[� OJ� �� Certiiied copy is filed wi�h fhe coun�y building inspec- BU4�iNG � - tion department. ADDRESS �� O�C�!+QU LOCALITV � �- � �1 NEAREST Da�e�� Applicani �' CITY l7 ZIP � CROSSST,� S '�!� - � ���CERTIFICATE OF EXEMPTION FROM WORKERS' ' ' � NO.OF e�DGS. ASSESSOR � �' -� � - COMPENSATION INSURANCE ' � SIZE OF LOT . NOW ON LOT MAP BOOK �� PAGE PARCEL ' (This seclion need not be completed if�he permit is for one 2 USE ZOrve /�wa - . 1^� hundred dollars(5�001 or less.)• • � ittACi d.7 BLOCK LOT NO. �'� NO. �5 d.�,� � S � � /�. TEL. SPECIAL a OWNE IC� (�b NO. SI" � CONDITION$ I�cerliiy thot in Ihe performance of Ihe work for which this - � �ISTRI�T GROUP TYPE FIRE PROCESSED BY �permit is issued,I shall not employ pny person in y monner qDDRE55 � ���0 . CONST. ZONE V so as l0 6ecome sub�ect lo fhe W ers'Comp ion L ws. ) �O � C Da�eZ~2� �Applicanf ' ��TY � � Z�P L`��� SfAiISTICALCLA IFICATIDN 1 ` APT.�'CONDp. - �O . NOTICE TO APP�ICANi: If, ofrer makin i is eriiflca�e of aRCHITECT OR � - Te�. . E.emption, yo�-should became subjecf the Workeii ENGiNEER NO. CfA55 NO. DWELL.UNITS_ CW, -Compensolion piovisions of Ihe labor Code,you must forlh• - qD�RF55 � � (�1 t/ SEWE2 MAF Z �with camply wiih zuch provisions or fhis permit shall be � deemedrevoked. . . � - � CONTRACTOrt P�j� � - - BK. PG, VALIDATION , .LICENSED CONTRACTOR$�ECIARATION � � liC. I hereby off�rm ihai I am litensed under provisions oi Chap�er 9 . ADDRE55 . NO. VALUATION ' �� 2��2{� � (commencing with Seaion 7000)of Division 3 of the Business and �i�. \� �O� . � � ' ' Professions Code,ond my license is in full force and ef(ecL� fITY � - � ' CtA55 5 �•��.�••.2 3 ' SQ.FT/�� NO.OF � NO.Of CHECK � • .g 5 b 0 �I License Number Lia Class 5¢E ✓ STORIES FAMILIES ONE. � � �ESCRIPTION OF WORK s '� Canimctor Dare NEw ❑ z(�� (�Z� .'. .8 S 6 0 c=+ � I�am ezempl irom fhe licensing requiremenfs as I am a �' "7 '��j.�N� ADD � . � ' licensed architect or a regislered professional engineer . ., , ., ALTER � FINAL � . Q,�,� 5�-$2 � acting In my prvfessionol capociy (Secfion 7051, S� �, REPAiR � DATE I. G � � � � Boslness and Professlons Coda). USE OF _ ^ 2 r ll� � - � E%ISTING BLDG. •V r V O W r- DEMOL ❑ By A� �1 . LiC.or Reg.No. -DatB APPLICANT �' TEL �' . � - - . ` -- - OWNER-BUILDER DECLARATION- � - - �(PRWT1 N . � O � / , I hereby affirm that I am e.emp�from the Contracmr's License � .C. . . � . . . Low for�he following reoson($eUion 7031.5,Business and ADORESS 11 � �� s�,oa ProFessions Code): - FaE en,i � � �� , O . . ' . . . , BUILDING, . . . . . .. ,• -I, as owner of fhe properfy, or my employees wi�h nDDRE55 '�� � '�TJ wooes as thxir sole compenso!ipn,will do tha work ond � �� �tha shuUure fs nol IMended or offered for sole(Section � ��A��TY � � � �.•��5��,�2 Q 7044,Business and Professions Code�. MOVING TEL. ' . ❑ CONTRACTOR - NO.. . , � •:� �5�;2:O I,as owner of the property,om exclusively confrocting c_, wi�h licensed contraUors b mnstrutl tha project(Sec- aDDRE55 - �tion 70a4,Business and Protessions Code). -�- � � � � - (]2�(7�$,2 REOUIRED TOTAL SETBACK FROM E%IST. � ' CONSTRUCTION LENDING AGENCY SET BnIX YARD HWY PROP.LINE WiDTH � � � - � � � � I hereby affirm tho�there is a mnstruciion lending agency for - FROM � ' the performance of�he work for which�his permii is issued �a.t. � � � �� 6 7 9 A �.. (Sec.3097.Civ.C.I. . . . SIDE . .. . . . . . . . _ , P.L. .. Lender'SName ..._ . (7 \ . . . . #i�:���'�.�.� , � P.C.Fee S OS. V Permt�Fee Uf/ � ���..��_�q,5 p iender's Address 6 ! . � I certify fhol I have read this applicolion and slale ihat the ��• .yO Issuon<e Fee d'J� ••�1 7 9 5 0� , obove informotion is correcf.I agree fo wmply wi�h all CouMy Inves�igoron Fee � � � � - ��� � / � q � ord�nances and State laws relo�ing to bvilding[onsl�u[fion, Tobl Fee� 'I•J U � O p 2 G"'$2 and hereby auihorize represematives of this Coonly to enter - . � � up n ihe above� entioned property for inspection purposes. , � � �8z. -- � � SEE REVERSE FOR EXPIANATORY LANCUAGE - ' � '� $ig r of Applicani,, 9en1 . Dote �. . . ��'� _ T. _ ! O O .e L� G� �'-: ' � � m ,�, N p fn0 � � O A 7 O- � C' O .� � ` �. � rtt T ()2 p O 7 p O C tD n F. p '�^. n w p S . � ., o..o o n y. .... y; � m n 1 ,�r T 3. � �_ v_ � , a. .�o ; m v D o A o N --� -io d a-, a o D� � o.� �� a m D - o:� nA il � o � �� o- ^r� v a � 3 a v =- b % h,� o_. v; � � .�.a. 3 c -^ v '' �c 'm of � N_ wt �: co o� :o o � 3 0 � , o T 'V� �0 7 O �` � � V V'• �� 9 A 'm m � � � �.� O_� j4 C I a,t� �! � `G •) "C + �?- � . n'� � � � ., � � v� ` " � D ll z j " N �.3 O � O � � e e D pS� " .p o ro c c r � � � m 2 o , � o- � v n o p . � O ^ • c�o y� N 9 O I � :s ' C � O � ..ya ' ' � � e - � ,\ - c • ` . . . ` -.r _ -. `_ \ t - . _ % � ' • - , . , i ' .- . ' .' _ � , ' I N 'Q ' . ' ' � �. � .'2 ', A i _ - r1 _ O _ . _ , m h . • �. . -. - ' 7 tr��e S'= ° �'CtT£ �' s ^o o'a U c�, y'a � m s � / . . . � nb o-P v� .�C � o -� c'� � m o x�t o sy a ,�, a � �.� w o . o � o o � n c�.�U ° • � F a o "'� •;m Q�.a°'°,ti,,r o L'v a e', N m o U �p o � � "�CM'�£.� � " o � 3o°bo" n a -a��� 0^H'�~ an '� O ' � a h " � � x�. e'o �"� ot, ^c o � o qT�"ao :+ a c `^ cc n '`..nm �`-„ =��`'� � � o,�r'.' -. � o o ♦ h� ._p o�••o e-m x n � rH a x a � o e ^ � n � .� � ...o �n N mb - �" '7'' N'.N. .o.A-•m o C Rr �'h `�.� � b TR�'yt 3 `"� ... Eu � ° oo'vqo a b'" � f "o� �b,� � oti � o 03 � . . % .r,C�'ti p,w f `,r a`� o � A � > > 1 ,� o . � � fi .:�., x , . .D 'xotiaa.^o �..� or�o � zcc��•� o e�,� ���°, o.�x �� oa. o�C � o ` � � -n o � ., a „ a 't' � A a � y� s A oa �� a o o � 3 �' n��e�w�n�"o M '^ o Q C7 , � Q '�� 'v'��� t0 C-�'.� ��,a n°"m v `.; � °,b �� o c � � m A - � N `oo'�e�M N� �°^S �� n-SAoov a.�.a:G�c� `o »o: � �oC � � N ' n� � �R.� � ^� � a � A p'� o't Hm?� x � � o x n,10b,:.^.� �� ��r � o n� o' «wx � e a�,a m £ ° :'tr'ti� a s o `° � '- ° o � p M �F a.� 3 ��.�`,sin�o�=3 �a cna h z � ° c s`��° 3 ° o `c b " N � x'a .o � : .. : N C.^ y n_n .�� �.����� o A ay�A'p � 0�0�'� o i �r,�-I., • .O ,n „ n S �e '''m ,o•C-a n N p � n m . �f , . � ��+.,�,"�N.. . v � o �`�$•�e..A^. c�n mv �A �.o-��0 0.L�° � �n:Z -, ' � � � h A'�* �.� �,w A o� T.' O p^ H ��� 'tiV�A V„y� o p,•'s � . Ito p n o a o � ��". 1 Q�,a-a m o�co y o w t"��.�.C�i' n �`� .v � � �. � ..n w`,b � A n � ti G L..4 n �.0 �"'.^.7r N O A O� C•A ,�'+,�.O � W n . 1�r p � �_ c � 3 A�,p �a v_ O�,�n,� p'tn p�.�'Z'� o o � w F n N ..� � .`. � �� �• `.�".c O�Z�" � ?�w H �C'�a ' � t O 1� O Q lL''t.Za`w 0 �o a T ' ��G C te . � . N � �� h ^ ^ ~ ~ '