HomeMy WebLinkAbout1239A 1572A (6) _._ . _ _ __ .._._.. .
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� WORKERS'COMPENSATION DECLARATION ;..,4_.,... -` _ �:•.,._: -..., ey
.. ..,.._, ..,. .. .. i�
I here6y offirm ihaf I have o cerlificofe of consent to self qpp��CAT��O�rr���t�B�J��IL'bI�V�G PERMIT LS
insure,o�a cerfifimte of Workers'Campensation Insurance,
or a certified copy ihere f S c.38 , ab.C.) � � - �
(,? �+ �i����� f COUNTY OF LOS ANGELES BUILDING AND SAFETY ,
� � �,� � . . . ,... . , ���.,,._�.w,.�..�.._,v.... _____ _, ..
P❑allcyNo.�_�'"i Compan`�'j'. . . .
Ce�tifed copy rs he�e6y furnished. „ FOR APPLICANT TO'FILL IN ADDRESS �u J�} .
� Certified copy is filed with ihe counry building inspec- BUILOWG / �{ .f y�% y
fio�deparfinent. ADDRE55 (t7�� /V.�IC CM4'r:K.� �-�' YJ/Y�` • LOCA:ITY r
/ NEAREST
Date � Applicont CI7Y��(.'.yYiC{�� �(�j„r'� ZIP G �l�T:r3 CR055 ST.
CERTIFICATE OF EXEMPTION�ROM WORKERS' NO.oF B��cs. a55E5soR
COMPENSA710N INSURANCE SRE OF l07 NOW ON LOT MAP BOOK PA PARCEL
(This section need not be campleted if the permi�is for one USE ZOnIE MAP
hundred dollors($100)ar less.) TRAC7 BLOCK LOT NO. NO.
TEI. �l�f t'9 f1P� SPECIAL .Y
I certify that in the performance of the work for which ihis OwNER + ' - /-- �-�'�NO.�` - �' t�4�� CONDITIONS �
permif i5 i55ued,I 5hall nof employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY ;�
so as to become subject to the Workers'Compensalion Lows. ADDRESS_ �'-3 . 9 �.'^� � • CONS�T. #— ZONE
CITY S s L:• l7��S� ZIP '^.� L'"D �� � _"�" �
Dafe ApPlicant STATISTICAL CLASSIFICATION APT. CONDO. �
ARCHI OR 7EL. �N¢ �J
NOTICE TO APPLICAN7: If, afler making fhis Ce�tificafe of �EER i• _ ,�S NO.�'J=;-'�'�' -f CLASS NO.�,�DWELL.UNITS '�
Exemption, you should become subject to rhe Workers � �
Compensation provisions of Yhe Labor Code,you must forfh- ADDf�E55' „j :, f � (� SEwER MAP y
with comply with such provisions or this permit shall be TEi '�1 ,...,
deemed revoked. CONTRACTOR C � � NO.G �=i" BK. PG, VALIDATION
LICENSED CONTRACTORS�ECLARATIt3N � uC.
I hereby affirm ihot I om licensed under provisions of Chapler 9 ADDRESS.'h�?:� i+ �iy'. -NO. VALUATION
commencing with Section 7000)of Division 3 of ihe Business and yp ���� i
/�Professions Cade,and my license is in full force ond effect. CITV -�'-�/�/IE�f� �7/1%.fF' (, 'J CLA55 $ 1�'�'�
j� �.j Cyt SQ.FT. ,',l NO.OF NO.OF CHECK
� License Num6er��'� t��� % Lic.Class �7 SiZE �'7'�'� STORIES � fAMILIES ONE
� $. �� 'j�.���� {! �- �ESCRIPTION OF WORK NEW
❑ �
Confractor t� �'i� .! i:�Y r Date��� ���,
ADD � ��I G�J:Q
� / `�
I am exempf under$ec. fm q�7ER ❑ FINAL / (.es �`i a e o 0 2�
B.&P.C.for fhis reason C��" ` �� �'t� REPAIR DATE � �+
Date: USE OF ❑ FINA ,_ ... � e °�Q C/�7
EXISTING BLDG. /` ' = +� DEMOL ❑
Signafure APPLICANT � . ^ TEL. ��{' J ` B g F, � �.,�,��.Q O u
OWNER-BUILDER DECLARATION PRINT� _ �� .� NO.� 3-c`-�
I hereby affirm that I am exempt from ihe Coniractor's License � ' ' R y�� , ( �,L�—FS�S
Law for the following reason (Section 7031.5, Business and A�DRE55 `O-"��+�4 �90% 6'i9 t..•'• <�/7t�T7% /Rv'�'
Professions Code]: pRe M
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as iheir sole compensation,will do ihe work and LOCALITY
ihe siructure is no�intended or offered for sole(Secfion
7044,Business and Professions Code). MovING 7EL.
� I,as owner of ihe property,om exclusively confraciing CONTRAC70R No.
with licensed conirqciors fo consfruct fhe project(Sec- qDDRE55
tion 7044,8usiness and Professions Code).
REQU�RED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SE7 BACK YARD HWY PROP.uNE WIDTH � :%; .�. /�G A
I here6y affirm that there is a consfruction lending agency for FrtoNi
the performance of the work for which this permit is issued a.L � - s e a e �
(Sec.3097,Civ.C.). SIDE
- v� I � i 1 i,7�
o Lender's Name �}+-
� P.0 Fee$ aY3� Permil Fee �� � ° � � ��•�� `��'
Lender's Address
I certify that I have read this applicotion and state ihpt ihe Issu e Fee �19 "- � "'��'`�
� above information is wrrect.I agree fo comply wifh all County Imes�igatla�Pee Qn� j (�.�
g ordinonces and State laws reloting fo building construction, Torol Fee 1 �?
and hereby au�horize representatives of ihis County to enTer
$ upon ihE ybave-mentioneJc{L,!p�roperty for inspection purposes. �
_ � ��-��.'f�� f�Ly-�' s�.i �.-a�' ��� SEE REVERSE FOR EXPLANATORY UNGUAGE
Signotvre of Applicam or Agent Dare , �s
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e,,..r. . r,.>--.t-�s.a--"-:,'---... . . ....._._.___________._�._._.�.�__ <UrN�-'�2"L"1i`l D.C-. .s2�'--�Gn
z 6LA�F8 TB A�PfISANi. .. , . ' . . IN6PEC30R'S PV07e5� . .. . , -_•v � ,�x , . -e� i. ..
� _ . ._ _ ___.,.�--«-.,.�.._.-..-,.-..___ _ . --,-.....�-_..�_,.._.� I horch p`airm'nat'o�r eror-�p7 fron t`�e C.onf c or�.,
eo. `�'�8�utw� — - - Lice�se Law for ihe following rea on (Sec 7D31.51
�'; p+PPrtvsd f3 x e: >( tia�zs C u /'n}.r O ccun ..•bzrk
9Vo.i �J 4.,.. , ,Nia - V^ �� - r.,.� . a ,�.t . jf� - - .- c�;.n:s��,
�—�- ---_____ _.f�_______-.,� ;--_---_ __ --— ��r ,A � ,t� E� , �� s Ye�,�_r�.s
�th ar�X car �or s c�r crn��t . f�-r xr..d.��u?er.aent
� . — ' "_ tl. 4 (cc e p r r( -6:�'r� ssaws of Ybc C.�n-
tr tn � r .! .( br,ru 9i(tone ne r .��eeh�ec
i �--� fdo 7�U)�u J : r' �i!r�e Buciae c�n2 Pr j:±ssaons
�F- �� � C, d o ttist"� s--rcn]�s ihzre,fram ars Sbe gusi�fas•r(�e
� . -- - ,„.,,.__4.._....J,..._....,._..._.. — —_--- �!t c roe'on A��r:.ta*dos:oj,Sneaeo,. ,�33.5 6y
I �a�zured �.�fecRmeaivtd ,.ps.c.r.��rr;.r.�:aitsaix,'�•stsf.'�ech�licWaa!?a�sciael
`ar� c,aia er Rppreved — -_--_-�-_—- �;.-¢ 5 . v:o- .t.c-r.�s & :.�recf u'r�!.:,s:/ai0^/.l:
^` Yes �a
I �o r of iha prope 1y or my employees w�`h
YdaPa �-rt�f c���_�.. � , ^ �_. � . - ------ wc,� s tF�-c s a cca:per a-�_,w do ihe worlc,and
__ � rha siruc!ure;s net inience�or6i�erod'icr sale;Sec.7Cd41
Heahh Depar9n�nf ..�.-��.���. . .. . _---_ .,, si v.�:::_=n�c=rqjr::r±�:ss Cnrle:'_'Y,�Cr,�iSractor:s 7 ice:sc
�. 'av<•�doe.c,nb oj:�`y to nss ce��r.c:c;jr•ro�e:ty wyo build,:
; �Piro�e���'menF � � � � -- . . -- cP irzr,'�so�e�ifie-eo.+r,c�.l���i�o:,'ce.r:ucl:aark hi»ssel�nr
�... � tb:�nv�;o,6i.r oceix a.:;picysc;.:L'rn,�id::l f,'at sucl� �ic.a-
��. -li� . � - —__ '. ��r� rnc xfa ¢ ; ed �r sfe c�for sa!^. Tf,
3 __i h - . � r�J.r e�. t r dd �;rs qne
;nnlcg-ea� i I ^�er . 1 r .s� �e rl /-svc ¢be
� --'_. .__-_.______,L__.�.J 1� . . . .. . _ ,?fi.rn ,�.f,. _...xr.t... . . ss.,ro;�
��9sir:cr.Protetlicn � —'—_' -_ . ,bc�),:,rposc cl�a,ejre. .
!IFcr,t�?(CanocYi � ' . . . � I,a:,-,wnernrt{�eprnperty,Qm c::du:ively cn��itroc
tlrr-m�lfh liccn;oc�oi�::actors to conalruct tl:e oro;eci(Sec
$pe<iaf Insp?ction � � . 7n:;<,;:' .,�.....;;=e"irn(sss:�su�Cv!`�:1�bn Cr.u,'rcctr,r:c
I(Cenc)(i5asanry)(VvGldinG�i . . � .. ----.:—___-_- i.icesse�!... ,:... >';?� , a;���:de���i u,�c
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