HomeMy WebLinkAbout1554A 1756A WORKERS'COMPENSATION�ECIARATION �
I hereby affirm that I have a certifimte of mnsent to self �
insure,ora certifimte of Workers'Compensafion Insurance, ' �PPLICATION FOR BUI�LDI NG PERMIT
or a cer1+,ied co ih eo (Sec.3�op,Lab.C. '
� pY�„j' �L 1 , � �,,! ,,,.yyy COUNTY OF LOS ANGELES BUILDING AND SAFETY
���',��I���f�'�Compan�`� /'l':'n:`• ��J�.�"L �/ . .. . � .
�s
Cer�ified copy is hereby furnished. � FOR� PLICANT TO FILL IN ADDRESS ' s d� /fI� s--�-�-�C. �"L
OCertified copy is filed with ihe co My building inspeo 6UILDING 6-� .„^� � �
tion deparimant. � y ADDRE55 �.(�7/.-- �t.�/��� ' ✓�� LOCALITY �.r!,.� [L.E��
I✓/N(1��'� CITV j• �, C— ZIP Cl �— NEARE57 ��}„�
Da Applicant � CR055 Sr. � t ��+��• C
CERT ICATE OF EXEMPTION FROM WORKERS' NO.Of BL�GS. ASSESSOR
COMPENSAiION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be tomplefad if the permit i�yr one ,�-- USE ZONE MAP -/
hundred donars(S�oo)or less.) TR - ,�`r��ct J BLOCK /"7 �OT NO. NO. � '�.�'+�S�
OWNER �H �- �� G�-/�L.c NO. SPECIAL �
I certi that in fbe erformance af the work for which fhis �r�� CONDITIONS �
fY P DISTRICT GR04P TVPE FIRE PROCESSED BY +�/
permit is issued,I shall nof employ any persan in pny manner .�`� . <;�}� �r � CONST. ZONE `-}
so as to become sub�ect to ihe Workers'Com ensation Laws. ADDRE55 _
i P , j� � / ,'„° Ca
� �CITY , ��� Z�P / "'y ' STATISTICAL CLASSIFICATION / APT. CONDO.
Date Appliwnf ARCHITECT OR TE�� �'
NOTICE TO APPLICANT: If, after making Ihis Certificate of ENGINEER NO. CLA55 NO. +�� DWELL.UNITS ''"
Exemption, you should become subject to ihe Workers' '�
Compensation provisions of the Labor Code,you mus�foith- Rppn�� +*" SEWER MAP , �
with comply with such provisions or ihis permit shall be - `�y-''�
deemed revoked. CONTRo.C70 (.`,�'.� i�" �Y N0.7 t �'..� BK. PG. VALIDATION
LICENSED CONTRACTORS DECLARATION ��; J/�/�/ �' - lK.
I hereby affirm ihat I am licensed under provisions of Chapter 9 ADDRE55�� y p� !L( 7" NO. ���� �/ VALUATION
(mmmencing with Sedion 7000)of Division 3 of the Business and r ,. ���. p / �� 5 J�.�+A
Professions Code,a my lice s is in full force and effect. CI7Y � fLl.? � CLA55 � /� �+ /���'�'� '�- , e e
7 SO.FT � : NO.OF J NO.OF CHECK r � e 2�
License Numbe� /'� • � Lic.C,lass� SIZE k.� STORIES ( FAMILIES ONE � I � a G�C C
Contrac��•�"+-�•�/`�-��'c-`rD y� DESCRIPT�ONOF WORK ADD ❑ v o z
� -LS,CC�
❑I am exempt under Sec. �A` J�_ ALTER ❑ PINAL �/ � 0 G� .Fi"�a�l
B.&P.C.fo�this reason �'� � REPAIR � DATE i�
Date: E7(�SONG BL�G. DEMOI � gINAL ._... .
APP�ICANT e � TEL"'� Y
$ignaturf PRINT) ��� �' � f � �-
OWNER-BUIIDER DECLARATION .
I hereby affirm that I am ezempt from The Confrac�or's License ! r,. G r / `f '
Law for the following reason(Section 7031.5,Business and /+DDRESS 3 (yff(�"" -•Z ��'�� �'L� ,���` �/3� � ` �� �`�,';1��
Professions Code): PRESENT „ � � - E t
�BUIL�ING A�
� I, as owner of ihe property, or my employees with ADDRESS � . i �4�:�
wages as their sole compensation,will do Ihe work and
ihe structore is not infended or offered for sale(Section LOCALiTv _ ...
7044,Business and Professions Code). MOVING TE�. � � - ` "'' `��'
� I,ds awner of the ro ert am exciusivel confracfin CONTRACTOR NO. �f;{.
P P Y, Y 9 l:1 r�:
with licensed mMractors to constroct the project(Sec- qDDRE55
tion 7044,8usiness and Professions Code). � �
REQUIREO YARD HWV TOT}1LSETBACKF20M EXIST.
CONSTRUCTION LENDING AGENCY SET 9ACK PROP.LIN� wioiH �
I hereby affirm iha�there is a construciion lending agen<y for FRONT ��
the performance of the work for whith this permit is issued P.L.
(Sec.3097,Gv.C.).. � . � SIDE - � � - �
_ . . . . , P.L. . .
$m Lender's Name ' �
r p )
Lender's Address P.G Fee$ ,Kj-l� Permit Fee a7C _ d{�
� I certify�hat I have-read ihis applimtion and stata that ihe Isso ce Fee �4�T ✓��
q above information correct.I agree to comply with all Counly invesrigation fee an ` ,•'
ordinances and S te laws relating to building construction, Total Fee �4'r 7.5
� and h eby ih rize rep esentatives of fhis County to enter
� upon e v menfion property for inspeciion p�rpos . � � �"� � '
a „�y;y� i J� '� � `' SEE REVERSE FOR EXPLANATORV LANGUAGE . _ ,
�gna�ure of Applicani or Agenf e �f �
����.p.�.�....REA9dS YO kPS'I:ICANT � . - IPlS�ECYOo�'S NOTES - '.� :•:?riA-;?Ui:,�L�Si iif ]AR 9 TiON
.�.-..-. '���^^•^���yyq^^� � .=..�-. . 7 .. ...,,.-�..�.-,...---"-.;��-----4-.-�,,,-.r.-•.-�...��-- I hereby u4tir!n tlac9 i ani xc'r� 1*rom'he Con<-actor'c
���: � I R�p�r��� � �ice�az Iqtiv ror 'ho foi otiving reason (Sec 7031 5)
L—_---�_....._..`_.._ I � A�Re'mv�d � � - 'Fiu.:rt;c,>a•;d.Pr�fc :,nd. _n c:tyorc�u:xtyc:�lzcd
�E1e.!- Z`.¢ta F3o.� 3aSe.._ �re�:c:e,,..7�•rr - ;;r. �� : �.r.p�»s:��+^nm(evJr
.�-.�,p.-;,e;�.�-_�—=� ,. . .—. es rc,(>c�c,�;. r c f rre o a c r xu�nea,=Lse requ::n..'
I ' � �. _ _ — .. .
Ps�/e 4.Sh1'Cr:Y£_!f;r.M.:.C/J�{CPm�t 20 j1?e a Stf�+nelZ.;?Qte!ltend
- I �`. � -c-ns.l -. �.i:o:bs/�so< caio�s 1l.L-�Cor-
i - - � � � .. . . •s-uct r� d c s;s�La -(� rr�:er3,l�rorrtynennr� a:�itfiSe:-
' i , l%o ��f) nj 17+i r oro 3�f S�c S�es�r2 se and P'rbfesstorc
' � �;n�r./n.SSet��isx rsna�ttAerefro;nandtbel��srsj�rche
! � � �,�_� — --- - u7! r nr.co..�±..t z 1 0� qf Sec ron 703f.5 hv
� .��_-� �ar,.u3:oS .:r. e a � lere:`e:�:;rrs.��� t syaanpt'cafsife,cr.'iit
i ._ . . G16}¢}Z@6R�it3�
.a 3 a 'i. y� ___ yc�-o.. j �_s,.c,��;Y�.n�� 1.ar red dn(tars/5S(JOJ./:
ar Approvad
�&`: ' '�c � .. � .J H o `ha p ope Y,or my Employecs•,H'h
�,�`-,�,ir c�'E rt.�~�.�_��_�___9. ��- . �. � - - �--�-- waye,.m t _r sa o +-ipanso.ion,w II do tne work,cnc
� r"`�<�'� . � . � � ;ha s'ivc'urc>is r�..b rr„�dcd ar 6`fared for sala(Scc 70A4��
Heelth Department � ��^�'- , � � . l:u:i;o�s.,a.;d nrnj�sseen;C,^u�::?he re?:tr^<to.-`r,:cnr�se
_ � _ "I � Laa�'.�as nci rrj,ptf�rr,en�e��eaer o}`�hr ft.,rzy u:.3o burlds
��.^_ �nri:+r�:�r.:. inc:^.or,'^��:��%oc�uPssrrt,'.sr�orb�l�imsel`or
•rRa�ePorim�ari � : I � - �'- . �--'- � �'�"�? J
� ' i.nrnz,�.g�!�is oteu r.::F?.?YaC•;, rigcrici�� !bc? sucfi iaz-
s3�adiri9 � �T � f_,,,--,-,--,.-,.- ""�- ' _ prni.��;rrr�'.; cr�o�s;iii in>�o=Gc� n=� ��;feiou�fcr.ulc. 1f,
_._ _��. � . i>oa,r::cr,:i;:li�cidis:tr:rir.e4>nr�visr:neisao?dv.•4ther:r.ax.=
�Geotogiccl � � "- ----'_ , con,nf�;?��::� :b,a.ot.��=r-b„rdder v'dlf hcr;¢ tl e
�__________`_�`._�� �£ ���+79'Utii:�.•' ..I:>C.'.'.!S Y7!F2::lG:f.Y i:`�>n2.�,�%.'
I^edesPrian Prctecrion ... ., Lhe�n,. csc oi�sala/.,� , , � , .
�('anca)(.=c upy) . � � , .. �-�e•l'.a.o�am�,r nt!�c�xaoer';.,as sxclosive!y coneroc.
S___._ 1 I . . � '-' firig�y::th'�.ice��sv�d:� ',-cclois to'c9nstruci tl,,�-proj��ct;Sec.
�$pecial inspociion . � ' � _ 7�:;A).u4s:�r:z:;s c�ari 1';-ai�:'-'=°�:z.c Gn�'e: '$r Con6rarfors
'(Cene.l(�asonry)(�N�!ding) � .. .. /,icc�a.;eLac!��,:�s�ntanfi:�:��..oee:z=rn�p.�e crt�ece;o
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