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HomeMy WebLinkAbout1513A . ..___ . .. _.. . . ... _ I -.�. .: .. ,,.. _ . _,.. .. .: .... __,. _ . WORKERS'COMPENSATION DFCLARAiION I here6y of6rri iho' I havr. o cer•�ica'e ot cnnsrn� eo self . nsure,ar a ce����ca�e of Workrrc'Compensa:o�'nsuroncr..or '�^<salr . �� . .��,.��, n ce.+�f�ed��nh�{epJ f5ec 3800,La � �eaos�a¢v eiai) ' /� �`�P J�.p^� ` � PoIeYNo „/'�17+=ST�sLy npany _��. �U.11d'-- � /'9P�,�A,IL�rf'se�V� � e.,�,.�._-.,,_a.., . . y._Cer!�i c�c`6F�i'�h�'�bV��rn�shed_ _ __'__ � JE•YLR = SEW�►GE�I�I��'�S��r,`t,r-,z, .., _ ��....,,;wr - L 'F.I Cerlii�ed coPy :s h'ed wnh•he co���xy cuJding insuecrmr COUIYTY OF LO$ANGELES BLlILDING AIYD�SAFE7Y de tmen . . _....,_.._..�....:.,..�.,,.:,�-,a...,,.��,;��. 2:^+.'r.ukA„-::��.��5' - r r+.� .. .w:�.Git:.. .,.;..,;,,.�d.�Ym:si�i�...".,:.i:;::..���.:, :. ��`20�86 _..M, :,,�:a. ..._ ..;.,: .,,. ��,�,-------- --A�,p;,�o,,,_�'reeman FOR APPLICAN?TO KILL�IN.,,,._.._.. . , CONNECTION DATA ------ CFRTIFlCATE OF FXEI'NPTION�FROM WORKERS' ! '� --'—'- �� _ _ :0�5APENSA710N INSURANCE %?��FS� ���l��������__n� �"'��^v -' ,�� >:, .. :r. - r .. ... ._.,_.............M.n. ---- ' ;Ti+is secho•�nced no'be;omu�e�ed�`�`�e work involved by tFe •„Ni•�;.:,�FF�,�\;� �� .'rrpa :�n ��� riT.ti �.r'�� ..., �- ocrrni�is for orr.h�ndred dolinrs(51001 or less.j '' �� -• . . .. .....--�-.,-*.-,��« u,:..0 �cna> / -- T�:[r.:co\\tCrCn �raGn-rxCnn I mrtdy �hot �.n�'r.c perfo�m�nce o4'ho wnrk 4or which in�s ;r�;scy �r.y,���� ��t��� y - � ❑errn;��a issued i sf+oli::o�wnala nn ' CUk9 •.'I ': ,,, ,��w„� y y person in ar.y manner =�'�--� "�� - � � so ns'0 6ecomo tiubjec+�o en�+Workers'Comnenwuon Ln�.vs ii1V J� 'ti t U y.��� ::�'a ur n'; r..nc ��;��,, Pc Box 33?° - Daie_ _'AUPl�mnt ... . _ _ae.=s�,'r.0 "[z:.*n:. _. .. ..> NOTICF TO�APP!ICANT� If,�o�i<�� mak�ng ih�s �',r......,. �.f Y •� . � _ - �,+. •.rn�.re ,n,�•:.ni � ,'�e����s-x ao.•• ••,n�•�•••,� � �ovina -�. �c 81� ,,¢aampnon. you shou�fl bG'COTP. so6;ec� �o .....� 'L.r.:,..: '— — - � -' �� ��4� �:- . . i r:�..:, . ' �oensaho�prc�'isions of the iabcr cade, ou musHor!hwiih �;-•� . , .,... ,.., . ,.. � -..,---�-�---�- y ..,;ori;��i �.C.1N(: _ :=ORSi WIDEN!NG .n��y witlt S�iGI:p/pyi5iOf15 O� tfii� nerm�shn,; ce deemed '" . 35754 -- ._ , �. �evokeo ,iccK 'xac- ��-erata6A2�1 FNY""` '" ".. . � UCENSED CONTR�CTOBS D'cCLARAT�ON �: c;�.�cs ';x:"-No ���:�� .::v.:�r..' . i I�errby aif,rr��n;�!I mn iicensed��nder provisions of CF���ar -..—i -- , ,µ 9 :comrnenrinc•rvrn Sec�io�7000;nf D�vision 3 0'�he Buii� ,.�j_�!!�;y: J1T1�'y 't�G'3. ;��,pzr,_5 � ness ond Pra�essiC�s Code cnd•ny Lcense�s m��I-forte nnd -- ----�-- — — ciicci �7 :r,�•rn-oe Fl�'EEI�:AN COIIST. c;:r.�_r-o�:;n.ce-e� L:Censeh�m6e•414SH7_._uc.Closs_.�34_, p��� �^�—,,-, . _ _ ._ ..._. .�„"" ..,,".,`�". o . ,:;;fP''S'—r.}-S7.:Lj.._yi�r.i.i+-b[1J.tlIL�.'-_"—_ iF•.:SJRS`:•fV'^.c Con�ractor� e�m.an_oa,e_�?0 86 .. � -r +7�� p/� G " . �..' r•.n ' , ..CoY .�....-.� ' ...,... ..._�. • ' �": +�:�(�^�. ' ' V ..�yp�a.•' . . .��1�te .IiOIII4 . __...__. !.l Cll' �. . .. pG� � i^:om exemo'undc:Sec.__,_ cf•hc I.A Co. ., . i"}�!(�fj,j`� ^"�� ' : _..�.__._ _. .. _.._. .._ ;: a (:; o ._..---......--- - •�....--�--. . . � .,:::".,;..... .. ,..i . .. � Pl�rr�bingCodeanc'c•Sec_ ni•I:e �_ ' " -"' V '___. _. .......,.._ _,�_.."""'...'_""•'_'....�_.._ . B 8 P Code ior+�c'rollo'.ving reoso�,"_' � .''',, '' � . ., ' .'�r;�V ' rb�z2� VI►LIDAT101y,.,._,__�,.,,, y _.._.... .--•--' .... .._._...'-..-'-'- - , --�_ _ o a _ .... ..�_na,t_� . ,: ': - - -�---� _ , _.._ .. - �- ,p---- - _ ..... . .:- - ,--.. .. - . .� �-- - .. ...-----I .�. . ... . F .. Signc��ro—_—.�'_ ._.. ..._..... ._._.,..w,.... . • .�.. . � .,• . . ' -' _ - "'_' OWNFR-BIiILDER DEC!ARAT:ON �� - ' •" -` _..__:..: �:..-.... . - -".-"-"- E' " - - - ._ _. , ... � �. ,. � ..�. :.. . �. ,,. . . . , '. _ I here6y oFf�rm t.in:I am exemp�1�em�'tir.Co�vrauor's Lcense ���� � ' �ow fm'ne tollcwin:�•ecsor.i5c.•en 7U3�.5.Bo�sne.sx cnd�•o_ .. . � �._ ._.... _ '_," •_;,_ _" _""'_ . _._ .... .._... _.. _, . ..., �„'�•,ior.sCode.�, , .,�., ,..: � a^ '' .'A _...; . . .___::.__..,"_ '...._. .'_'. ,. ..__. �z I J 1,� .I,as owner of Ihe property,or,� .,,•..:::�..m•^,r.�•�woges as ..�.. .-•,- .. r;� ° � o I �i �heir sole compr.nsN�o� w�ll + u�sfruCture ' �s nat inrerded or o�lc•eti ior c::'.���,i•�. �'-�� F''.: 9usiness � ard Prorr.ss•o�n Code• QH/NER�$ Permi� 5 ].Q �jQ 1 �'�� �7 v�i r�� os owncr o4�im prooerty.Ur.exduvve�y co^+•nc;�:nfl wdh AUTHORIZATION�OTAL F�E �r �Jn u,� '. ��,.'`�,�3 I�cersed:' , . ..�,�the proierv 'Secuon 704n, ,�.�:,:-�.:i,, ::a..:�mtkr.�'n-.:*=;. ........,,..�„ ,.,.,,.. F:c�tC\";A•:t^�"::\"k:.:!JG".: Bus:ness ::,;::....'.:., ,,.,',' ..,;: c:�.cr ,.:,,.�:�:-5cair=r.�x srivn:�.�i�.c c-r:�o.:a.-� .. � 0&.2 9��3 b CONSTR!'][TION LENDING AG�EVCY ' � (7 � � I hn.rrby a?fvm �q�i ihe•e is o censt•;;c�ion lending ogency ' SIGNEDTHIS� �� DAYpP dr '^79� . io� th�a n@f�pIM1lUI1:G ^� '�P wo�k +or wl�,�r.b this permit �s OwNEROR �c�� :�s��d�,SE� 3097.Gv C; .:n'.'as`..•.�G„ — ��' _._:n_. � ... Lrnder'.•.Nnme _... �. � - , � - - � . ,. . ...._.,.. ..,.... .�_ ._ . ... .. . ........ _..... .. ... . ......... � .. . ,_... . . ... . . .. .... . .... Lender'e Aa res=— - .. . ... . .. . .. . . I cerhfy thn• I heve rend 'I••s r.pphcaa;on o�in s�a�e •no••n^ � above iriormarion is r.orrecr.I a��ee to cr.mply wrti•,oll Ccen�y ordinonces ond S�o�e iows re�u'oting P�urnn:n�ond Sewe!s, nnd here6y au+hori�c represr:n+nr+ct a`tti:s Co�n�y ro un•r.r upon me nbove mennored prr,party ior i•�sFrtcL<:r:,u�ooses ����.�c�, _..�=�s-���- . .. . . .. . .. .. , , , Siqnot�rr Pcrmitic!• .a:w SEEREVEftSEFORE%PLANATORYLANGUAGE � _iwsa�craxs wos�s � _._.._ .O{�NER-�CT�I.DEIt�71ECI.�RA°d`T41V . �'--'—'— .,,... . t -.._. �...,......,�.,....,..�..._�...n-„s.,:.���_.�.,.. •,, �. n�a�avn�s____._L_a"� I II�SPECTOR'3 SIGYAiURE '"_' y C rereby:,::iru:ci�ac.i am�x::t:�:i ix<:ae ehe C;,:itractox'c Y-:-- r s� - . ... .,... _ . ... ........ .. Ljcense Law ior e?�c Yo9:uwi:��:�awa/Ssr.ri;:r,7031.5, NEWHOUSFS`.W:^. '�'' .f .��=`_i BHS�#BSS astd Peofesslm�s CadxJ:A+ty dP�,�r or rnmaty '•• ••a, . .^.' H P _" _" , mhNea.�onricrdn� � , .�,._ . �..__�. ._.,;. , �..,,�,r�.-+�-�•-�...�.�. ...... . .. .aobicb re ire.e a parmit to rawstrv2t,._qYder, improno, ' BU'LOING D¢�YORK .�'__ �47iDI%d�J�s'St)t6�t"C93y SbP`YBC$AeW°��pf9pV'$O�iPdi 1558!(d'NC¢y scPnc TaN�srtP.virts� —'" � - . . _ . . �._.::.... ..�... _;;'� �:..; .-�-... .,._:alm rres th4 Gcaat� r satb• se�ta rJe a � ANUiCk�RM1vFlE.� ... .. _. . CO TBtftt� tt��'� lf0 �UB97Te f cEssroc�p nuvN:.�i � — . , ; siMne�acn�so�rc-wt ?Sa¢he ir dreestsed pursu,�at 80 8be I pmoisionr uj.:b�-�o>tEiwtto✓s f.icensa I_au�,'CbqAt��s 4 NiER,REiAIR,SFWER OR . % i'CO.Y.i76&fl[Y91�vnab.S:etdo»70fJ0}aj i�se�esir n 3 r,f tbe SiWACaE rAccOSAI GVSTf%.^ . . ._..,_.... ..,.....a.,.....,�.:.w...»+se . ' .,w.aa,.-... . , . . r3usine�.a�?r l�n-ofera°fnaa �adej or ek=F "r,s z:¢�rempi DIY,.Utih�Cl VLI:G AND � —_�� — � aanNoon uouse sFwek ._ aberefin�r.��w idie basis�}or ahe a7Teged rxe�rebdlon.Ax,y �—"'�. I .• . �"�Aw�•�.� •. •.(';. 1f0DliYEfu�: 9G'r'a�u7031.3 69d O CfC�!'at 09'6 6CHt4R 9ACKFILL SEPII^.?ANrS❑ 1 . . .. f ;�' y�p� J p SEEP,PR(!)❑ Ccc5PC�15 i] _'_._..___ _ .__ S4bEfCCti:FJ3.Yf�C%:�liJ3i.'..'+.t..YU4.ti(.'9T�i.:1'y 0�6801 fqOCB ffJfi/d •••'"�_ --; . , •— ,4va rax.:,'e[t..:nYa::a I,d7cJ3.: � �I,as�he owner;,f tLi_1'GeEY�y c�rsEi do the mork,aad • - � ' ��:� � tP�e cvur.i.nre�s uot ir.t�:,ded er airactd for sa[e. � pSea ?D4''' t�tavr.�a�r,J.Aro}rssrcas L::ds:7F'"�n- . . —...—.-- . . , . � �, tr'actor's Licen.�F La:t.e'oex aoE?bf�iy Ec�t�m �af _ properly eufia'&ui:ds a>imfirsvar:nrreoK.a+ad wbq does ----'- . . . suru mor� �imteBJ g�rovlded b$ut sucb dmprovemettts :se n.nt swsen�ed or,offered j'or saTe.If,t�murever, abe � bseLiimq ur�:aiyrrovement ss aold wdabin dva¢ysar of .. • , .. co,n�la:io», :�-+ •;s;rnc.baiW.^• •...ri' Laoe tke 7surden ' � , , • o,Fproairg 1ia�na lid reni bniiu ��<•imprave,fot ibe _ • — ---- Asrposc f sak•.1 ••.. ... : .,.� �..,,gj ... ,,.,, , � , . :.: , .. .... . � I x���Sr uxcde�r�cs�.._�__.. . _ � _ ., . 8&'�.C.:trr t:ais reas«n_.�.._._.---- ':,�4 - . . . . . , __.. . .. r.eni2 ..._...._ _ _ ._�..� � -\ ,,, , . ... - �._...�_ � � � l�WA2L--__'-_--..__.__..�_._..._-'..� .�..�......�.___......,.....,...�...�-�..-.�..._-....' .. ..,,..�....r.' . ... . ... .. ... .. ... . ,. ,.. . � FMSPkCT�R'SyUOTF.S � " ,.;.;..w,.„;_,_,,c,:._,.�.,.,.. �,�. ..,.. . . ,,, . .... . , �. . . �..�__.�.__.�.�..�.........,.._....�. < < , . . .. .. . .,.� .r-w�. _ .�......_..�.��._""�.�'...__�.�r�..� �'_� -._......_-�_'_�.�_ � .,. . ... . . . �. ..! ..,, ....- .....�..._ .,.. .. ..., . . ,.,,..�, . , � . . , ... .. . ..., ., � _.�..-_._�._.�_.._� -- _ . — ' . r ... 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