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HomeMy WebLinkAbout1425A (8) . WORKERS'COMPENSATIONDECLARATION � - AP�PLICAT�� �" ' N. .��..� � � ..�.��: � ,...,,< I hereb�"affirm�thot I have�a certificate of-conseM to self ON ^�C��t����l��� ������ � �I�fR1U1 � , '�esure;br a certifimte of Workers'Compensation Insorance, , ,. or a certified copy thereof(Sec.3800,Lab.t.) � � - � , . . COUNTY OF lOS.ANGELES BUILDING ANb SAFETY PolicyNo. Company. � . .. . .- . - � - .. .- . .... . . . � Certrfied copy is hereby fornished FOR'APPLICAN7 TO F1LL W nooeeu � �L a�: ' aCeriified copy is tiled with�the county 6uilding inspeo eUILDING � /� \ fion department. . AbDRESS� (.+ LOCALITY o � { / NEAREST� �t Daie � Applicant Cltt� � Z�P ! (�6� CROSS ST. .CERTIFICATE OF EXEMP7IQN KROM V✓OHKERS' --��� � �/ /�� No.OF s�qGS. rSseSSoe ��.� COMPENSATION INSURANCE � �� SiZe oF�oT ��f !(lG NOw ON�Oi I�MP BOOK PAGE PaRCEt (This section need notbe�completed ifthe permit is�for one � p('� � � ZONE�� �nnnP t� ^'� hundred dollars.($700)or less.) � . � TRA�T�t��+� eIOCK LOT NO. � ��� NO. � ,d��� J � . .- .... . . . . . � -. V '�'''`` j �'�TEC � p��7 .. SPECIAL I certi4y thot in the performance of.the work for�which this OwNER i-.-� ..}—c�r NO: D 8.,3 6 , �CONDITIONS� � �-� . A�. erm'if is issued,I shal)noi em �o an erson in�an manner D S7RIC7 GROUP 7YPE FIRE PROCESSED BY � so as fo 6ecom subject to ihe War sPC pe of� .�.g. P.DDRESS � ' - �� CONSiy f . { ZONE S.l [�y�/fj}' �1��� 1 �� � Date �� -`� ApPliCani CTY � ' ZP STATISTICALCLASSIFICATION � �� APT. CONDO. � NOTICE TO APPLICANT: It, after aking this��Certificate of ARCHITEQOR TEL. ENGINEER NO. CtA55 NO.�DYJEtL UNITS � � �Exemption, you should become subject-to the Workers' �. - Compensation provisions�of the Labor Code,you must forth- . ADDRESS SEWER MAP� � '� � with comply with such provisions or this permit shall be� � deemed reyoked:. � - � CONTRACTOR r ,� NO. � sK. PG, YALIDATION - � LICENSED�ONTRACTORS DECLARATION- � � �� � . LiC. I hereby 6ffirm ihat i am licensed under provisions of Chapter 9. ADDRE55 - NO. VALUATION � � . (tommencing with Sectian 7000)of Divisioh 3 of ihe Business and LIC. S !'� �Qo Profeisions Code,and my license is in full force ond�effect. CITY CLA55 Yh , - �. � � � ' . �- � � 5q.FT.--y L NO.OF NO.OF CHECK License Numbe� � Lic.Class � SIZE J� STORIES FAMIt1E5 ONE . . . � � .. . � . `�"7 NEIN � $ Confractor pa�e ' � DESCRIP710N OF,WORK �I am exempt onder Sec � � � ,�� noo � G . AIiER � FINAL !Ln � B.&P.C.for this reason � � � � DATE �;�� REPAIR .. - � � � U5E OP FINA .. Date: :. EXISTINGBLDG. �E'�`�� � gY .Signature � .. . APPLICANT },,� � l. OWNER-BUILDERDECLARATION� � � PRiNi)- ¢..� I hereby affirm Ihat I am exempl from the ContracfoYs License � ► - � Law for the fo�lowing reason (Section 7031.5,�Business�and ADDRESS Professions Code): � � P E '�BUIIDING � �.-� c� U��,J.Q �I, as owner of ihe property, or my employees-with ADDRESS , e wages as iheir sole tompensotion,.will do ihe work and .�:.o a o g� ihe sirocfure is not intended or offered for wle(Section �«A`��TY � 7044,Business and Professions Code). � � MOVWG ie�, t,a ���O G � I,ps owner of ihe property,om exclusively contracting . ONTRACTOR� NO. � with licensed contractors fo wnstryct fhe projed(Seo- qDDRESS ° °�'�>-Cl�� � tion 7044,Bosiness and Professions Code).� - REQUIRED TOTAlSEfBACK FROM EXIST.� CONSTRUCTION LENDfNG AGENCY� � � � SET BACK YARD HWV pROP.LINE � WIDTH , �8,2 C!'-'F�b I hereby affirm fhat ihere is a consiruct on lending agency for FRONr � the performance oflhe work for which ihis permit is�issued P.L. �Sec.3097,Civ.C.). � � � .� - � SioE � ' - . .. � . . �P.L. � Lender's Name � � � � . . � Lender's Add�ess �� � � P.0 Fee$ Permi�Pee ��. .. I cenify thot 1 have read thii-appiimtwn and stafe ihai�ihe � � � Issuan<e Pee � �.1.5r � . ¢ above informatron is correct.I ogree to comply with all Coonty� I vestigorion Fee �� t� � � � '� ordinontes pnd Sfpie�aws reloYing to�building construction, � � .���?oml Pee 'V� and hereby uthorize repres �tatives-�f this Counry to'eMef . � opon the -menT ned r pe f r inspection p'urposes. �. .�� - �,� . � . \ ve �y�. �/ SEE REVERSE FOR EXPLANATORY GANGUA� . . � t? �� Sign ure of ApPlicant or.A9ent . - Date . . . .. . .. . . . . . �s . . . . - .�. � , _�,,.. . .;.: „._,... , .�. , � -... ; ... .� , ��p��' .6� �:'`.�"�,-„�.- r�����.��.�s��,�..`. � � taw{vw�z�€ri�,��R z�a_c,a A���i4�- , .. :��: -�� � ;. I FLerebY��.�kdf.�.rthcr t.pxn ex �oi�..�o.m�tJ��Cc�irac or-: F€r: � .,,���I �teEucn�d � . . u a r ry� �__ � � '-� l�cenee ,aW t6r ht':follo�n rty �r�cson f5ec. �037��5) . �....�.__.... E w "- � Apya¢ovmd '� .. a b "� - i7 saas.,.sndY f zc Ca !' y�ty o un ,.cb cl,r � 4V`o:-_. .-'g2�i .. .�Sbo. �.`6a4e .__ - �,.,zxas: -.�' ..�-:� ��,'�,='�"��3�" .� �`...rc�z¢tst`�n ffer t �c�.,t L ci 2 s�ame��-a''em 1 h; ; � . � • ,.;. � . .-, ,�� �— ;-.efic pJr�lir,�titf�.�su.c'd��ennat�«o��xi�asace,�"o Qq.cc.r_es .. � . . r ,_. ....:.:.. . ...:� ....,_. . . . . � . . . , . .. . .�_ _. _..... -.. . � , , �_ . , . : _ � �i � sn r�eoz�fesi-s t .' �'�. .. ., `_�.. ' - ,.... . ,.-.... ,,_�----�- Ed�at ha as�scensed j�ur.raemne te tfio'Ji7`6r�ssioaas of tbc L"nn ..._._ ... .. ...._.� ...,._._.. , ._ � .. -_ . .....- _ - . r� �- :� - ; tr�ctor s L:cense�.,..,i<((',xiap8 r n fcnormaracing ze-2tls S¢o- _... '-. �- 'd'.:' � ' ' _�" ,--. . . ' . - ..,..-ticn 7'J60)of Ua�uusero�:of b¢Exesu�ess aRd�Prof¢sssoiu � � .:�o��eJ or�x�emnj�Eaoa�er+:"�Y th�s fr6�roa dacd EFrC b!`zsu for th¢ , "'... .;.-.--«. .�� �-� �-"• ...5 I � ` ,V'.''.- "{ �v�kctzoa��n}'SecE osz 7031$fiy . , ...,. . .._ . I "'as�v.6�rsrS .Pta 6deamobe� � .. ' �� � 1 &'1� � r� �sa,ly ts�Yb sy�PlacanE o�tao#d -.... k r��als p ` . ., �� ��, or:Lg�grorae� . .�. . �_ . .. — pe aab q c}vso8 r.sore Ebmr jave l,E�7Ss'�clo[¢rs'r$>0(jj f: � ; Y� �3� �� �....—.; � � � - '- � I� I ��cZ er..o �'(hep�o�o tv o m em loyeos.w ih . Water C�rS x ccie� ,_..I � .���-., ,�., ���� — w� �� ,.wc�es�s irpeif selm co�ep..a'�onalwtll,do�4he work,and ._ � ... . . � .---- ._-- . .... ... -.-- -ihzsirucnrre�isr.'�tmtEn2J¢doro`Ffiecedfiavsa�c'jSec.7044) ... c„ � lietalih�3epd ment ,-5,.. ..L.�_ J '�'r —��.,.,.� `. .... — _ -��rumossqr.d.F�rafesxieczsCod•�'be;t',owlractor'aC.dcaa�.aa � � � �. �- ' - .Gdw�i�a�rot cppF�£o.cn nmrer,af. raberty wfio Su' s . cT � s.,�..a. . '�_:'�. h�. .. .�.�i_,.. _._.__._._. _.. _ y a�d { a D2pa ,lePt -! ,, .'. .__ ,�� ���o�ElrrestCs tia7ereo�t'cnd.vno do2's�Su[k"s wordz baals.�lf or Fie . .,.. . ..:: .. .:.., . . �1� ab1 5s ozG^js em'/✓y es ��ra�sRd Lb t�stscfi t �- .... .. „ . .__. . Gradi�g � �� �,: , � ....._.._ .�._._ ._..._._... . , :. ..'� � 'dxE 7a� cr��o}�y'e ed;Jlir nle � ' �° t� �,.� .- ��� " '' 1now,eec,Eb'e busdr rzg ni�c p5rrve aezt sg s�Sd wetheva oyie Geao cal ..._.. � � �- — _ _.. .. _., _ yeu �f crs�apapd reon, ?h uu ert-,ald r ws!r��¢s.. t.Fie 9 I a-:;. ., .. 7.,___ ,:t a"E .f ttir�v r C,^wt te �' �� .w��or dn:�o✓e!i.r -----i r . " . , :, _ _ Pedesiriare ProPecsion � . � . .. . . . ,�;. �,.z,ebg fiw�e.s�.of s¢tef .: ,_ . ,. ,z (Fencej(CanoPY) x�:.. . .v r �x� -.:� _... „ ." �:t::�s.,owrero�`PS�e�pw y,emcacfus�velycontrce- ___ '° . � t r�vviih;icenaed c�ntra.-'ors ro c�rstruct the pro�sc7(Sec. ,...... :,. ,. Sp�<ia!Inspeci�ian � � :- �.�- ..__ �. ,_ ..., ......ZSl44 T3utircc 1 A.rnf P2s.��e „e,5e L'nzar,arto"c (Conc.)(MaeonrY)(W'eldingli �. ., --'#� � Z.u'en Zawdne o-^;,pdyt> r�u qprein rt ln ; ---,— . ,.... . . . .... ..... . . �- ._._.. _. .,.. _..:. _.._..>n .,_.G Irl or s_r,aprq.v��` hvr_or aqa�w-s.D.a eo ceues jor such � LotDrainaG� � -.. 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