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HomeMy WebLinkAbout0762A 0763A (4) . .'3, jJ . . . . . .. . . . . . . � .r � .�� ''/ORKERS'COMPENSATION DECLARATION ' " � - �� -� � �� . �-, r ` . _ . . .. . �� --� '����'�.�«:,,�ro',eofwpkas.'�om'ce�;�,o�=��s�:o,�a" � APPLICATION FOR BUILDING PERMIT ' ;_;'��ied SqAy,kgrpQf(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � � W4LlJw3Y � � � Compony��g ��Y _ � ILDING . 'jertifie o eroby furnlshad. FOR APPLICANT TO FILL IN � pp�g ��..'�;�.,�j�. ,g�(�� ` •�:•'Cerlified copy is fi�ed wi�h the county 6vilding inepec- BUROING -� � "Iion deparlment.. � A�DRESS � G` �,, `<r; — , T/ll/$B ry;�ncoo� .fAr�L i_ .� _.... aiv ' zip� � iouun . , . - CERTIFICATE OF E%EMPTION FROM WORKERS' � Ho..GM BLDGS. r�neEST � , � - � COMPEN�ATION INSURANCE � SIZE OF LOT ON tOi p105S ST. � � '��is SeCtlon need net be completed il the peimil h fCr ona �'i � ' .f �p�� �,'��.,�, pA� pA�• } ��ndred dollars�=100)or less.) ". - TRACt 4 A BLOCK tOT NO. .. .";. .. . . TEL USE 20NE �� � ��''. .��+�cenify tlwt In the performonce oi�he work(or whfch this �ER �' � �.:; ri0. !'/,� '.•1 f 0 ;5. . V ��barm�t is fesued,I sholl not empioy ony person in any monner Ao�Eu 17991 Hir.chell Sauttii � ro;o'�,a,,,s � ' . � �- so os fo become sub�eq to the Workeri Compensation Laws. ' � � OTY ZI� � � Dale � - Apppcortl ARCHrtECTOR � TEL..: � OyC. NOTICE TO APPIICANT: If,offEf ino4ing Ihis Cerl�ficala o( � DISrRICT� GwOUP ivpE FIRE ,'ROCESSFD BY; 7 E�emptlon,�.yov ehould become wbjecf�to 1he�Workers' 'F ENGINEFR ' - NO: � �'p�s� ZQfJE �' � Compeasonon prov�sions of�he lobor Code,yoo musr!onh- � ADDRE55 1�I YOr�?S SC. ��32� 1�18CjS1 f � �',� �� ��� '�` ' ` '�/ O � with�tompy/wiih wch provisio�e er �his pe.mi�.sha!I be •?8 !FL STATIS11Gl QASS�FIG710N�..�,;��_, ^ �rr.^ Ca+oo +�� � � deemed revo�ed. ' . . � CONT OR 41p. . � ' y7. f�' .. � `�� .UCENSED CONTRACTORS DECLARATION �Y// . � p�, a.455 t+0. ��' �'� �wEu.UNI75 ! � � .`.\I hereDjr affirm 1hot I om licensed vnder qovisions o4l�bple�9 ADDRESS / � NO. (eo2+r�ncing wHh Setlion 7000J of Division 3 of rhe Busidesf and - . ��C . SEVJER MAP � ' . . " -Profess�ans Code,ond my license is in full forca ano e1&:t. Gltt �'� M55 VALIDATION � 1 . "'�. � SC�.Ff. • _: NO.OF .' NO.Of CHECK BK. � PG. _. � . _ 5 ._.... ..i. . "�lkeme Number �274 �IC,C�aSf AI 512E - ST IES FAMILIES . ONE �i a f�f,�� , . - / VAWATION . f . CooNONor �ESCRIPf10N OF WORK r NFW ❑ U r�!. :' � � a i��.i'' .. ]. � Yreslej� oar�7/11/86 . � p s i � �1: �i . ❑I oen axempl onder See. � �... ALTER � ,!. . . i��!,9,fi.,��j.rr. � { `� B.6P.C'fa thls roawn ' � � � � � % eEraiR s � - -. . . f"i G .. . ❑ I,��..�:.��rJ�.� � �Dole: USE OF DEMOI ❑ (7 _ . EXISTING BIDG. ' G'�,�:f.t,'�F�f' � . i , '';,SlqnoWro . . . A�vRiMi .TBCIC LL1Ce - Trio. FINAL �,(i . , . . . J OWNER-BUILDER DECURATION OATE i S 'U •� � ��-I heiaby offirm Ihat l am exempt(rom the Conhoctors litenu � . Law for Ihe following reason(Sec�ion 7031.5,8vsiness ond A�� flNAL � -hrofesslons Code): .. . pR er • � •;..�; �` eu�m�� � :�t'1. b../'• I 1 � 1,os owner af ihe property, or my employees with P�DRF55 - � � . J woges os their wle tompenwflon,wi�l do the work and `��m ��:�N t •�) i �'� ' the snucwre is not Intended or offered for wle(Snc�ion .r, y„ � ` `/❑, 70M,Buslness and Profeeslons Code. � AhOviNG TEL. , . ' C� � r � � ��)�S.t:,.,J.CQ 1,W owner of tha property,om exclusively eonlracling COMTRnRdt NO. � � .- with Iicensed conkodon to conslrocl lhe Projx�(See- A�� � � . . . . . .�.,��+5�::Q�'a G 2 �• � tion 7Wa,Business ond Professioro Code). _ � ' . ' f � �1' REQUIRED YARD FiVlY TOTAL SE78A�K f X . G;,�,'f��G �, .' CONSTRUCTION LENDING AGENCY � � gi ep,CK PRov.UriE wtDiN , � � . � . � I hereby'6ffirm rhat Ihere le a construdion lending ogency for FRONT � . . �� �he perfwmante o(�he work(or whlch this permH is'ssued p.t. � � � � � . ' � ' . � � ^• (Sec.3W7.CI�.C.). � S�DE I� � . . je _ n i . lendx i�bme - � ,IDMA Rei.R �� l'ender's Addrosa � P.0 Fee f . ' . �� PermN Fee � I . , � � i. � �� �,�certily thm I have reod thi�opplicaflon ond s�ote iho�ih6 . - ' :;.�'.� � �� ` "' �ssuance Fee i. , . LDM4 P/C� ,". ��, :above informotion 1�correct I ogree lo tomply with all Covny � � �,,,,�iyo�;on Fse � . � . . - . . + 'o r di n o n i'e l!on d S MI e�aw�relalin g t o b uild i n q e onah i,cli on, � iorol Fae.�� �.; • r��'' - IpMA pxm.N � ��7 ' ond hereby au�horim repreeemo�ives of this Counly ro emar � . �� . �3 vpon Ihe obove-men�toned properry for inspection por•�oses. . � ,� . r,. � � . � 2 � ..i a ; �^ ,-� � � . . 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