Loading...
HomeMy WebLinkAbout1390A . ;WORKERS'COMPENSATION OECLARATIO.� � I hereby affirm that I have a cerfificote of consent to self APPLICATION FQR BUI �� �I insure,or a cernficate of Workers'Compensation Ins�rance, � or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ` Policy No. Company BUILDING n ��` �- ��`�� cenifed copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 L �� ❑ Cenified copy is filed witrl ihe county building inspec- BUILDING-7 ���a / � ,� tion deparfinent. ADDRE55 L. LTE;.�.t�,, � -L.-� Dote Applimnt QTY h • ,S(� ZIP LOCALITY ���`�X1V�J�,L7. NO.OF 6LDG5 NEARE57 CERTIFICA7E OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CR055 ST. '`� QU� � COMPENSATION INSURANCE ASSESSOR (This section need not be completed if ihe permit rs for one TRACT BLOIX LOT NO MAP BOOK PAGE PARCEL hundred dollars($100)or less.) ��. `� /y � OWNER �.-i�,l si'��( ✓'i p, USE ZONE NO� ��t J L`F I certify thai in the performance of the work for which this c ,I� SPECIAL } permrt is issued,I shall not employ any person in any manner ADDRESS`�j���'�� �i- � y'yVc \`�� CONDITIONS �- so as to become subjecf to ihe Warkers'Compensat' n::�•. Q CITY ZIP U Date Applicant�' � �' �`I� ARCHITECT OR TEL �-' NOTICE TO APPLICANT: If, afte akin�l' is Certificate of ENGINEER N� DISTRICT GROUP NPE FIRE PROCESSED BY CONST. ZONE � Exemphon, you should become subject ro the Workers' � � � CJ Compensafion provisions of ihe La6or Code,you must forth- ADDRE55 � d with comply with such provisions or ihis permit shall be r+ ,�TEL STATISTICAL C SSIFICATION APT. CONDO Z deemed revoked. CON7RaCTOR --�75�{ �Z' �,�E<sNO�'�'��j)r�� LICENSED CONTRACTORS DECLARATION S'�q � � f� uC , � aA55_NO. �� DwEu UNiTS I here6y affirm fha�I am 6censed under provisions of Chapter 9 DDRE55 ��C+�'�� �.,.�.�y`�+y � (commenang with Section 7000}of Division 3 of ihe Business � , � r\n IC. (�,� SEwER MnP and Grofessions Code,and my license is m full force and effect. �TM "-A' �^� �'� BK PG. YALIDATION /+��� � SQ.FT NO OF NO.OF CHECK License Number`� � Lic.Class��'� SIZE STORIES � FAMILIES ONE VALUATION '� �c r �..4�. .1"c r,t t b ti e m Confractor�'�`�'��`�� Date ��-'� � � DESCRIPTION Of WORK New ❑ $� ��.� ' �I am exempt under Sec. Yif'�.. � �(f- F�- ����( AOD ❑ , tR����r ALTER 8.&P.C.for ihis reason �`Yn �" REPAIR s ' `.�-_.���� D te: u5E OF � �, � � IXISTING BLDG. DEMOL❑ V�� 1 —�� S'gnpture� L'L-L��' APPLICANT TE� FINAL . (�C OWNER- IDER DECLARATION (PRINT� NO. DATE ,cl� r,l I hereby affirm that I am exempt from ihe CoNroctor's License Law for ihe following reason(Section 7031.5, Business and ADDRESS FIFIAL Professions Code): aR65EM 8y /�,_,� BUILDING I, os awner of the property, or my employees with ADDRESS wages as thei�sole compensation,will do the work and `�qLlrv , the siructure is not intended or offered for sale(Section 7044,8usiness and Professions Code.) MOVING TEL. ❑ I,os owner of ihe property,am exclusively contracting CONTRACTOR NO. with licensed mniractors ro consrr�ct the project(Sec- qo0RE55 tion 7044,Business and Professions Code.) REQUIRED TOiAL SET6ACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BAIX YARD HWY pRpp ��NE WIDTH I hereby affirm ihat there is a mnstruction lending agency for FRONi ihe performonce of the work for which this permil is issued P L. (Sec 3097,Gv.C.). SIDE P.L. lender's Name� $ P.0 Fee S Permit Fee } b LDMA Ref k Lender's Address � I certify that I have read ihis applicption and state fhat ihe Issuonce Fee �S LDMA P/C# , gabove informarion is correct.I agreg to comply 9 ith all County inves��got�on Fee � ��„) e ordinances and State lows relatin }o buildin construction, o�ol�ec I�b�n�rri e Q and hereby authorize representatives of this County to enter f f,, � up t�,e ove-menti55��n d property for inspe�c��[wn pqurposes. � � 5-E=C� "'}�l 1 `�1�'` SEE REVERSE FOR E7CPLANATORY IANGUAGE � Sign of Applicant or Agent Dote ^'r~ .,. �.m.a..�� .�....»..,_,,....,v..,. _�-.P�+�+.���:aa;.•,...+,. . ...�......e...—.."_,.._.s-�''�� , .. ,: : w A, , �4 F:� .. `� �:� ��•R'� �,F.x f � e e r '' ��a��y�y s �>f, , .��tr � . , - .,� �£+i �'��M � ti�:3 �o- �.� . . � . ... ..._. ..... _.._....._........... _.._...._..._..._._..-._......____....._._...._....-r,._..._�.,.,.__......,,.............__.___.,.�__..._....._ _..._........._.....�_....._.....___,. , . .. ., .,� ' ,,..,:: �i-, �. . � : • i �ry.r.a���e;�•r,unr�s i,..::..r_, . , ..: -. . ::�.� . � ,.r..�. :�i.At:S�.UY.!�'i�i.i:N���F� � , 1..........�..��...,.-.._..�.._..�._.,.._....._.._.. . ._ "'..........._.._._...—...,,. Vt',r34'2�] .'I:..�••':[P::. ,'.:". ..:.,:SRPi'88t0f�3 ..................._.__._...__._-_.._._.._.__._______.___._...._..__._.,_.. "'_.. y a.':.':,: ,;: �.y��M� . . Liconse znw Eor the foilewing reasar {Sec. 7037.5; To: � ��rQy� _' _�,_____.._.__.�_.�.._,__ .ausinassanaPrcfessiens:r..ra. •� .:.. ..•,.,. .�-..-. z ui:es a err^it te consf.. - � .___ ,... ' ,. ,.. "�,�.�,.�.;....., .• •,,. N�.T..-� '�sFe ,No. Oatr-�._..e�r..._ � � • 4 : ,.�. .• •- .�, ynQ.:. ...;:•.i..c �_ �-•.•_•--.-•.-_ .� ..._____.._._..,.._.._ �__- ...__� ._s D$ifa 'SFILlCYUl6. G.�0��6/SSUB�.....8lSOYa^�,fill@,. � � �- J ----- . ' . ib¢2ppi?cant;or sr,ch�e'r.m;F ro f?de a si�neC sPa?ement �-�---�- -�--��---�--�---�--�-� -�-- � - -�---�---- -�-- --�- -_...._._---- -. . ..._...._....--- -�--------�-- edpurs^u ha�roti . eCvn- �. �._._._... ----- rhaiheisUcens snt8ot �is=or.safvh �J � �_�� ' ' �. � -`---��-----.�. -�^. ;actr.'s�LicenseLavy(Chapter9)(r,er,.m�ncin<<vi`h5ec- ---�:__�..._�; � �_��. � , : t.or 7C-0Ufof D � � . I , -- - �^de)ar_Fat he!s�e:nFh h�ztror.+ana�ne ba�Ss`cr d.�.. �._��._.....�.. ..i. '---...-�----------------...-----�--------. ..._.. .�----��------ .. �h.eallsgec+��ampllon:AnYvlo�atfoncr'Secfr'an.7G3P.5r1y ...........,...,,.�..._...._._. ^ . , ..,.,.,�.........._. � � � t��K���^� � 9:>7.4Pceiser,! I anyappticarrtiorapermi;subjecfsthea,alacanita.aciviJ P :ar�re;veis . , . - - ---��•�- 3J3nefty�of r.of more than 0=v2 hu�dred dcl;ars($fi00).}: '__.. '_""" �---_---- �--Yes Pde -'urApp:au-M� . . - .-... . .. ^ - :C] f:asowneroftfieproperty,ornyem�loyoaasviih �ws�es as".heir sol�co±�?pensatien,aiili sJo?he�a�ork,and 4;a;z;Ce:t�:icatc: I � � . , . - _� . .- 'Y tne sfeuctuie is r.6#ioiand8d o!'o{7ered tors2t2�ac.7C44; ��_.��._��--- --- . . I � F,/aSIP�""'':.' ' . •:"..�1",'�i:04'B:ShBCORSCBCYOP'5JCQPtSB �haaiin DePartmsnt ' ^� ---_ �.._ .—.._._,._____—.. .— Law c,:�•.::�,,.'+�::;.�F�.f..�n oarn�r,of prageKy v�bG baifds �. . ���. .. ,. �.� . ' �. , ��.. .....� .� ---- ��: .. ^ .< <A/ OY94 ih8!@Cft;2/?O�WhO J068 31ICh 4Y0/'Ff A117t8E1 f 0! (/11Qf �'.` :�;'' �: � � . . - . .. - " � � Phrough�:is awr.�en�oloya2s. p�avidnc�'that sz+ch ;m- ----- �� -�--- --.--�-_._v._._._ . �_�-�._.______....__._.-"----'-----"----' or�vements are��o�•r.��ende�ar catc�ved.`cr SaJe. IF, �C�r _=G:r,g --__..�.... ^-�- ---�-.-- howo�er:Pn�b.!i:di:�gvrt,^;Pro:s:rsn*issaldvri'Nir.ors � vsa�oi camp!�i�ar,,thc-or,�r,er-nurldk�:ve!7f h�+�v�the hurdp� j n:^:ngir.�i �^. -----I------- ,, � . � ' . . � ofy�roviriythatSretlld,Mu!fauiFaloP"iM�rov�fCi'th2purpose � ��... � ,-�� - =:-- � . , ..�., . .� .� . �� �-_--_-_ i .�- . . .IeJ., . . , .. i� ,)�� PY1 ..._"'I _._.'�.____i.--___.___'_"'__'__'�'__^..'�"�"_.�.._�_ ' Qf`r 1iC 5� Y$2{COfi- ?ca2-•r•o�P;o°ecEior � .J i,as a:°aner oti tt?e crcpa:,v.ze�9x�1Usi T-6r�ce Gano __,___ -�.__ __ �tr�ctinQ v✓Yh ensnd con.raotnrs fo oons c.#hr p;o- !( _. ._.__.,...-------� . . � iecY i�'ec.7C�44)B��s'�::•;.��,.��:.".::i:�rx'..:�, ,q e:The Con- :.- ---,-----._.�.._.__�..._.._ I P � ,r(s) . r � ;•n�' '.c^\ 9) ....d..-�-----�-�----� R er s ch�ro eafs w'Y !� con�cYo n !ce seQ er ei p�¢- �••�c,o, � _�_ - :�o4o;'s Liasnse•: i, � own � Con�.j nF.noonrv� YYe.d�n 1 -.-...-.____._.____.._�..'_�.--_.. � a CanYiar:; ..---------- - - . . . __ . . � !o u ' i h a r r C,oursaan� _ .....�..._� . . !_:,:Cra:n����• , � . - -.,. - � . Pa tha�onYrac.qr's Laoona�S.aw. , , ------ -� -�- -� ----.�-_�._.__.I..._... � ..---------� _ _ -'r- �Fa,king -� .-._�- . . . �.^� ` . ❑ i��r,s�amp:under:..�Br,._'_,B.$�P.e..TO�itVS �_'-'.-"_.�_- � __ _.�.._.._,....____ �._. n f I ' �'-_ '.�' � f88E..f��_'__"'_'_______ . . ""_�_'_........_ _._____,__ I �.»r...___�_ __.�..�_. i _.�___._...._��.____ __.._. , 47ate..._�______...__.,_�._�..._�.Glwner__,..�...._ �__..e.,.�..m,,,.�....,__._.._.�-_�..� _____�.w. __�. . ---- -�._._...,_...._....._ �._.. .._.......,.. �� _.»,. . .....,. R�ern��als � �B� !ns s:¢�r°e S: naturs P 9 .;...,.�.. _..__.._._ .......-n....-w... ........T ' �-._---.._�-._.-._ _.,__._�_ _.�, `RSr�C?�a'�;oeED7E5 �.__-_ _-'-----.___�..__�_._..^----- --�--- ..._._...-.�.._.._..�....-.�__.�s..�_.,.....___.�._._...._._a...._ S locatloc- - , [.ISeFh2ck z`faresl�_� �__ � _. �. .�._.,_.'- _-��..�� _ -.,.._ �.�._._._...._.____' ��Faon9z?iois 3 . _. , . . - . �_�-� _�_.�_ � .�_______�__.�._.�. � ��_T- �.A._��._..�..,_._._.�_ �c�_�tr__-_.-- f .i._..__ _____ �._ .. -, -_ . . .. . ,� r ;�a:,,� ;s ;Y� , . �� ______ . ----- _�:_._____. --_ ____._—_ � Y: �b'vu-�.– ` _ ' Er.erg�/Irsula?icn � '._�.Y E . . .' _ , �_.__ � �__'_!. ...� . . - --5--- __�.- ----- ----��__._�___�._.______ ___ - - -- - --__ _ .__. _ �xcn�orywa;�— � � � �.�- _r irterior I .� �y� ;�, "L. , �--------------�---'- - - '----- -. ._.. .... .—f-�-------�--....---._....-----....----.__.----•------._.._.�._......_ �.......�...._,....W.;,,.,_....�.�.�.�.�-.m..�....�a_.>.m t!..- .r..c:iar r �y ' � . . . _ . . _ , - _ [ _, ��_. ..; I i" � __ t � --�-__--_���___ _ __..._�-�.�'___'_.'__-�___`_�____.�___ ' Flouse�lumbeP-�-� �Ccrrzc°&?csted ,�._._.._._.._.,_._.._.. �� _ __���.__.__ �..�_'__..�_...._"._'_ ��:n2!- ��.__ �-� _ _"-'-._� . . , , nter�n FrOnY L_� _'.r_�._-- _ e�..,______-.r____.�_...._�.�._..�..�...... .�....r�_ _�_�� ..� � �=---,—j---1-�-�---� I ;1.a�;.r,i.,�_.:i_.:.i?.���L i,=_-L..1 ._�.-�..��.�_� -� . �_��...�._._.�____._..� ._.V._------ ,.. -. --,--_.._._..n_._.._ �---�------.___ti i___ __�__. ___�-.___. ___.___ _--_--------__----- -----___