Loading...
HomeMy WebLinkAbout1176A 1624A (9) � WORKERS'COMPENSATION DECIARATION _ � insvre6orot1erlihtaielofWorkeseCompenst�on�lnsuranteSolr � � APPLICATION � FQR BUILDING PERMIT � a certified mpy ihereof(5 3800,Lab.C.J � ' ' � Y ����1 Y n��� I - �COUNTY OF LOS ANGELES BUILDING AND SAFETY Polic N ompan � 4 �. Cer�ified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Q Y�'U"� ��� '� •���'J �'�1i�1� �(`"y�' Cerlified copy is.filed wiih Ihe counly 6uilding inspec- � BUiIDING O �� ��' Lc���/ �Jg� lion department. ADDRES '/t.e� d� �� IOCALITY � �^^`� '' _ I�1�7J' PP� .�l� ' ' NEAREST . Date�n nconr • arr �: ',,.G �zivi ceoss sr. ryr�'+t-�- � � ' CERTIfICATE OF EXEMPTION FROM WORKERS' '� NO.OF BLDGS. .4SSESSOR � COMPENSATION INSURANCE . i SiZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEI (This section need not be mmpleted if the permit is for one � US ZONE rnnP /( hundred dollars($100)or less.) . . . TRACT BLOCK LOT NO. �'3..6'�NO. �1-3'�'�"� } . TEI. SPECIAI a � OWNER NO l� CONDITIONS I cerlify thai in the performance of the work ior which�his 0 �permil i5 i55ued,I shol�not employ any person in ony manner ' ' DISTRI�T GROUP TYPE FIRE PROCESSED BY , AD�RE55 � so as ro•become subjeU 10 the Worke�'Compenzation Laws. � !O ' CONST. ZOn� �� O I'% Da�e �' Appli[ont ��TY Z�P STATIS71CAl CLASSIFICATION APT. CONDO. V �NOTICE TO�T: If, aNer making �his Cerfifimie of ' AR�HITECTOR . TEL . W Ezemption, you should became su6jecl lo the Workers' ENGINEER NO. CU155 NO.��WELL.UNITS y Compensalion p�ovisions of Ihe La6or Code,you must(orth- qDDRE55 �/ SEWER MAP •'- wilh comply wilh such provisions or Ihis permit shall be • ' ' deemed revoked. , . . TE�' gg, p�, ' VAIIDATION CONTRACTOR NO. . UCENSED CONTRACTORS DECIARATION. liC. ' I hereby aifirm tha11 am licensed under provisions of Chopler 9 ADORE55 N4 VALUATION $�•� 7 G A • (commenting with Settion 7000)of Division 3 of the Business ond ��� , : "Professionz Code,and my license is in iull force and effect. CiTr Ct.455 S �L�� ��Si��••'�3 50.FT. NO.OF . NO.OF CHECK �liCente Number Lic.Closs SIZE �/i�� STORIES FAMILIES ONE �.�' � g(i Q ) p� S 1 ControCto� Do1C-y`-�-�-`E�- DESCRI�fION OF WORK NEW o • � � I �4 O U � I om exemp�from the licensing requiremen�s as I om a J � A�D licensed architect or a regislered professional engineer ALTER � �FINAL �1 1 2 31.—8 i1 �acting in my professional copacity (Section 7051, REPAIR � DATE � l� �oc, Business and Professions Code). USE OF � �FINAL EXISTING BLDG. DEMOL 8 �Lit..3r Reg.No. Dote � APPLICANT iEL. Y � ��� � � OWNER-BUILDER�ECLARATION � (vRiNi� Np � I hereby affirm that I am ezempt from�he Coniractor's License `` , . ' Law for Ihe following reason(Seclion 7031.5, 8usiness and � ADDRE55 . rof sions Code): . � . paES"eN� BUiLDING - � " I, as owner of ihe properly, or my employees wirh AD�RE55 ' ages os Ilieir sole compensalion,wiil do Ihr wark and � ' �he structure is no�in�ended or offered for sale�Section LOCnLi�Y � � 7044,8usiness and Froiessions Code). MOVING TE�. . �1 6�2 4 A � �I,as owner of ihe properly,am exclusively conlrocling �ONTRACTOR NO. ' wilh licensed mnlroclars fo consfruct Ihe project(Sec- qDDRE55 #�'���,• •�� .....- lion 7044,B�siness and Prolessions Code). - � - - CONSTRUCTION LENDING AGENCY , REauieeo VARD HWV � TOTAI SETBAIX FROM exisi. I;• •3�1,�5 O SET BACK PROP.LINE WIDTH D n'�7�,���2 - I hereby oHirm�ha�there is a constroc�ion lending ogency for FRONi , � - G L �' ihe perfo�monce of the work ior which�his permil is issued at. � ' . (5ec.3097.Civ.C.l. - . . .. . . SiDE .. . . - . . . .. " P.L. Lender's Name � v ,//� q p � � � lender's Address P.C.Fee 5 D•`� Pe.mu Fee oC J, �� , I certify thot I have reod this opplication ond stme that the issua ce fee d�-�0 . above informotion is correct I agree to tomply wi�h oll County Invesbgoiion fee /n � � ��, �oid�nonces ond Sio�e laws Felaiing to building conshuction, To�al Fee ��.J" . '� ond herfby aothorI'ze epresemaiives oi this County to enter ' . , upon Jh obove-m( oned o rly for inspection purposes. � �,i`! �� 1� '-�J � . � SEE REVERSE FOR EXPLANATORV LANGUAGE . ' Signa� e o�ApplkoM or Agenl .�oie � �� Z o `o . � � o• ' ` � o � � . �n �� o o" a p � � o ,e r,o„� ;o� L-`'�� °� r'a o 9 sr t.� o . � �1�;� � �Jr� . a 3� p � o r'�,. �Q. �� c p � ��' •�-t7 �o �f' ' 3 m �' w Tri . u� o �a `o ,o� ,p-'^v �o" % v� � 'o � �f�_ 9 `" � v 'a:- ' a , r- � 'a, ..Q' `o, n� v +� � o ��, o O O .� -n C�S � 7 ^�r C�` ` � �� � O 7 .�.i� S' 7 . .p � 7� �c ; �Q i �' � �'�, �C � ,�,. �l'G � r �o c�o m.c ?, • o � r � < �+ � n o � :.y � . 04 � , a o. M D 2' 0 � wc � ° o�. „ � � r o o� �• .T. 0�d � \ O'� \ '� p q � N,m � � � G 4� � _ � i O , o a � . �o . �y°� . � i 'O � O 7 � � � Y. . t':t O P 4'6� w • � . ' _ M N, � � w \ p . � . e . Z _ � ' ' n � O R r " ' ' O � N ' D h� �' ' L--�W v. � O . . �, :t �n � � �' � � . . `Cr F r`O.O� 4't} "'� p � r�54 �}x�� `v��.^�.v� p D,p �: �. �,,,� ^�„,�,��A «�,m l3 p+b Sa.�p�7'i'�P 3 b"C„4. .''".,"�, ' Q.�L � � 1 •� -N � f� O �^N � b � v' A�� � ��'� o�G N! ^c�.�.~�,s�,o `�' ` �-..�-� c O� � �r Qa p, a 9ab � V. � O ^.. '"..� ��„ O :'N ?K+ '.2 `O � • A�O Q b m p � 3 C'O �n 4 S v » 'c7 L r'j a e� -t� O nn .� n xa�-.,: p � � a m � o �-.... A ...�,au o � � r ' Q W O���P.�� �L. .�'C Y O e� �+N.N M 4"�: n 7 ,+,� y O N�• 'O �y n D �� O a -, � '" A t�s' °`'° � `a '" �, � '° � r' t':' = N o3 l7 1 . � 0`0 � � � �� �o �'e' � w � O o�,o,� �° '`.v �oa '"t,�cr % M . . � �, n O C C`i7 C lb E e b�o .�,w� n F !� � "�O Q 6 � o �;�'�� � £ `'.,a 1;�• � o�.e� � ^ c��b"'a�� �»�-`t.m C� ,•5 � � O T'��� A P G-� ie� � 3^' '�' P..p N �9 .D� �,w K O !�i C'�i� ~ � Q...'�� �% t� } i� p ^A ¢��, � 4.O �~p• O 3 b P."' n O-7 O �.�'. »� � V" C��-w'7n` ie L�C (0 "^Z' ,,+` 9� N � w u�d�' �• �,t�+ �...�W S�Q.� ��t0� ,C", � o o �^�p �N� ... O � Z''- ; , 7 �� ��Vp�`� 0.�� a° '^ P.n � �� P.�"��wC� � C.u3� � ' T'.. . a- '° N o ° o t" o 't c^= o . e a � � '� n -�.-� �,m O � , Z n F oo.v oN� �;,� � ov� �,o c, to4 �t,,t, ,.�', p,�• �ow � � $ pn'j. T n vx=nU,7�n�� oc-��` � xRcua.3c ob^ mc.' � o.�a� ^ 7 ,`i . f�,� � �'-P"x C�7 O C`F'"'�.-�-�.•.�II'�'� o� � P a« ?�C�`''~£,� e�,�,ti VO O , � .� a�p`3� ' �.�N•��o�� c� m o � ^o b•:5��•�_� � e'°%o � � . N � e� O o .�'. � C � .�,A�Zf' �-t t�JN��' N� r��+O T,.�' n G '��,T', �L•-•.�i N •i O 'O y"�„w m '� ~��"�" 'a u.a'O C':f� F�, O n�' ��� 'y..�, . 1 ..t � y.b. .d i a L,...Y, ^� O'i. "1� 'f'. .�M•��L. . M � 6� , � a ?.�°o a m n ' � � a:'�`=.«.3 >D.3'L... �` , � �.. � »��-.� K .n.� m o 3 O o✓ � � � �l ; -' n o H�o�� �Q��~. t ' ,C,__N p���, � � , . � • �