Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0954A 0955A
' WORKERS'COMPENSATION DECLARATION � ' � Q . I hereb aFfirm thal I have a certlitcate of�consen�to self �� �i � insure,oracertifieoteofWorkers'Compensotion��,�.a��a, �� APPLICATIQN-FOR BUILDING PERMIT � L or a er if,e�{c��p hereof �epo lab.C.)�.� � ��� �'� � � �CXS/�JO'3 �b / " �- C UNTY OF.LOS ANGELES'�_' BUILDING AND SAFETY /PolicyNa. �Pany �a�'�1'vL� � — � � " � � Cenified to is hereb furnished. BVILDING ❑ PY r FOR APPLIGANT TO FILL IN a�oeess �.��J�. �G � Cerlified copy Is filed with the co�nty building inspec," , BVILDING � � . Ilon departmenl, , . � ADDRE55� �S LOCP,LITY� NEAREST �Date Applicont . GITY ZIP� - ' ' - CROSS ST. .� � CERTIFIGATE OF EXEMPTION FROM WORKERS' _,NO:OF BLDGS. ,, .� ASSESSOR . COMPENSATION INSURANCE � SRE OF LOT�•� `.v"��� • , ��Now ON tOT � ru+P BooK � anGE aaRCEt . �(This section need nol be mmpleted if tha permit is for one . , . USE ZONE MAP �, hundred dallors(5100)or less.) TRAR ' � BIOCK �. " LOT NO.'� � � NO. � �{'� � TEI. ��� $PECIA� . �- I 1 certify that in ihe performance af the work for which thia � OWNER , �� . �. NOZ/ C7 � CONDITIONS� �- I DISTRICT GROUP TYPE FIRE PROCESSED BY O permit is issued,1 sholl nat employ any person in any manner ADDRE55 _�_L � ' CONST. ZONE ' �� so as to becoma subjecl ro the Wvrkeri Campensation Lawz. . _ .�rt . _ . �- .�-� , /y V Date � Applicant . GIN. . . � c..h. ZIP I � �' StATISTICAt C1A551FICATION .. . . APT. CONDO. '.O NOTICE TO APPLICANT: If, afler making this Carfificata�of ARCHITECTOR - 'TEt. .� ENGINEER � � �� NO. cSZ-�I�I� QA55 NO.�DWELL:UNITS W �Examption, you should bemme sobject to Ibe Workers' !i Compensaiton provisions of tha Labor Code,you must forth- . ADDRESS l.7 V /� � ��'-' seweR Mnv , � .� with compiy with such provisians or�.this pe�mit shall 6e� , � ' • � . � deamed revoked. � . . . ' ... .� �COMRACTOR � � � � S�CIVII�.. 7 � c� -....-. BK:. .�.. ..._.. . . VALIDATION � . UCENSED CONTRACTORS DECIARATION� �- IIC. '- ' � I hereby aHirm that I am Iicensed onder provisions of Chapter 9 ADDRE55 .�A�'[��` � ��^ NO - �� �y �UATION :� � . � (commenting with Setlion 7000)of Divislon 3 of the 8usiness and . „ , �i�, Q� .,` s�O �� � � �. Professlons Coda,and my license Is in full force and efiect LiN� ` A • '� ��CLASS U ► � � � �y'� �P 50.FT NO.OF 'NO.OF CHECK LI[Bnse Number,��?C/(1 .LiC^•C`IOSS`� � $2E� $TORIE$ � FAMILIES'�. ONE`• � � . . . .� ��)`�'' I DESCRIPTION�OF WORK . � . . ... . NEW.... s . Contracto�'1'i�.�IIUPS �C'�Sate� � �� � . . '� I am e:empt vnder See. � � - ^ A�o.....❑ � � � � ��9 a 4(� AITER ❑ DA E` "' ///(��. . .. . #• • • •�.� ��. B.BP.C.for ihis reason � � - . . .. . . eEPAiR I. Dale: USE OF . . . DFMOL ❑ FINAL v ... . ' � •2 9 9.6 3 � E%ISTING BIDG. - -- S �� $i9flafure � . . APPLICANT Te�. � . •�•2 9 9.6 3 U ,� OWNER-BUILDER DECIARATION PRIM�, -, � No I hereby affirm that I am exempt from ihe CoMractor's Llcanse qDDRESS ��l��/� -,..U(G �.i����%L ��.� Q�8 4 Law for tha following reason(Settion 7031.5,Business and � � Professions Code): � � PRESENT � �/�/i�� �n 9�5 A � I O , . BUILDING . . ... � � I, os owner oF the properry, or my employees wilh ADDRE55 i` wagasastheirsolccamperx!icn,•:+illdo!hewcrkc.^.d ��C%I-"f' •� � � .the structura fs not iMended or offered for wla(Section �� ��`��TM � �� "� �� �- ' � � I • •6 3�3 7 � 70d4,Business and Professlons Code. MOVING TEt. p n� � � I,os awner of the properfy,am exdVsively conlratlin9 . NTRACTOR � NO. ,.Y J Z��Q`( �7•��• ��e�• _ . 6337� with licensed cantradon ro constrott fhe project(Sec- ADDRE55 � � ' tian 7044,Bosiness and Pro(asslons Coda). . , � --. -. _. ... . . .- . . �1,� �'8 4 ' � REOUIRED TOTAL SETBACK FROM EXIST. ' �- CONSTRUCTION LENDING AGENCY � � �T gp�g YARD HWY PROP,IiNE WiOTH � 'Sea3097mCiV C f tha work for which this permit9s issved �P OM �� � ���- � � � - - ► � �� � � � I I hereb aifirm�hat�here is a cansnuction lendin a enc for � tender s Name ' . . . . . . . . � � � . . P.C.Fea E Permit Fee �� �0 � � ti�'� �UL , Lenders Address � � �,� `�'�l� ' � . . . . . ..,. _.. . . . I certify Ihot I hove read this application ond state that tha Issoance Fee 1 Cti� ' obove info ation is torrect.I agree to comply with oll Coony in�e:+i9ation Fee � C , , , ,. �ordinan and Stala laws relating to boilding construction, � ���� To�ol Fee '` and h y outhoriz representatives of this Co�n�y to enter „y,� .upon e e tioned properry for Inspactio ur ;es. , �� � �� - - � -��� - ��- --- � `l Y" � � � � ' P . . !/ � , � SEE RfVERSE FOR El[PUNA70RY UNGUAGE ,.., ,_.,. . �� . .. . . .. ...._ . ignal e oF Appticam or Agenl� e � . � l __ __ -- _. _ . __ _� Z o a .. . -' "', y. _,- , " Z_ _� ,_`_ ' t=: '�� , . .,� . p O \ 1 .- " � �l . �m p jy, �� �� - �'�, .-�' m aa ° °`�: Q ,o m ; a � n9 � � o � o �' =� ti `, �. � . ,� O O A (� � O. V . p . . � . � . Q ��. 7 p �^. n� ` � �p � p c � �, � 'i � � .� 'x 0 ('�7 .Sj 3-� p N 1 �� i �.r D �y j ?� 1'. ?_, �v. \ -.+ N� ,� � �'� p' U O � 'c' \,.... �� �` m .�. P �� P O �(` •�., _ �fo:. O� �.m 1�. `.` � �'�. � � Z , �� r, 9 � � � 6 O ^�a Ss �� �? ., Q' qC m�n C1 o T � � ° . 'o k'� %� . �- J` � '`� �,p •, r ^O n� \x m� N �� � `w , 4 � ,. Q �p � � �,..; . Y .� � N �, r, � . �\ p�Z m ° o o -� � � �c, ��1: p ,p,�. Zi 'O �aC O� � O \ � . G 'Y O 7 � d� d ' '� � � � . 1 a � '. ,\� \• C s ' , � �' . a . , wo . ,� � .� . o.. ' , �' �!, �'` � � .,�p 'A �t , .i � b � � .6� i� ,L: C' O • �-r• ` �4 y`j��'�. .. (.,,> M j . ' +�- O � 1� 1° ' VJ � r �' � � , `l � � a A d- A` A r • - s`1 � �' �� QI �C. � � � C-, � � �tiz ��t-.. ���fi. O N:� 4 �.��'t o�,� .o z � � - C� t� ;•. , ?� ,� \ Z, �, -A. �. � �, ��. " `�� � �� `� �� � p' �j.r � d'. C1�,c, � n `� �� �,� � � p � -� b o ,�R �� � ,.r . '`� ,�,� c� � 70 , y A' �,:. o o. �, .����' z �`,. - , n � � •,.:� ' �. �; � � �n`,Z�l ° °� + t � � , �` Q � ��, '+, � � O � � � � N . f�. :. :."'� �'� �. �� � � �� �`' �', t ��� ,'•, '�� ,t..� � ' !C' O �f � C � " ��t V. �� � �:: , L o � o K. ' ,` ' �,; � R�. �` „� �, �,. � ,, . � _ , b o � � �`, � �- � �' �- � �.: � '� ' , � �, � �, .. � ��. � � r � � , \ ,, � \` ` , �' 2, `- ,b, ; Z..: � � . �. � o �', � ` `' � 9� � �, � � � ' � Z. c, 1 , , � c�, y � x d t� ?0 �1: � '`, . � f , �` ` ,- � � . to � � o :��� .,` ,.� � s : ` , - � Z, : :. -- �-�-,�, ' �:: , 1 ' A � �`.7' N N ' : � :1 .... U.�p O n ^ L"y '1 y CJ d"h`.�. ` . (� . R ��m C..= L'�J P �' •G � U l. �- � �L, y. � C � r �✓` , � �ps0 . �z w -.�u,c, a na .�p r . � \ . � ' �,-O.�.-t �, � S� U ^^7.A•� G .-.P S'"7�C � �'�. . �,!' � ` l0 _c`?'.� G l',.,' �.,L t� "^l , , e.�'7 w O O p 3� ?' C !� O �.Y. 'G-` �^y n . N �� p 3 �'',.� '� , 'O F y � +'KA,a O H �N � ...,�. t 'a w`O-^: N`'�"` `.--.^ C� . . , � . - . �� ` �'�Yi^ vy� Q",�-t'''' o A O�i'" p n 3 O o ",`�?�.C." p,� ^ c �„ S 4 N-• .. .. � ` O .��� _,l���i'J�i1� �� •N 0.�`N(^' 4 r ' O .1`n�� ^K O � � . . � � .. � O'. � n n���__ o`'^o , �, .. '�',a1aw, c. • , N ��.oN��OC7 � . _ � �\ O 1 � � .7� �'..-SO i�.y',� �'.y o'��c.b,yV O nR.✓o 3 �r.�� �'.� ��;�. ,., .� � .�,. \'� �,•�` p ^� c c� '- n'ro �?.. .- "} 3 w o .4 '-� p• - • J � ' � N ? .� �...G -..'a � �.;S �•!'�n � �p + ~ t�� � �� C � `�' ; � � 3� � c"'',o'" ^ � ` �'-^� Y C o� 3 m :. � »`^» -� ='A. � � '�� , .` . .'.c. � .:,rp.� � z, a _ � ? r L+w t�-v b �� °`n �+ ° � � L,�� ~=� , // , � ` . , % ` . (` O �,. F ...V fJ 0 r'y��t.f� V' r'+'0 N fD �� �,m, �; �, %..^ e, c^.`� c"�o-p�v . 'i �'` "�i ° � o,.b S . ' -� YU r^- � ° � ...m -....».o'`. . � �-v\ - .�.r. � � - o "a � o o r '^.� °� � o m - - n � � 03 �.'. �N�a ;G .3�.�.M p p�.�V � �r+. • , � . � �' ' =1 .-s t� 'O , ^ C ..�. . � � X .. O '3 r ^s O .., �'S Y : �, :' � �.-a c, o , 'c c -, t;,• r_.�, �-1� o -as.s�-.a,N � � � � .��,cs G :. ',, , . � �i �. Q .� O .,� O� S G �.to tn? � pp� e> O n. tP_ � . ,• �\ " ' ' l. ` � `i3" j ''�. O � ` 'S .�". s O•� .G� C>n'%'3 Q'`' ^'¢t' ^ C .0 4 ^� L!(� �O,L.. ` ..� ` '.' . �Y ' • m f. .j`,G �..� � .. r, �.�a O .�. .,,G �q O h �.N F..�n: '1 �.� � y(n_ O W ^' F. .fa. . \ . � ., n \\ ^ v`JL.•3�"i j Q ' '"'�w C'Q`5 N O � P P .'L Q`�W`�+.G y'P'v�'O`O'. � � " ♦ ' ` ' p v S M � �a� F, '� p � " _ F. x'Nm '. �,`�. �� oe• :, m ��o ^ ot.;,O•y.rr+wOE. �.p . � v� o��:' � � 'o p-—-•`r o �- ��°c w o�o� �n:��:��^cr,�N_ � w SC N'N m �, .cn O Z � ,a,�_�, +-i S� . :F„o s c- n ° m o p 'v�'' o � 's_„^�" • ' O. • t''� `°--"^ m � •=�.'+ � �,o r,.a F N a e a-�'� � , �� � � �; . �� . .�< �� f'1� m "Y°�" r..��.��.�� O O £ . ::.`� - ' ', c t N ::O�; , �p '.,�,� C}O"..G ^ p�.�. . �^, •� pL O-3,:�. t' �� 1t . ,. .s ' � p N A (� � � �'F�i.A✓ . \ ' c� ,d .� .�,� ={�� �y �n .O ,;•• q 7n � 4; 1 � � ` , , ��� . �. O.�'J �•, � �"''.�p ,� C: t' . ..0 N F D A n ' �� . . '� \ �'� ' �' c ` ?, t��C'p '�" /. ' ir ,'v� ,` l i -', �. � < r'/. ` `(. :i . \ .