Loading...
HomeMy WebLinkAbout1789A 2181A (10) I ,� WORKERS'�COMPENSATION DECLARATION , , � . � . . � �� •I hereby o(firm thot.l have a tertificate oF consent fo=e�F .�.. .APPLICATION FOR BUILDING- PERMIT� , insure,or o certificote of Workers'Compenslion Insurance,or � a.cgr�f�q�cop'y+hereot(Sec.3soo,�/ob}.�C.')e N • COUNTY OF LOS ANGELES BUILDING AND SAFETY S�t�d . Ooi�Ynl�o`����.2r'LCompanYr—�l����// \ Q PY y FOR APPLICANT TO FILL IN AD�RESS �p . i � Certiiied co is hereb Iumi4hed. '. � Certified copy.is filed with�he coun�y build�ng inipec- BUIL�ING ��" - ' tion deporlment.�� � � � � � ADDRE55 � C�C1C/� � LOCAUTY � - . �f � NEAREST Dote �S Applicanl���i1J�.� � �ITY /L UP � CROSSST. Q.SK� � � ERT ICATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. ASSESSOR � � � � � COMPENSA710N INSURANCE � � � SIZE OF LOT NOW ON LOT. MAP BOOK PAGE PARCEL � (This seEtion need not be complered if�the permi�is for one - u5e zONE MAP �l\ ^7 TRACT BIOCK LOT NO. � NO. l � hundred doilars(SI00)or less.)- � : � � } . � TEL � SPECIAI ' p� , OWNER NO. ) CONDITIONS I cerlify that in the periormance of the work for which this � � ,permif is iss�ed,I shall not employ ony person in any mannei DISTRICT GROUP TYPE FIRE PROCESSED BY so�os to become subjeU lo fhe Workers'Compensolion Laws. A�DRE55 O �' `O COt�.� ZONE �``µ'vv�. IK �..�/ � .Y� O . 'Dd10- ' Appli[an} ' � CITY �Y� Z�P � 57q7�5TICAlCLA551FICATION ' � APT. CON�O. V �NOTICE 70 APPLICANT: If, after moking'this Certificete oi� ` aRCHITECTOR �iEl. 7i�V ^n . . iy . 'Exemption; you'shoold become sobjecf to the Workeis' ENG�NEER /Q/,� � CLASSNO.�DWEILUNITS d N � Compensolion provisions of Ihe Labor Code,you must forlh-�� � qDDRE55 e � SEwER MnP � . Z wilh tomply wiih wch provisions or this permil shoil be � deemed revoked.� . . TE�. ' eK. pG� VALIDATION � . . - . � CONTRACTOR NO.SS 7'��� . � � � -�LICENSED CONTRACTORS DECLARATION UC. .. . . . . .. - ! I herehy affirm ihat 1 om licensed onder provisions of Chopler 9 .. A�DRE55 NO.a}`T sd VALUATION � � (commencing with Section 7000)of Division 3 of the Business and � • ��� • �� .?� 7 a�9 A• Professions Code,and my license is in(uil force ond eflect CiiY ' CLn55 - 5�� �� .. , � ' � ' ' � SQ.FT. NO.OF - NO.OF ' CHECK �',• •��'�'Z.3 �Ccenie�Number —�Q�jI�'�OLIc.Closs� SIZE � S10RiF5 FAMIUES ONE . - , . . __ . NEW � S . . .'�"3 8&8 0,. � COnifaCtor �� ��0 �!; Date �- �ESCRIPTION OF WORK �. , , � I am e�empt from the litensing reqoiremen^� � - . �-. - AD� � . . ' • •�J$�$Q c=a - licensed archi�ett or a regislered professionol engineer.,, . . . _ . .,,. . _ . . . . . alTEa � FINAL 5 'f �a � � �0 3 0 9-8 2 . ociing in my professional capacity (Setlion 7051, REPAIR � DATE _ . Business and Professions Code). USE OF ' � � � � EXISTING BLDG.G L GIO Q 1' DEMOL � e�NAL � , Lic.ar Reg.No: Date APPLICANT iEl. � ���� �� • - -� OWNER-BUILDER DECLARATION� ��� � PRwT) -� NO.. S I hereby affirm that I am exempt from�he Conirotlor's License D - . . . . . . . . . .. , Law for,tha follawing reason(Section 7O31.S,BuSin055 Ond "�' F+DDRE55 i5 E� � - • � PrafessionsCode):� �� ,aE EM - � . ❑ . . . _ . BUILDING p � y5" ' � I, os owner of ihe property, or my employees with��� noDRE55 . woges as their sole compensation,will da the work and i�A�iT�. � . � ��� ��he srructure is not intended or of(ered for sale(Settion�'� � � � � . . , - 7044,Business ond Professions Code�. � MOVING TEL. � � . ❑ � CONTRACTOR. NO. . � � • I,as owner of the property;am exclusively mntracting �2� 8.'.� {� with licensed conlractors to mnstroct the projetl�Sec-. AODRESS � � • . ..tion 7044,Business and Professions Code). -� - � � � ' � #',��• • .�.;� REOUIRED TOTAL SETBACK FROM E%IST. ' ' ' CONSTRUCTION IENDING AGENCY SET BACK YAR� HWY PROP.LINE WIDTH � ��I i�4 9 Q.5,0 �� I hereby affirm that there is a construction lending agency for�� ��� pRONi � � � � . ��' the periormonce oi Ihe work for which this permit is issued P.L. � ' � � � .�''�4 9�.5 = (Sec.3097.Civ.C.�.. . . .. . . . _ . _.SiDE -. . . ., . ... ... . .. Q cr� v.t. lender's Name � . . p I /� .. . , .. . O 4.� 2�8 2 Lender's Address v.C.Fee S 3 p� Pe.m��Fee Vp Q" �. " . " I cerlify Ihat I have read this applica�ion and s�ate that ihe Issuo�ce Fee ,J ' _ above informorion is correct.1 agree to mmply with all County mvesrganon Fee .. � � - � � � ordinances and Sa�e laws relating to building consr�uctian, To�al Fea � Q � � and here6y authorize represenlatives of this Counly 10 enler , .., , . , , ., ,. , , �` opon Ihe above-mentioned propeiry for inspedion purposes. - � . � � . . . � r��j'j���Q�q„�� J%�'�/D_2� � SEE REVERSE FOR FXPIANATORY LANGUAGE� . " � � c'c��0= Siqnarure of Applicont or Agenl ipale . . . �f m-n n= r ,.m T (n �n v ln T v � � �t .�= t 7. �1 > > oo ° ,�°� ,�, ,o os c° mn ° °, o� � °a m o' � � o` , o . a , � o cc c �- � m r 3 .' � ° �o n-� p, 5�� ; �. ^...� o a, p A � . o � n co I =o '� . ''� o Q o a � o ��o. ,;o'•".• � _` � s T �Z x m,� .,�, , � t:: o. �-� � j o � ' o � `°' o �p m' i O p 3 � � 0 �� � � N � I � m- 0'D Q� � 1 ��� - T , � � �W � �� r.o� - � ,i o o e � � � 3' o � .o ,` o,_ o.a � � � i :o a N � . � . , 'fl � 3 0 o O a _ �� L � �3 ,c.^ :� m: e o � v� � � � m _ � a, . � , �c � o � � 2 o � � Z N j ,. o .a O . . . ..... M ID �' C � � , � _ Q C r . . • = a . Q . �• � � O Q p Z' M O C` �-/ ro . � . j, ' N , " . . _ . O'O, 1 � �n - D q . vi � p - �L C , 1 ,� ,. , C ', . . '< � • . L . o . p,Q _. � e a c a ' ' � . �� . � �r . '�, , , /. . �. � _ N , �. m ` f � O I � � . � , � � ;• ,�' , • O . . v .. / ` ! ' N / . i � ' . � ' .. . � . � , r � ,. ' . '. . . . � �!!.Q-[•V" Q�tr a.'!? O,N Ci7 � ' .'O L 'n w O `� �j r trJ m o � a��°..� � �� �� ~ i fi °e a �•S � �� ❑a 4 00 0.'� n : e� �� '� o �' ti n S F f. b � � e� e '� �'-- rn ...'A A �.�o C°'o .��• � � . . . � � A .fi a c W'b 0.n ��'^ te�' A o o� t�~' � � � m i! � . . . . . . O �^ Z''.� � �i�.-b p�~ti A P p � w n O � �� 1'p N'�.�.ti'� N � o � . S'� _o Qv,� � a c a'� o �.n �.°, � oh n'aac r-'� p i 3 h-:�3Ea'� mRr � C-� �No � �cS�' a � 10 ^on�wx'es � p,�' . A o ti m 0._.�o 0 0 � � �, �e A 0. f C - x 11A��... A. ' � � �'Q C � � (D 7 N w.~r. ~ � A Q �1V� N 7 � �4.fJ C� �G ti �,�1 ��IT� � � � A ^ '� N.� C.N Q� �•�.`t � p�^.�O O W O Q `.t 'T'`�•C W �N « '.,,; O 3 � � 2 c � �''" oa° �, �" � ��° ` �� � � ,�, °. �b k ,�'�� ^ � o � soa � � , . '�C � � 7 ���"A C b? S ' p � A O O�? � �, �~„� �3 f.'i'�N C"� p O m C'.. "' � fi � �'o'�°o�°°a a��' � o�,aw °-� co °a `c'Qv,'��'A'e � '�^ o° C I . � . u+ �° �c,�.� o o . `° o ��°a � � o 0 0-� �O �� � ��°.'t°s � � o'� o a� trf ' � m ' �. �.v a b 0.A a� o o e'x `o C� .. ti m 5'0 �o � �.A o �� � � � �c N o � � o v m.,°:ti� c,A, o »' .^. n �,x { u� � so-� ° �� oC �y„ a.a� �,� ., e� o• � oC , ' Z n'.0.s o� � 7 V Q'tr o ti r'3-^� � � � o'��`C�o ^'a� � M� p c .�. � m c a-� � � o -�1D'.� tt v C�, � m , � o�.A� 3 e'fi � , n �~.�o �f o a'C'° .. a'?� � � � ^ o "'�, ° b' n • o�`c o � ' ;i . v� � , t�.,,, ,n� � x � � ���o � o=3 �°.a �� � � c Q � �•�' o 0 � � . 'o'� o .''3_ ^ �� N'Q 0. � ,,, o'� 0.,� � 0.A � �''^.,�,'y o ? 3 � � m m ti 'ib"�' o�`^ � F o 0.�,0� � ° �,3 c n o�m q,«.� � :� e° ^ m�i A' � R o �.� � '."...'�.o� �- c m� v a a a, a �,n A o TnnO i - �° � fib � o � S � ts-'� 'Lin o � ��� b?° ° o' -a ma '!. , .. � n A � .�C 'ts L�.... a , ,L�ti � f �c � p o F�"" � ^ ' o' i � ^ � ° e-a � 3 ° h;, ° m �„ow�'� .a� � N�e. '� p O C . O O �� ^y . A A .`t �u �' ':0.�fi F p�� O n �n Y � C`C7•_C p � �O � � � �oa � o .�'•-•a a, of ` . o'�+ ti�• o � . N ..�,.n L�ti n „ o C-� •.� o•�H ,�� � �':'�t�c� ^ 'Y. � �'�c'C-� . -' R L�'O M`• ♦ l0 IC� \ ti �0 Q S yi