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HomeMy WebLinkAbout0946A 0947A (5) � . . . _ _ _.,. .__ _.__ _.�___._ . ..__:._, . .. . . .. ., _. . __ __ ---- ._ � WORKERS'COMPENSATION DECLARATION .._.�,.� .• �. �� `. � �..-,�:.�. � . -�,, . .., . . . . .,, . ,... , . _..... _ ..,.. _ . . . . ' ' .. c I hereby aHum thol I have a certificaie of consent to=B�f APPLICATION���FOR�� BUILDING��PERMIT�� �� - i�sure,or��certificate ot Workers'Compensation Insumnce, .._. .. .- - --.._.. . ._... .... ._...__.f ... �... - -._.�. .__._� � :�-�-� or a wtiihed copy thoreof�Set:3800/,��Lab.C))�.�.• � � ......... .. ... . .�ccs�_ � ,LfID�PY'L(�QGor(/ _ COUNTY OF LOS ANGELES BUILDING ANO SAFETY PolicyNo. .3 �Compony --- - � � O Cer�ciied copy is hereby furnished. , FOR APPLICANT TO FILL IN euuo�t�G ���� ' ADDRESS � Cerliiied copy is filed wilh fhe county building inspec- � gWLDwG /�� p / " 'IioncJepaf�menL'.� ",,..'. � .. .' �'. � AD�RES$ w 1(� 1 � ' � � :..'.. �� , . �. . � . �.... . . _ . ._ . _ .__.__. .. . ... .__ _.. ..__. _ . _ . . �... . .. ___._. _. ; Dale �Z.�-t'i zApplicant CIiY ziP ' iOG4tITY � . . ��-�� ��� i � '� ��CERiIPICATE OF EXEMPiION ROM WORKERS. ----- . .' . . ..-..- .- . .-.NO.OF BIDGS.-._.-.- - .- I NEnliEST .. � .. ..-.---.._...-�"--� ._._.,........_._.._._..__.... ..: SIZE OF LOi NOW ON t0T ' CROSS$T. �•� � •'��^•�����COMPENSATION INSURANCE� � � � �� / � , �. . � ..,��. .'� .__.... (TFis section-ueed no�be�comploled if the permit is for one -- ��� / BLOCK� ������� � l0T NO.��� ��� � l�p�gppK ` � vnGE' ` �� hundred dollars(E100)or Iess.J ., , . , , iRAn3C 3`y�' � pqR�i '� ' '� � � TEI. �' �7 � . . '� � '.... pWNER 1V•� -� �"�NO. �-IG� USEZONE hl4P � � , I certify Ibal in the performpnce of Ihe�work for which,�this �� � �; Y so stto become su6aelct lo the Workers'Comn a any manner /1 . ..-........ . SPECIAL... . �.... ... ..:. .... . .. .� ...._�-.� . a P P Y Y P -..--' ADDRE55 OD I. �..[� ..'._'. .......' ... CONDITION$ ' ' ' ' , ��' U �, p nsationLaws. :�,�,. . � .. �... . ��. � .:... .. . ..:. ... �, . � . CIiY ZIP I . _'.____'..'_'_.,,._..._ ..... ' ._ _ _.... . ......_ .. _I 07 Dale� � ' �� ' AppliGant� �'� � � qRCHITER OR TEI. O NO710E TO�APPLICANTe�.lf,��eiter moking Ihis Certificate of �.�;;<<� � �,,,r, �-. ,. �!�.' � �8 DISTRICT__, GROUP NPE , ,__ FIRE _ PROCESSED.BY__. .., f.. Eaemplion,�`you�should become subject to��the Workers' -������ /''� / CA �T. � zCN�t . ,.V Compen5alion provisions oS fhe Labor Code,you must forfh- qDORE55 d C ` - C.fT' _. . . . _ _ with�comply.with such provisions or�ihis permit shall be ��� � --�- �� � �^ �� � � � � �iE��� -'- '�' � STATISTICAL QPSSIFICATION ' APT. COND01 ��Z c _ deemed.revoked,.,� . ..,.. ,: , .,�. _. . . � . „ CONiknCtOR�'y No � ' - C� _ .. .. '_ . . ' ' IICENSED CONTRACTORS DECLARATION ,�.. ,� . .._.__._ ....._.. . ._. .... .. ..._._. LIC. -..- . --_- '��NO.�g�QWEIL UnliTS�� : I hereby affirm�hat I am I,icensed under provisions of Chapte�9 nDDRESS NO. , ' � (wmmanting with Secfion 7000)of Division 3 of fhe Business and .__.._ _ ���.�. , � SFWER MAP � ' , ��..��•�.�:�' ,' ._.__...__.. . _. __. _..._._.._.... . ___ _ .. Profeuions Code,and my license is,in full force ond effect. Ciiv � MSS � �-- ---�� � ' '' "-�� '� ���VALIDATION��-" � .... .:, ., ..�.�. . .� . . , / /� SO.FT. NO.OF NO.OF CHECK BK� �'� ��♦ `�'�`-' LiC.CIa55� ...... 512E.. . _...._._STORIES '"""'- FAMIUES� �� � ONE....i .. .. . ','.- .�.. Licenso Number �-�� - � ' bV� ,. :. .. . � . �p .__VALUATION . Conirat�Of L�ltl�Rn/Shc�/�Da�e�`���0^��...-.... DESCRIGTIONOFWORK � �l� '-'"'_ NEW-._� s � �/'�T.', . . .7 [J , , . ,.. : [.JR// ^no ❑ ❑I am examp�vnder Sac. -����-� . '-���-� �-� � � - � ^�l B__ __ . . _ _ ..._.� ' —' . _i...�. ..,, . �, � ALTER . , . , �B.SP C.. ;.. : _ , .. .for IhiS reoson . . REPAIR..❑ ..s. _. .__..... ;.._...... . ...: .. ........ ..... .._.._..,_ � ... __........_.. .._....._....__..__.._.-._.Date:... ._ ,,. ; . .... _ USEOF i . ,. E%ISTING Bl D�`0� ❑ ' ' , � ' '_"__ . _. . _.._.._ . .. ""' APPLICANT ` •- iEl. / �L � - -'��-Signot�re ��' . ..-. ... . . -. � �. FINAL� . OWNER BUILDER DECLARATION PRiNi - J� . '� �NO. O � DATE� �'� - - -. ..._. . .._.__ � -'--- .. ,.... . ... .. _ . . _. . _ �.. , �1 hereby affirm that I am e empi from ihe Conuactor's Liwnse �2 DO (1 ' � R�a� �.� . Law for the(ollowmg reason�(Sechon 7031.5,B�s�ness and ADDRE55 vC E lS( FINAL��'�' � � . , . �Pro}essions Code):'.. ..___.__._._.._....._. ._.. ...... ....... .. . � PRE N _ . ., :gy.. ._.. . _, .. .. 'Q:9.�1.6� -_ BUIL�ING ' ' � � I, as owner of the property, or_my employees with ADDRESS ' � ! � �����'�2�J ' ' _.. ...._... . . __ ._ . ._. . ..__. _ __ _ . ...., .._ _.. .._ -. ,. .. . . __. . . _ . wages as iheir sole�wmpensalion,will�do the work and ' :- � the structure is no�imendod or offered for sole(Section � �aAurr , � � � a e 3 � -7044,�BusinessandProfewionsCode):�- � - � ---- MOVING ��---� �-- ---- � �--- - TEI: '. . 2'94. _...._ _.__ .. . _ __ _ �_ . . . .. .,. . .. . . i � I,as owner of�he property,am exclusively contracling CONTRACfOR ' NO. � • o.�.2 9 4 c=a ' -�with licensed contmciors to construct the project(Sec- --.. .- ----... . .......__..._. . __ ._... ... ._ . ._....,,._...... ..... . ........ . __ . . _ _. .. . _. __ .. . � tion 7044,Business and Professions Code). ADDREss �. RE�UIRED.. . iOiAL SETBAIX ; i�O R C� �S rI ' '�"'--�'-��-' -CONSTRUCTIONIENDINGAGENCY' --' �' �'" S�Tg,qcK YnRO� �HwY� pROP uNe - WiDTH` --� ���� �- �- � - �� �� � ' � i I hereby affirm thot there is a construction lending agency for FRONi � � �� ��� 7 A � -�the per(ormance of the work for which this�permil is issued ..__.._ P.L: .__.. .__. . _._.__ . -_--'-._.. ._. _--. ----... -.' -- -_-_- .,___.�.i _. ._ ..__. .. 9.�-- - -- -�.I � (Sec.3097.Civ.C.). SIDE ,�R• • ••"�� . m . _. ._. .. ..... .._._... _. ..".. . ._..._ .... . _._.._.. P.l. � � _ __. ._ ` " . _ _... ,.._.... . . _ . � Lender s Name .,' � • •4 9.2.rJ �� $" �+ 2^� '��' , LDMA Ref.M _.__ _ . ' .'_' _.'_' . . ........ . ....._ - . .,_.... P.C.Fee f_. � T. . Perm�Fee J O ��. . _. , 'o - Lender's Address b _ � �!��0 , � Jr c> ,. "'' ..I-cerlif Ihot I have.read Ihis a lication and stale Ihat the . a49,Z _ �. PP _. .-- _. ..-- ... __ __ _ iu�o�<a Faa . 6 '�i_... ionna,aic r. __ . _ _ i 0&2 1 =b 7 ' � above informalion is wrreU.1 agree to comply with all Counly imesiigaiion Fee '�. ���'. g .ordinances and Sfqle laws.relpting to building construclion, _ . - toral Fee ` --� LDMP,verm.M � - ��' "�� � �- .. . . .. .... _. ._ . .._._.. , , u and �eby aulhorize repreienlatives of this Counly to enler �� ���� � � � � ������ -��- �� � � � � � up t e obove-mentioned Property for inspec�ion purposes. _ . _ . .._..._.. ._.. .i_ . ... __.. . .._. ..._.,._ _. ._. .. ---. .. . .. .. . .. . )� .� _ � . /' . . . ... . _. __ ..__ .._.. �j' n ' " ' , r 2 7�$ � SEE REYERSE FOR EXPIANATORY IAHG�GE� . � � ' i '_ .___Sign ureo Applican�orAgen ...___ '_. '._Date _ .._. .__—. _ ._., ..__ . . �_... .. . ... ..... .... . ..._ '... _ ._._ .__ _..._. _..___..._,.. _. .. . � . . . ..__ . .....pO i I �. ...._ ._.... �,, , . ����.�� ' � i�, i � ~•�� _ � `� �, i , -_ ' ��. �.. 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