HomeMy WebLinkAbout1002A • WORKCRS'COMPENSATIOND£CLARAT[ON �6A642� APPLICATION FOR PERMIT �
CE BOB(2-80)
�1 hereby aff"vm that I have a certificete otcnnsent to self SEWER-SEWAGE DISPOSAL
insure,or a certificete ot Workers'Compensation Insurence,or
a,cqr�',fie��np�trye�ep�(�ec.3800�ab.C.�� n COUNTY OF LOS ANGELES BUILDING AND SAFETY
I F{3ficY I�(o. `f �l:ompany r/4� -
�Cert�tied covv is hereby furnished. FOR APPLICAN�TO FILL IN CONNECTION DATA
Oeu��mr�c � ^ sT�riOn G6�TN
Certified copy is filed with the county 6uilding inspectlon ADD11ES9
depertmenL p �+�'1 � MANNOL6N6F6RENCC VPPgp
LOGIILITY GM1� LOW6R
Date ApPlicant N6111�6lT TYYB OF CONN6CTION L6HGTM FXOM '
CERTIFICATF.OF EXEMPTION FROM WORKERS' cnose ar. S(,�,1�jr c � Y, CURB ..�. ..,�.to v.�.
COMPENSATION INSURANCE •.c.no.
OWN[R � CO.IMr.XO. JOB 1'10.
�rt MI�IL
`.,115 SCC�IOiI IIlCd 110�hCC rnmpietcd 1(t�1G WOI�C IIIVO��'&� /1DDq888 4 eQ 1 TRUMK�6RMIT HO. ROI1D�6RMIT NO, �'
by the permit is for one hundied dollars (5100)m less.) j Fo�p��� ,N,� �< <o�p.�,,.r�.� o�,� �
cirv re�.na. V
1 certify ihat in the performance of thr work for which this �ccw�
permit is issued,1 shali nnt empluy any person In any manner OE9CNIPi10N �or r.o. �
so as to M1ecome subject to the Workers'Compensalion Lews. o`� wwr.ox sr.winaninc �
BLOCK TRACT � O�J � fT��6 6NCROACMMCNT
�6MMIT NO.
Date Appiicant no,ov e�ocs. W
NOTICE TO APPLICANT:If,afler making this Certifcate o[ a�za ov�or tiow or��or Z p.
Exem tion, you shnulA hecnme sub'ec! to the Workcrs' �se o•
P � BUILDING9 � S CXARG63 Z
Compensation provisions of the Labor Code,you muat forth- —
with comply with such provisions or this permit shall be � CONNECTION CNARG6 vee
deemed revoked. conrwwcrow
LICENSED CONTRACTORS DECLARATION wooxgss �� R61MlUI�l6MlNT F6E '
I hereby afiirm that I am licensed under provisions of Chapter � *w�cr.. cwo�. r.• ..oci.seo.. . ,._.
9(commencing with$etflon 7000)of Di�ision 3 of Ihe Ausi• cerv � re�.xo. - f � �_Ie` -
ness and Professions CoJe,and my license is in full farce and ��C6N56 NO. CLI1B8 e � /� �� N �-+�, v""'�"—
effect.
� NO. DESCNIPTI N OF WDRK FC6
y,��,�� i1NAL VALIDATION
License Number�l.L'Z"rr� Lic.Class � u.'c:E.i+�o�������`�o C� owr� � �f
• . � / n� as.r�c r.nK,��....oa e r o �
Coniractor��//%dll�zJ�ate O ++oro. ..�..F�.� R ,
ous[sCreR CONNGet�l+c w FINAL
❑ w�vwT�o�frOs��Sv�T�r BY
I am ezempt from the Iicensing requirements as I em a eonnier.00�.�o.wr..�oc.ow
licensed architect or a regiatered D*ofessional engineer wowr.o wou..�iwew :
acting in my professional capacily (Sectian 7051. Bus- �ow s�o.ce.�•,o..�
iness and Professions Code). F c�s•roo�,ow.we«,r.ou.c .
Lic.or Reg.No. Date �
HOME OWNER�BUILDER DECLARATION
1 hereby a(f'vm that 1 am exempt frnm the Conttactor'S �NER�$ �fR11L t (f
License Law tor the following reason(Sec�ion 7031.5,Busi• AUTHORI2ATION TOTAL FEE „i,- �
necs and Prn/asions Code): ,r�.„�„e.s�x..
� 1, es owner of the property,will do tHe work and the o•w�.osuc s.w... ���oviToesennao aw�. �� Q Q 2 A
itruCfUfe IS 11oI Intended Of offered f0f 93�E (Section S�GNED THIS OAY OF 19 ' tt�'� � � �Q
7044,i3usinew and Protessions Code). ow�in o. � �
CONSTRUC710N 6F.NUING AGENCY �c�f��� I.� �2 2 S O �
1 hereby affirm that there is a construction lending agency • �2 2 Jr O�
fnr lhe performance of the work for which lhis permit is • . .
issued(Sec.3097,Civ.C.). ' �2�4.�8�� .
LenJer's Name
Lender's Address
I certify[hat 1 have read Ihis applica[ion and statr that the
above information is correct.I sgrer to comply with al�Cour,ty
ordinances and Sbte laws regulatinC Piumbing and Sewers,
and hereby authorize repres ntatives of this County to enter
upon the aby ve�mentioned roperty tor inspection purposes. •
,� � �� ��T�� SEE REVERSF.FOR EXPLANATORY LANGIIAGE
Signature oP Yermitte Da �
yN p� m
O Nq � �"d�C� ` -
NO T'� R'r N �a �2
mn vn�`n s . on��'� o Y'.b
-ax ZO,�� O S.1 Zn-1 y' -p
_ - q� �Z�1r'�'� ��'Q➢ N �
, . � -'�� Zm'ov ❑ �Y7`Ixp ^, O
„ z G
_ , ��• o."�,Io� � TVm�o'� � �
� dt Cr �n. x v � N
� '� c^��Acn � S^ '�c�
' + � �. ' �C� �'�, �� ' a'g v
' '� �;-� m> �n �' �'l � -
� p� �2 c.�� f. �� - t �
'� �r � o{-t mo m� �j
;-1 - " ' . ' � . ' �`t 4')U1 y y 1 '� Q •
� • , _ 1 . .
�i v / �� . . - 1 � ' ��� ' , 1 t- ' m ' .
�� •1 1 .
W `1.�) '�� �o - Z '-,,.! � t. ,, �
.> • .
.... � • � 'NC �, '• �, ' . ti ,
' `c . - � ' -� "
J, r' n • � � " .
� � ,
.� p _ 1 ., i � � ,
� , , � � � , z
� ' • - - ' � �� �
O . ' c .
. .-1 . . � � . , . m
. N , � • . . . . - .� .
- f . ..
;� � /,' ; . . - '
1� � . ' - . -• �. .
. � .. �� ... . -
. . - , � � , � ,. .
. �; - ' -
, •• . 1. ,` y � , .. ` `. b
1� � �
t , _ � � . Q
. � !•7
. ' tA
_ � ' _, . . . ' Ol
. m
N
' i . .l ! 'f ..
i .J . .
It S . '
� j .
� . . . ���.�...c�i'° .^-^ .
• . � v _ r. n M .
� .. �;, v_ o .. c•
p o " p a=N N•n
. . . yY C'�G _ � C �
� � �„c: " n n f � � ^�-•v '� O �n L '�A n v y� �
� C.r, n C ^ � i�i: �o O �n c' " ci � O t � f � i
� - 'C"C "P' '" } O� �G !C,... y ^ CV �'•o fc "' N 4 .� �.
. . � ' ` -c�t�c Y.�;o� w � :o'-^� c.?�ry' +� �� G
' ' "� 0 o N,a: �O y,C '^ G n�tJ��. � �� � �, � y�� —
G L n '.-L�' ='.Y�-„�. !: O C..'C ± ..���'�% �' 'i.p �r'„ f' ,
r r C.� --C � .- a �o � � ,.-
� r'; f✓' `p "`T' ' � � :C :•b • 7 c� �Q r'�r'v. V1 C o'�O v - � i V C'.S
, a ` ''. � ` � � _ y � ��� No �Mo �Lc � F^ ^ N »� G' r .
. / . . ('� . � � „_'_�v o w��'.. C `^ � ,,.O p�" y�' h " :'� C C 7'i, �, �
. . . . . r" �G � '� ,� p Q `n O� �'p �".O �,•�.^, ts �W � ("�
-f - C ^ C�--
11 . , ' ' , � • v' G �� ^��C' .r �� G C v `'.v —A o�,.,�' ;' v. v�c ... �. .
• . - �, - ' . . .i f.�i c~ �� L'C _� O 71 �--c�'i'' o�N�� '�y G:O ✓�
, , . - .. fi ' �, .C.C,O �O n ,C�, �jp Y p� p � „'O `C ��
. . '. . , p' n `• �^N O •:. •�� o 'OYi.^ "'�� ro��p M n.�pl(��j r
. Q' � o _cN G� .�'oc-pCr.� _c ^ �,n � _
.� --�-- =' � �; � -��.o� �v oc 7-
• - � `• R�=- = n�G� "'G �„n x ,,,�n 5 �.. � .. P .
- . . �.— .:o � n O O ' w� � O p "' _ ,..
�' _O O G.'�`a ` � _•t3 N.��,-�» G `r^•" C Oi.
� ' � ' ' . . ' , ' �,o r.`�»• �,.C fO �� � r O •
1 . � . � . = n ..._^. � `� � � C G n �o�� D ...
� � . , . ` q _c.00c- Y.,,� , 7' o',.,Y��'�"` r�h : ��✓f
. . , . c � Y ` y_ � !_ � �
. i - . � � ' � � � ' `� v t� '° C�i�'n ' � c���.v� Fo
`� . . ' -
�
. , . " ' ' � p .` �� CO G ..
. . . . " . � • ep f�'� ��r H 1
,, � .
_ �