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HomeMy WebLinkAbout1704A (10) /, � J .WORKERS'COMPENSATION DECLARATION . , . - . .. . ._ .� � I hereby offirm;�o�, ho�e a certifiwie of�o�,a�,�o self ,qPPLICATIQN FOR BUI�LDING PERMIT� . � insure,or o certificole ol Workers'Compenslion Insurance,or � a cer+�fied copy�hereof�Sec.3800,Lab.C.), � COUNTY OF LOS ANGELES BUILDING AND SAFETY . PolicyNo.�'� / Campany�i4/I2 rNc�AJr. . . Pr . .. i � Cenified topy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 'u J � �/�"� �--*�� Certified copy is filed with iha county buildir inspeP BUILDING n � tion department. � ADORESS � �� " LOCALITY �U�-�-�-.'wL �' �y,��' p� NEAREST /J t' '. �e_:�LYyL.Q_�APPIiCant� __ CITY / O� 21P / 7�i� CROSSST. .Q+[.0 .lJ��a-r-1 . � CERTIFICATE OF EXEMPTION FROM ORKERS' � ' NO.OF BLDGS. ASSESSOR � COMPENSATION INSURANCE ' � SIZE Oi IOT, NOW ON LOi � . M.4P BppK ' PAGE PARCEI (This seciion need not be complered if fha permir is for one ��jl�,,� u5E zoNE �P � �/ ��/ � hundred dollars(5100)or�e55.�� TRACT BLOCK LOT NO. � � � NO. `Y"� r5 �} . SEL. r/ SPECIAI p„ ' OWNER NO.���e�" ✓d�d CONDITIONS I certify ihat in tFie parformonca of ihe wark'for which this . _ V �, permil is issued,I sholl not employ any parson in any manner DISTRICT GROUP TYPE FiRE PROCESSED BY AD�RESS S G .S JVC . CONST. ZONE n so as to become subjact ro Ihe Workers'Compensaiion Lows. - �� �� -yy-� `.� �/`,�� G . . 11� 't�' V, Dale ��� - � - Applicant � UTY A U 'G Gr �C �ZIP �� � STqTISTICAL Ca551FICAiION APT.. CON00.-- • NDTICE TO APPUCANT: If, after making this Cerlifimta of �+RCHi7ECi OR � � � -�� - - -TEL � - . W � Exempiion, you should become subiect io the Workers' ENGMEER � NO. QA55 NO.�DWELL UNITS � 'N ' Compensotion provisions of�he tobor Coda,you muit forth-"'' '- qD�RE55 � SEWER MAP � Z with comply w"ih wch prorisions.or this permit sholl-be � � � deemed revoked.- . _ , . � . TE�'¢�. gg, p�, fj� �� VALIDATION -- � . CONiRACiOR� 1� NO.TJ J�� G . � � - - LICENSED CONiRACTORS DECLARATION�� �^ I hereby affirm that I am licensed under provisions of Chapter 9 .. . ADORE '3) _l/✓J2p Sb:- No.cil Jr'//y�� VAIUATION . . . (commencing with Section 7000)of Division 3 of Ihe Business and . � ��� / � � � Professions Code,and my license is in full force and effecL _ CrtY O/U i CLASS . I s �ba � � c� J 50.FT ' �NO.OF ` NO.OF CHECK Li[@niB Numbe��v�/• LiC.GIosS �/. SIZE J.J STORIES ( FAMILIES l ONE - � , NEW � s � /� �'' ��J� � �,J F�.., DESCRiPTION OF WORK � Controctaa rL— Dofe � . . . . . . � I om exempf from Ihe licensing requirements os I�om,a ^� % ADD - - . - licensed archiiecr or e registered professionaf en9ineer. _ _ .. n�TER � -FINAC � � acting in my professionol capacity (Secfion 7051, � REPAiR DATE , - 8usiness�ond Prafessions Coda). � USE OF � DEMOI FINAC - � � ' � E%i57ING BLDG. ❑ 8 � � Lic.or Reg.No. Dole APaicnNT iEL. Y ��.7 Q 4 A , "' � ` OWNER-BUILOER DECIARATION - � ' PRiNTI �, L � n10. � - � I hereby offirm Ihat 1 om exempt from tha Conlractor's License � � � � . ///y/�- . . . . .. �:�'� �,���i� . � low for ihe fol�owing reason(Section 7031.5, Businezs and AODRESS�.Z M S ' � Professions Code::; Pue ti � � G �i•�'•5 5'S Q . , BUILDING.. . . . .. . , /D d �'t7/�-�R = � 1, as owner�of the properfy, or my employees wilh � AOORESS •��.�5 5.5�0 0 wages as their sole compensotion,will do the work and � � � f�/T f��L. � LOCALITV �� � . � _ ... . �- � -the strutture iz not inlended or offered for sole(Settion- - �� Q��2�$2 � 7044,8usiness and Professions Code). MOVING ' rEt. , �YO f/�S� � � . � I,as owner of the property,am extlusively comracting CONreaCTOR No.. �- /� U � - � � � with licensed mntractors lo[onslruct the projecf(SeP qDORE55 ' � L'�Xsy{�t,¢�+'J � �-�- - rion 7044,Business and Professions Code). � �-- � ' �� � � REOUiRED TOTAL SETBACK FROM E%IST. �_ �` CONSTRUCTION LENDING AGENCY - SET saCK . YnRD HWY ppOv.tinlE WiDTH G�II�W�"....�� �� I hereby o�firm that there is a construcfion lending agency for FRONt the performonce of�he work for wbicb Ihis pe�mil is issued v l. . (Sec.3097,Civ.C.). . . . .__ . - �SiDE . . . . . . . . P.L �Lender's Nome � � � , _ � . . . � . , . .... , _. . . . �/ � Lender i Address P.0 Fee E � Pe•mn Fee � 7� � � � W I certi(y.that I have reod ihis opplication and slote that the , iss� ce Fee •� � • . ' � � above informaiion is correU.I agree to comply with all Coonry., imesngouon Fee- - � �� i � � ��� - � - � � � ordinanc s and State laws relaiing to building construction, . To�oi Fee �-��`3 v� � � and re authori representatives of ihis County to enter , ._ _ . - ��_� .up the bov m ntioned property for inspecrion urp ses. �� � �-� � � .(7,��'�"�}.�. SEE REVERSE iOR EXPLANATORY LANGUAGE � ' � '� " � Signa ura ol Applic i or Agent Doro ' . � . '�j " - _ _---------- ----- - -. . � - � , ` . . , ,. . . � . . . . .. . . �uoij uo�atu3 . .. . . . . , . � � —�oui� � . : . .._. .. . ... . - ... .. . pa�sod8l�aiio] � . .. . . , - . � . � . ' —�aqwnN esnoF{ . . - . . ._._. . _ . _ . �oua�x3-4+�7 , - . . � � . �opalu� ' —I lom��d/4�°1 � , . .. �. - . - - . . . -' uoilo�nsu�d8�au3 ', . , , . ' . . � . , ' . � ewo�j . , .. � � ' � � 9°IS ' � - . . _._ . - � D:7(_=u°�tqpunoj (tPioA 9.?I�P9�aS) _ � � . . . .__ . . - � � �—uo��o�41 � 5310N 5.801�3d5N1 • � . � o�nysu6�s s aopadsu� a�sp � s�onoiddy(j . . . . . . � , . � .. . . . • ) �aump. . . elo0 _ , . . . .. • uosoai . . - ._ . . . . J ..��� � si �o - � '�a �a un dwaxa wo � � `'� 4J l'7'dS'9'. . S P � I ❑ . - . 6ui�iod �'- � ' •(mvq asua�r7 r,�orav�auo� �, •.����- , � . � , . aqt o7 ouanunJ pnsua�rt(rfivt�vJtuo�v rytim st�alofd _. .. � - . o6ou�o�0�ol q�ns�oJa7.w�7uo�oryn yaa.�uoa�ayJ s�no�dmi.ro sp��nq,� , � . � . - . oym 67�t3�oad f���mo uv o��ttddn7au r�op m�j asua�r7 __. \ , \ , (6uip�aM)uo,ipedsu��o;�adg r,�ot�nl�uo�ay,L f�po�suoissa�old pun ssau�snII.(pyoL � � . . , . , . � oag)ioalo�d oyt un��suo�oi�siouo��uo�pasuao��y�im 6uii . ,�� , -oo»uo�.f�anisn��xa wo•,(�iado�d ay��o�aumo so'� � �`���' ' ` � � � � , �� (6douo])(aoua j) , .. . (aras�o aro�Jirtd aqt . �.� . , , , , - ' . , uoi�oa�o�d uoi��sapad so/'oaolam��o pjmq�ou prp oq toq7 8ujnoad fo uap�nq _ � _ _ . nq� onv9 llim.roptmqdaumo oqt •uopald�ao�Jo�na6' . .:� . . .�mi6o�oa�j aaourq�rmpfornr��u+�no�d�!�oBu:ZyenqaqtVonamoq _ .. . . � . . � ' . . •fj •a�vs�of pa.�affo ao papua}sst tou DJD uuawanold' ' Buipoi� -wr qons paqJ p�p,+no�d'saa�toid�ua umo nq q%moig7 - . .. . - .. . . � . �� �o�asm�qy�omq�nsr�opoqrnyuv•uoalaqtsanaid+u�io _ �uaw�iodapen� apjmq oqm F�ada�d fo��u�no uv oJ Fjddn tou raop ma7 " .. t;".�.,. . - . . - .. osua77s,.�ot�vJtuo,�agy:apo�suorrrajo�dpaosraurrng � � ' 1uow��odady��pap{ ' (VbOL'�eg)s�os�o}pa�a};o�o papua�ui�ou si oinpn�i:eyi , ' .`�; + , � , . � � . � puo'�io.N ey1 op��irn'uo�josuadwo�o�os��ey1 so sa6om - � o�oo��µ�aJ�a�o/y� yiim soaAo�dwo�w�o�A�10fI0/C�B4J�O JBUMO SD'� � , . � .- , � . ' . ��YOOSSI Un11�PPa.rpan�r ani�ra�7 osoru tou Jo�C7lvuad . . , penoiddy ao �N f°A - �s�anaECy . . prnnno=�un»rddnayin�a<qnr»i�uada.roj�anntddnFuv �. , pon�aoayo+oa Pa��nb�ll . F9 S'7£OL uaJ�ag fo uoirv�oin�tuy��uo�JJivax�pa8a�io . . a�p�o�nmqaqtpuowwja�oq7Tdruax�rjaq�nqt�o(apo� . _ . • . suoisrafw�j puo smursnn ayt Jo f uurrrnro�°(OOOL�aN .. . . , , . ya,r ytr.�8unuaruwo�f(6.r��d°47�ma7 asua�i7 r,lotvn�t . _ . ' . � . . . _... _ -ao�aqrJo ruainno�d aqt ot tuartvnd yasaaxl si aq payt . . ,�- � � `� � . .. .., tuaeuo7atr pauErs v a1rf ot I�uuad q�nr fof tua�qdda aqt . . .. ��... . . . -.. -- � . ��. - .. _ - . _ . _ _ - : . s��iabaa orlv'��uonm syr ot ioud��1RF�M/TS�LftO J1D(IJJ 10 'qrqoruap•onold+ur Jat/v'7on�Fsuo�07 tru+.ead o sa�mba.t � � , . . . � . a7op- •oN eSnO . - 'OT7 y�rr�mrl�uno�.to6tp�tu�:apo,7sµousaJofdpuvsrawrnp�� y penoiddy . . � �S'160L '�o$) 'uosoe� 6u�mo��o� ey� �o; mo� etuooi� , . . _ powny�g , :ol . slopo�luo�eyt wa��dwaxe wo��oyt w{y�o Aqo�oy� � � NOI.I.VTIV7�3Q ZIHQ7ICIQ•2I3NM0 � S310N S.M01�3d5N1 - � 1NtlJllddtl Ol SNtl�d . I�