Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1024A
WORKERS'COMPENSATION DECLARAiION - � I hereby affirm that I hove a certificate of conseni lo seff �r-��I�.e T�_0�-�-�o� -�����D�-�V- ■ ���.`�� ■ insure,or a certifimte of Workers'Compensation Insurance, ' - - ■ �-1� . or a certified copy rhereof(Sec.3800,�a6:C.) F.s� COUPITY OF LOS ANGECES BUILDING AND SAFETY PolicyNo. Company�'"���� � � -. `--`- =- � -- - Certified co s he L5"furnished. � �BUILDING �.� ', �� ����� d pY' ..-�Y FOR APPLICANT TO FILL IN aooaess Ye � � Certifiad copy s�filad with ihe munty 6ullding inspec- BUILDING - fion dgpd�ment. - � - � � A�DRESS�� �� 4°. !�r-,�'. _,, IOCALITY ,��„�. Date .qpplicant . � QT ��"�Z� �� CROSSST.� � CERTIFICATE OF EXEMPTION FROM WORKERS � � � NO.OF BLDGS. ASSESSOR - COMRENSATION INSURANCE - .. SIZE OF LOT NOW ON LOT .MAP BOOK PAGE PARCEL (This section�need not be compleied if fhe permit is-�for one 7RACT .i /� 6LOCK LOT NO. O� US�N�� -�OP s��; � �� ...� � hundred dollars($100)or less.) � , �- -� .�� q SPECIAL - � I�certify ihaf in ihe pertormance of fhe work for which this OWNER ' . NO. (0d� CONDITIONS� �. '/ - DISTRICT .GROUP-TYPE FIRE PROCESSED BY � permi(is issued,I shall not,employ any person in any manner qDDR�55��.�7y��� ��..t;hati4�:�' CONST ZONE - �� so as to become subject fio ihe-Warkers:Compensation Laws. � " '— - Jr7 ,�yr'y/ ��.y f- ` �� u.� � L1Pfe�'�-3` F��`""� Applican�' ��_ �-Lh-) CI7'Y ' �' � Z�? � STATISTICALGLASSIFI� TION� qPT. CONDO. .� NOLICE TO APPLICANT: If, after makirfg this Ceriifiwte of F+RCHIiECi OR y� iEL � � - r,� �Exem tion, , ENGWEER NO. .: CLA55 NO.�DWELL.UNITS_ -� � p you should become subject to-"ihe Workers' �, Compensation provisions of ihe I.abor Code,you must forth- -- - - � - � with comply with such proyisions or this permit shall be ADDRESS � SEWER MAP � � deemed revoked. � �� �� � � - ,(/ TE��/' VALIDATION . - CONTRACTO , y NO/'� e�3,e{ BK. PG, � UCENSED CONTRACTORS DECLARATION - t. � t!c � I hereby affirm ihat I am licensed under provisions of Chapter 9 ADDRE55%��.�� e,�� NO. VALUATION (mmmencing with Section 7000)of Divisio�h 3 of fhe Business and . �y . Prafessfons Code,and my license is im full force and effect. CITV_� q„� _p{ ,,. C A55 "� f`��L����' . - � � '�/b '' �- - SQ.FT NO:OF/ NO.OF. CHECK , . ► � Ccense-Number F�—� �r� �Lic Class � SIZE,���� STORIES FAMILIES ONE � ,! �y NEW $ ,�7 Q�,L:� Confracfoq���E�L�� Dofe�,v+���"..._ DESCRI,TION OF WOR - ❑ , ADD Q �� � � � �'� ❑I,am ezempt under Sec . . _ � .�`�`t-� ' � �"�-"• AITER ❑ . .FINAL '�j . B.&P�.C.for fhis reason � - �,�L'��,q,�,,.• � DATE (,� -�� � . � 84 �'O��; REPAIR USE OF � Date: - � FINAL i °� �" J L,�i J i: ._ EXISTWG BLOG. DEMOL � Signature � APPLICANT ... TEL By . •�� 0 5 c£:•...8 c OWNER-BIJILDER DECLARATION � PRINT)' � NO. ' � I hereby affirm that I am exempt from the Coniractor's License . � � ► - . �Law for the following reason(Section 7031.5, Business and ADORe55 - - - - � Piofessions Code): . � � � � PkESENT � � ❑ - ' � -� -�BUItDING . -I, as owner qf ihe properiy, o:�my employees with ADDRE55 � wages as}heir sole-coinpensation,wi11 do the work and - . � �he siructure is not infended or offered for sale(Section LOCALITY � 70d4,Business and Professions Code). , � MOVING TEL - � I,as owner of�ihe property;am ezclusively coMracting CONTRACTOR � NO. wifh licensed coniractorsio consiruc}ihe project(Sec- ADDRE55 � Yion 7044,Business and Professions Code).. - - . .REQUIRED TOTAL SETBAIX FROM E7(IST. ' CONSTRUCTION'LENDING�AGENCY� � � SEfBACK YARD HWY pROP.LIN� WIDTH. � , I hereby affirm ihat ihere is p constNction�lending agency for FRONT � fhe performance di the wnrk for which this permif is-issued p.�.:� � - �Sac.3097,Crv.C.). � � � SIDE � � ,,, / P.L. Lender's Name�J L'1✓;t1.�C� - _ $ � - P.C.Fee$ �� Permit Fee �-,,�;;,C_ ' Lender's Address � I ceriify�that I have read ihis applimtion ond state that the � � - Issu ce-Pee �� �� � � p6ove in�ormoti0n is correct.I agree to comply with.all.County �Imes�igation Pee . a� e,�.. � ordinonces�and State laws relating to building consfruction, / . � Total Fee 'J v and hereby authorize representatives of�this County to�enter . m upo ihey�b6�-mentioned prapertyfor inspection-purposes. � . � - � ---� -� � �����,rt;/� ,t..ry+-y�-`�-^'� �j' �-��,,,-�}f_ _ _ ' 'SEE REVERSE FOR EXPLANATORV LANGUAGE. � Signature of pplicant or Agent Date-� � - . - ..�s _.__ �€ � : m-r � P- '� �� c� 4 � 5 � ° c°'o. � a� $ vs b =n� Gg � � T?�� s R � ma � � ��O O E � � Q i a & g� G � 4p �.. t F -G. i nro fD � CC 5 ,� ��:. �'t6 � � � � �"3 �tJ fl (� � � I —� � S � k 4 �' �.-�.� � � � � ^ � �. �Q [a.: �, � ¢D � f , � �� I ��� ii ��� _ j � g ° �-o q �' k � ' '� i 3. �� � �` q ,�a � � s � �, �� , � � �� � �' o � � � � � � s'� I � k � r � �� �y � �� i � -e�" � � �• � i 1 � � � € �O d ,� � y h �s � . { i fi,� Q Ti � .:`d,� @7 ;I 3 ` Q ' ' � m � � ^ � ` [� � 3 � � �� ?�r�� . � � a 1 i � � � � � � � � 1 � r � '� � � 3 � � r � ' �s�� � .� i i, � i', � I ,( Q; i K � � � � � -� � �� � r r � �.:' � � � � J � � � � d � f � "� � �� � y � — �! ' ' ` j �� � � � ; � � � a � �� �.��� �� _ � , � � F! ' � C, µ � ' � i� � � --�,��" —,�f _.,__.� � _ � �_- .� k �- 1 ¢ ( ' � , � � � ; p � �, � ; ��� ' a' F I i �, ! 'f � C ' ; �� ; #»,� � � k i � � ; � s 6 � _��� ; _ _ _� i �, ' � ; k a ,� ; �,.___ , ' , ._� s ',_ _ �� _.� �,__..LL-.-c. }_.�._�� , � � I , � � � i � , a_ � _ � ���.�� ti i u � , i i 1 � '' + ! � � � � 3 � � � � �a � � ���� � 4 , � v , -�r---S---�.�------j ig___4� � �- �..__' . � ..,:.I :�,� i,, N� � $i c: �---r—:; .a e--, �� W y I ,S �� � � j � ; � - ��.� -� � ,i � � � � � � �'� �� ��,..m...,.�� .! �3��.� ` i j � � � � { 4 n k� � ��:;� �� � � 11 � ������ �� �f �� � ��� � I � �� ,� ' �l � I f p � � � . f ��.� ��. � � ��n � e• ���� , � � I V �y � , � � r '3 P � I _.�.��, � .� � ..� �{�W I I f : ; � ? rv�,m _ i I�e i I �� 4 � � :. , w��l� i ��"�[ �s Y�..w�q_ ° P �� � i � j � � ! i � { � ° !�I �, � ; � � t��� I �i d i� � 1 I � � � i � i i '� � ,� �'� � r � � �� � � � � �� t i ( 4 , � � ��' -` � ? d�� , '�.�.rA ��.��.�.i��_,�P� �: � h � � ., ; ..€ ���4 � _ . i y � � G � u L � E � ���� �, �� � � i , 1 i � '" , � 2 . � , i �.�` .J�, � . a � i F 1 � r � � _ I � � I { � , � {' � � � � � � ^ & � i � ° i ��...•�' �. 'y � � `� e� �� `.i ' I ( � � '� � p..._. C....._...._t � .._� . �..� { .4 �� ' �� � .�' �IyI, _' �6 �'�.<, _ , .._. .. ... ..,._ � � �l ,. ' ' '�. Y .�. I .. i�. ..�.,,.. +� ��� 'I � � � �� � i i � ' � � ` j. �f 1 !I � '___� _,. -. �..,r�i� ' ' I . ' . S ' '� �� � M1� ��: � � , �� � Y ' , f �` '� , � - + - �. . ..# y ' .. . � � I� � ��� ` � ��.� I� � � . . . �i ` '1 . . , � . '�. ' � I� I . .. I' . i . . . . I . , i � . �, � . . � I � ' . � - � I � LI i I $� � h �� I '. . , I � 'f,' i ' t � � , I ' � P I j , � % '� i � � � � ' �I ! ��� I a . Y ; } � f I i- I � � .. � � ) f � � '. . � � � I . f ' il ,�,. , � ' j � V VI . � � � � f�� � E � � � � �� � � � � ��� � ;'� + � a 4 , ' �� I � C ; , ( ' , i , � i , . , � � i I i , .. � { , - . , , . { I . .. � , l I . � . . . . � � '.. � , � ^ , h . � k � � � r � ; I ' - . ,, . .... ' . ' ' � � . , . r ' f g, � � I ` . I � ,� X�, 1' � - - . � � ... i �� � I � ` II. I i � � �' � . � t ' I j � � � � � � , , 4. ��, a''' �I, � � � - I k' r � � � ; ; � � i � , 1 ; ' ; ° �t il I „�r ' ` ; i b,� j���. i� � i � �_ � i � � �', I � - ��,, t. �' , i .t�/ � o'. 1.: j '� �. i � � � ; , n a � � { � j ' 1 i � � , � ; � � 7 � � ` { ; � l � � �' ,� � � ' � ; I � i j I! � � ,, �.. � i i � � a. � � ' � ' " t � , , , ; � � � , � � � I b , ` � � $ ' � � � ; � � � � ,� 3 � i . � ' � a 3 E � � � " �' ( � t r � I j � 1 � i �I ,., 1 . ,. i i [ . F . _ . ,. � . .. . ��� . � - � . , .. . . . , ._ . . � . . I . � � � A � `� I � � i: � I � � � �I ; � �, „ �. ; , ; ` ; , ' q ; � E N. i : ' I� , � II � � ; i ' 1 � �", '', ` ? � i : � � � I � �!, , , P . � . -., . . . � . . . �. �. . - . �9 . � . . . . . - ' , ._ -. « . . .. .. � . 1 , i ' . Q � `°'_ � P `r ; _ �. .� � t,�r � � �. a� � ""�v� � -� � I �� u . � � I - � � �' � -! L I � � ; . � '� �i ' � �1.w � �- `�0 � . S. o , R..^ -� c . _ ' t c r' `� -' 'C , p, �a f � �_ i � f� � _ � - � -' � .. . � F '�� � � "` C � � 5�E � `�y � , .: ,, ,d , ^ ; � _ r � � � , � . � � .i y � � l _ ra €; `">=r �,` ' � ;�� ���a � �` y " , � . . � F ' e � �. � � ca : � � v p :�- , �. � r , �: Eg t_ � I , _ `� -� o � e;� _ � � z f � Y � s � � I�; t > � e, � -W.. �-.� ,y�+ � ; q . 2 ; . � -.z . ' �, � w ``.�ra i � �y - �� `� 9�' t _ , I x , 1I; ; q i ;. r� �, � � � ; . , i � � S c ,.c 9 - . i � � t � � - (_`. J � "S , t � ° � � - ".. . � I ' . j �" ; : } �. ' C _ :. ' _ 1 �.`�� Cy h . ,. - r�'(J ' u e� . u w �. ��. ' � I '.. .. I ' I Y t t �' � - ... A � f �r r.; > { � �1 � . ^ - @ t � � � .k. -r� C'`i _s � (J �'. l � '., ; f � � . i � I _ � G _U � o ' �-� � �. L a � �" � � �� � i > , . ..i � ; . . � C F �� 52 � c .. < � �.. S, � , � �. � - I . . ., r � ' J . _ _t` � � '� � i c. � „ -.� J - _ i �' . . � E I � r � ..i � '. 7 -�,! :'S -.� J - , 4, ` k ' i I' � f il -� ` ' � �,� ° � �: ', ��"�°a-r� � � c( } i', � r. ' � c� �s ❑ c � ` c y � � , ' .t� . I � I�� I ' �� �' c `3 -c^- � -,� ca � � rJ �L � ��: �� q r� - �y^�" . . , .� � J . , .� �,� C:.�-. 'J. , '�i [-�v^._ j `"�� �`3 p � ;"2 s�' - tl .�� i � . �� t . �;� � i.'. f �,'S��F '. {3 . f `, � _,� Q �� a � ��'�,..a.. q� . �q ea g�.�,w "� ���� � r ¢ <� . . � � � � f I a � e I . � ��'s N �.: ra _ � o� :� � p w ��r �a �. o ��"� `� �- �3 �� 1 { ,;- � : � , { .j'. ��� � � :-r� � _ �� ' v`.�, ro c .^��.�� �,.��-��-� e �"3 � %.� m � �-y-.e�a � '' n - , . a ' " � . I .. � I� � � - � ,�. n a G:,� EJ '��`��� A 'p CD l� -G w: �-� �e` `s - �'� � F n f�� �.. �- �, �, � � � . ' � Ra °'c, "� � �s. �S .�`� a �,�,`�� :�' � ; � � ;�,� �e+ �. � � �, � o" � o� �ou�,�i'�°�,�a�� �c� . � � o ns � n p . O r* �r'�..� �, P�. m �ra ��.i..,�,m � - m a ti . . ' f ' ° ' ° �`� ��,� � " � `�'`� ��� �N �n=;�p � �;`�� eo,�, �Q � 1' � � � s �n s�° m a , °,�,�.�� ° ���� �� `-e @,y,°� �o �'� '� � �° 3 � � r '�S-O �,'� . w ro ^� ro f,.t-�- r'� co w �ti�- u �