Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0794A 0795A
WORKFRS'COMPFNSATI6N�Ff.IARATiC)N � '�* �� � �d�� � @ S 9 A Cl I hereby.,affirm inat I have a ceriificate of conseM to 5e�f � A�PPLICATI:ON� FOR _B�U-1�3�I����:��Ri�11��� � i� insure,or a certificate of Workers'Compensation Insurance, . L� or a cenified mpy thereof(Sec 3800,Lab.C.) CpUNTY OF LOS ANGELES BUItDING AND SAFETY � Policy No. Company / � BUILDING �9�1 � ` � �e � ❑ Certified`copy is hereby fornished. FOR APPLICANT TO FILL IN AODRESS G� .❑ Ceriifiedcopyisfiled�witkthecountybuildinginspec- BUILDWG.,_,�c� +1 ���,� tion depar}meni. � � ADDRESS G�.l �� 'C-• ,-ll�lti �'�'� � ' r-�^� Date A licant clrr`�-�}�� �� ��� ziP C{.1l�� LOG4uir " �.. .__.. �7/��0.✓'''lC3r�� ��(�� - PP- NO.OP BLDGS. � _ . � NEAREST CERTIPICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT � � CROSS ST, - COMPENSATION INSURANCE � ASSESSOR (This secfion need not be compieted�if the permif is for ane 7RACT ����Z BIOCK LOT NO. �� MAP BOOK PAGE PARCEL hundred dollars($lOD)or Iess.) � TEL. � . OWNER�� � ��S NO. ����'3'3I USEZONE NIAP -I certify ihat in the performance of ihe work for which ihis NO. - SPECIAL } permif is issued,I�shall not employ qny person in any manner AD�RESS �%�JP� t�-' d"f`41� C.t<vv��iya C1�2- CONDITIONS o so as to become subject to Ihe Workers'Compensation Laws r U cirr i,�A�--rsv"C ziP �t t� 3y3y -.�afe A licqnt:. � � ARCHITECT OR � TEL � � PP DISTRICT GROU° TYPE FIRE P CESSED BV O NOTICE TO APPLICANT: If, after moking lhis Certifimte of ENGINEER NO. CO ZQ t"" .Exemption, you should.:become subjen to the Workers' �. � C w Compensation provisions of thelabor Code;you must forth- ADDRE55 � ilh comply 'th-such�provisions�or ihis-permit shall be TE�� _. STATISTICAL CW IFICATION' APT. CONDO. Z deemed;evoked. CONTRACTOR t�i'���=�- NO. — LICENSED CONTRACTORS DECLARATION .� LlC. ctn55 NO.�oweu.urvi7S � I hereby affirm lhat Inm licensed under p�ovisions.of.Chapter 9 _ _ ADDRESS N�' SEWER MAP (commencing with Seciion 7000)ot�ivision-3 of ihe B�siness LIC. and Professions Coda,and my license is in f�Il force and effect. ��T� �"�s"`� ��Ass gK p� VALIDATION SQ.fL, NO.OF NO.OF t CHECK � � - License Number Lic,Class SIZE '��� STORIES �- PAMIUES ` ONE . VALUATION � DESCRIPTION OF WORK NEW �❑y(_ " .Conirador . . Date� , - . . . .ADD j�J .. .s.� . .O..O 1, { ❑I am exempt under Sec �� �� �� � � - -- - � `� !� �r, ALTER ❑� ► J; � e e v.�, 8.8P.C.for this reason REPAIR❑�: -�S � �:a� .`�(` � Date: USE OF � ' a/]i F fi�; EXISTINGBL�G. (�"v''� DEMOL o e - Signature A�(PR NT). `j7h°'e'+1=� NO. - �FINAL - -- �z z 0'��% . OWNER-BUILOER DECLARATION y j DATE ��?Yy �� - I hereby affirm ihat I am exempt from the Contractor's License qoDRESS FINA � -Law for the-following reason(Section 7031.5, Business and � Professions Code): - PRESENT - - � BY ��� �s---' - 6UILDING - ❑ I, as owner of iheproperiy, or my employees with AODRESS ..� �y) /ut�r�.•� � � wages as their sole compensot on,wil I do the work and . �, � � �[�, ihe structure is noi infended or otfered for sale(Sedion ��A��TY ►�',n.�x.. �v�. i`'�"`� =C 7�'` 7044,Business and Professions Code.) MOVING 7EL. #' n�.s s.� a � - ❑ I,as owner of 1he�propeny,am exclusively contracting CONiRAQOR NO. wifh licensed coniraciors to consfr�ct ihe project(Sec- AD�RESS �I o °�!.7� tion 7044,Business and Professions Code.) � � . - - REQUIRED TOTAl5ET8ACK FROM � EXIST. � . t ^ r��z CONSTRUCTION LEN�WG AGENCY SET BACK YARo HwY PROP.LINE WiUTti � ��$�` +� � �-�' I hereby affirm that ihere is a construction lending agenry for ���FRONTT � ihe performqnce of fhe work for which this permit is issued P��� � ' f�x,����-^�� � (5ec.3097,Civ.C.). S�oE - � P.L Lender's Name� . a . r . � ..�,.�/ .� LDMA Ref.# m . P.C.F�e��$ S!J Permii fee - ► 3 Lender's Address � I certify thai I have read ihis application and state�haf the ��� Issoance Fee ���� LDMA P/C# � above informafion is correcL I agree to comply with al)County �nyestigation Fee � ordinances�nd Sfate laws rela�ing to building constr�cfion, � Toml Ree � � � - ��MA Parm.q Q and hereby authorize represenfatives of ihis Coonfy to enfer � -upon the above-mentioned property for inspection purposes. . ��•��--�� a � . - . SEE REVERSE FOR EXPLANATORY IANGUAGE � Signature of Applicont ar Agent � Date - ` _ m?� n s r r m �e �n � ^r- .-.��k`:' _'-- �q ,w; t,-� > > o o ,n,' �?; �. U cn,� v r n tr, �� G7 � n „_ � ` p �, a tD!U C m � � C @ r �1 O Z7 9 iA `-� . ; p � .'"' S �� �" �i tmy L'�� I 7 O �.. � � G'. O. N"W'9' .: A � �� I ��.:; 4 Q_ c� a� � � }6 ';O p .�a�.c^. �` � � tn '� � w n ci � ,A , � � O m r��` �yp ,� ' p .. �- .� �1 .. �� x �'�( � s� � . t�a � � �-C1 .'."�, 3� o �3 � s'o'� � � -°° tw I �` � � �� 'w' ; w '�� '. � ca ���:. , -. _. .�_ c �� � o . . -, ; v, j� ( 7 w � ° 1 �', � , � w � ' m �� o �.�. = 3 r�.� � � , � , �'•'�� � % � �o n �, as � t..�, �o o 'a ,3 i�,.�. � �.�:�..., �a' � � � `" � �o `��;, � c� , m �. a,�. � I , .. ;� �. ' �.. �. ._.; �, ° � a.: ,�a,-.r � c"��:.✓ ,.� i� ..,-.�.,�. � e . � , .., + F^y�`" � i� r'� � � . i ,� ,m-,.,`,�'�.�: � �.�� ;� � � � � _. � �-= � � _ v � _ _ � � ; � � � �a � � ��,� _ �� � ; � � � � . _ � _:� , �a . � � � .� , � ���v. , � . , � � ����.:: a , 6 � � � � � � :w ; C � � x�' �' . � � a ...3 �s ::��;�� .� $; � d � � � , ' . P 6D md ��'.J Z. � ; �,r.•-S�'� ra � m '�"� co: &/D p . �,,,.��: � : », ,! � �o � � Ta C! , �.� , � �" r. c . � ' ��� , � ; . .. - � � '. a d � � ' r: x->• ' ' -; a, � � 'o � ' � . � � � � � � '� � � . Ef , '��, , ' dPJ �i;� . . ' . . ' . ; ' r.- � ; . �� ..,; . . �a . �. '�, � . ;;� � � .� � .: . . :�� ._ �::. , � ' � : ., _.. .. - - .. ..:,. .. ... . . ..:... . . ... � � . ' . � . . . . . : � . . � , S i � � , } „ � :t _ , y my�'o `^3s °w'-'� Q c^< �'� �' Q i•^ � ~'e� ar� �,' :� � � � ❑ `saa.� ��^' ��l�.�m � ° �� � � �� �� `�° nao �'.`DQ'� �'" s � �c moa �.� � � 5'�' w ��m �c�- su � � mm ._ ; 1 , ;`'� � O � �c at� g �s o � - ; S/a -. � b =.� _ ; : �.C��sraj c�i'�' �? j,ts p � $'0 6� � �m `��q �eq o_ �� �'�Q' y ��m �° } . .. �. �' I�� p.:;`°a� 2r ;,�Q � ���.�,rn � � ree � b � eo .�r ca Q.w 'r-°� .�. ': , � ; " .. .: .: � � '^wa '� f�-�Q J) . +S�' +T'n y pi � 1 PR Aa �1.�J�'Ly.p �.01 .'9� a� � ; - . i� C �p ,A�° � M;� N o 04� �pQwk �.,�tb = �� ',5 �� � nn `c�v � m»�': �u� � R � � � cr; "� 'ro, � ' , � _ � �� 'o �.�� �m :;��m;s � b� mar�s � a ��`D.�,'�4°.,o �'n � �°�� ' � _ ,^����-, `a'c�ua �'o;.'-� owa�� �m� �� �•� �ocuza � �� u' r�� •: ; . = e�.-�, .y�4 :� � � c es � � �.a� � , � ¢ ;3a � � � o � ��.� ����a � �����'�c.� �°w��Qm �o3n � �: �rj � � W ac�. � :�•�aa� a"° ��'� o �„� �: j.�a ,.,� � � o�xtrt ^ . . , .: , ' . �, -� gn�.. � � �m:^+a i�r�i 4 :°.swq�y v:a-m Q �� �iti',r` �m � a:� � � �T ` : I �.-s � 'Q � � ° `� a. . _ � ° m � � ma s� W i �yr , I ]] ;;�.W� 6� � °� --��y'e m �...�o,�,V� � �' m y �s o y t�.��� ��-, .. 4 . �! , 4� � � A�9 y N8 4C �•q�� ��.Cg PF��,�� � � � y C' �Ca.� 'V,; Fy ��: ..,.,� a�ni' a',�a°Q �t ;o � ��a�� �S�� '` �`_m y .�n � d � �`�� a�'i �a �^ ° � �� ti.� n � :< _.. -cc ea c� �, o -w.=� � �, -h c,. � r aa � ,�;m � a, <. < , a. .v� � sf _ _ '� c� Ct ca �. � a a �e a. . � a -, xr a r� � � � { , � � � � � a'� � Mx .omaR �� '��' �, pm �-�� ��cu � ��•� � �,n �,,..� � � � � � � ������ ���M������p o�o`°���� ��r�uo��fi� a ., _ .. .. ; {� . T7 n i'a � C; BD T'�5�. �.Vi 3 3'L7 C/7:2`G ti .�,ty.4 � C 4 j C% �. , E � ., � � � �' � �ym -r�e 'CSr m �y � Q "`c> "� � tis� �v, tn � �� `� �`� '�� � _ � ...� ,:.� : -., -.L � � �"?�:�'�y -�'c- su �y `° `° cy �C a t's p �: ?�oa a� � `-���, �:�iay �� �.o�.��°a � � �� �?ino. �y -, tr � tt.:�":�...^c -� us � a..�u�s .,M....,..,K' - ,� �