Loading...
HomeMy WebLinkAbout1565A 1566A (9) WORKERS'COMPENSATION DECLARATION � � I hereby affirm that I have a certificate of conseni to self .insure,oracertifimfeofWorkers'Compenstioninsorance,or APPLIC/�TI�N �OR �UILDIN� PERMIT a certified copy thereof(Sec..3800,Lab.C.) � � � Pou�yNo. 7634-811�Fy,mPa„y Pac. Indemnity COUNTY OF LOS ANGELES BUILDING AND SAPETY ❑� BUILDING �� �p,� ��� B Ce�tified copy is hereby t�rnished. FOR APPLICANT TO FILL IN ADDRCSS �y l�tz-C.�eti !M�—�-' � Certified copy is flled with the co�nty b�ilding insper gUi�DINGJt � tion depariment. - ADDRESS 7r3 $ld . ZLF ZZH79 H11t.0Il Head �ocnurv 1�-�j • . NEAREST Date npp��m�,r S_Mr�inniG arv Diamond Bax �iP 91765 � cuosssr. � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLOGS. aSSESSOR COMPENSATION WSURANCF size oF�or Now oN�or MAP BOOK Pnce vaRce� (This section need not be completed-if the permii is for one USE ZONE MAP t .^���f hundred dollars(stoo)or�ess.) , rencr 36346 eio:K ioT No. No. �, ltL. SPECIAL (g, �certify that in ihe pertormance of ihe work for which this u��Ntk �.m nS011 17CV N CONDI710NS � permii is issued,I-shall nof employ ony person in any manner DISTRICT GROUP ?YPE FIRE PROCESSEO 6Y � so as ro be�or„e sobje�r ro the wo�kP�s Compensption iaws. Aooaess 1001 Commerce Dr. �� � covsr zoNe � cirv Irwindale Z,� 91706 f""� ' � �Daie Applicant � STATISTICaI CIA551FICATIDN AP7. ON00. {�j NOTICE TO.APPLICANi: If, after makir,g this Certificate of ARCHITECT OR �TgL" _ 4 �, � exan,puon, you sho�id beco�.,e sub�ed to the workers � ENc�"�ER B&�' En �. e�.i254S134 � cwss Na +'�-�' ov�Eu uN�rs � Compensation p.o���s�o�s ot�he tUb�r coda,yo�r�,�s�torih- -�,��kEss �� $25 Colorado LA 9C1041 sewee nnnP � � with�romply with such provisions�or this permit shall be deemed revokPd. . CONTRAG70R m N' BK. PG, VAL�DATION � LICENSED CONTRACTORS DEC�ARATION LiC � I hereby offirm that I am licensed under provisions of Chop�er 9 ao�aess 23861 El Taro No.46$688GBC VALUATION (commencin �th Secilcn 7000 of Dlvisior.3 of ihe Business and .. � n O� r Professions Code,and my license is in full force and effect. � ���y E1 TQTO � �ASS B—�. $ a z I ::G..•�, , -� SW.FT. N(J.OF NO.OF CHECK +7¢ C a �['� uce�se Nu�.,be� C�hShRRARC i�<.Cinss R—1 s¢e sroeies Fannwes oNe Ahmanson Dev. oEsckiviicN oF woRK Trash Enrlosures NE'^' � $ Y ' ° 7 u."4 Coniracfor �pte ❑ �� � I am exempt from ihe�iCensing fequiremenfs tl5 I am a ' ADD e _� � � y,`;�,,.:�j -- licensed architect or a registered professionnl engineer ALTER � FINAL acting in rcy professional copacity (SeUion 7051, � DATE ���� Li(,� ����j REPAIR Business and Professions Cade). USE OF pFM�� � FINAL ' E%ISTING BLDG. By qA: f�i Lic.or Reg.No. Da1e APPiICANT T9 d t�'_p- - . OW'NER-BUILDER DECLARATION (PRiNiI 5. MCGlriri15 N�JZ4S61Z311 . . I hereby affirm ihat I am exemp�from ihe Controctor's License � y Low for ihe following reuson(Section 7037.5, Business and .A��RF55 ���90Q GOZdEII S T1R s Diamond B3 �1 �E�E`�- Professions Code):, PRE EN? . � � . - � 1. as owner of the P Y, Y P Y ���IDING � � . . `� . . . . r;�$ 6 m � e.� pro ert or m em lo ees with ADDRESS wages as iheir sole compensation,will do the work and I e s[F�..�1.(; . ihe strudure is nof intended or offered far sale(Seciion �OCALIiY - 7044,Business and Professions CodeJ. MOVING TEL . ; q F ��� z n - ❑ CON7NFlC70R NO. � - ""�'�''' I,os owner ef the property,am exdusively contracting wiih licensed contractors to consiruci the project(Set- qDDRE55 �'�� n'��'5 � . tion 7044,Business and Prafessions Code). - � . CONSTRUCTION LENDING AGENCY RE(:UIRED YARD HWV TC]TAL SETBACK FROM EXIST . SET BACK PROP.IINE N/I�TH I hereby offinn thot ihere is a wnsr�ucfion lendiny agency for FROM � - � the perforvnance of ihe work for whi<n this permit is issued p.�_ (Sec 3097,Civ.G�. . SiDE � r.� Lender's Name ���� P.0 Fee$ 7erm���Fee ����� Lender's Address____--__._ _ w I certify that I have read this application and state that the IssuanwFee �� ���� Qabove Information is correci.I agree to comply with all County Inves�ig�tion Fee � _ oralnances and State laws relating to building consiruction. Total Pee ��'� � � and hereby authorize representative of ihis County tc enter , . - _ � � upon bove-me t" nad pr5�per �nspaction purpos s. . ' a . �Ji'C.p� at���___li�// . SEE REVERSE FOR EXPLANATORY IANGUAGE � . , ,. . .� � _���. � Slgnat�re of opl�an�or�Agen� re / nPs � -� � � c� � � � Q U� T.(D (S� Q � n t� . Ob� G O�9 .� Q� O 4- . �'J S . � '}'� iP C ir � n � ��. `�-• �� � � . � � . y- Rt T Q b [D C 3 4 --i 9 �. � Q � -� g (" �� O O s S. � � � 4L Q O, ,� � . A �i' A fl 'D N Q � �� � �� { co c x-- .$ ro a��.o 0 0 � � ro � � � m � Q <i q�� "' o � a +� � n m c� � � -. ..� @ � ° Z ?; �` � v� � `�' �o ---^• � � a,c � o fl C n � 3 0 � -19 -n> > Q Q � a o � o � . � � v+ � � o a� ' � a- � o � � �° � '° � -C � � 'a ��a � 3 P �� � ', � � n r=- �� � . .. . �_. q � �p � � Y ; .f 'o � -d r G ;.�� 3 � �� � � � w � ' ;cF w � � � r � �,' -'', � � �,- �� w � � � � s�. ein � ,;� ` � � 6 � � � 'c9 tM fi � 70 V+ � 0 -i IY+ iR � , �y y.-,�L �°'tv.1 �' �p� � A io y��.�.� 3 m - � �Y,.c2 3'� a"'Ot � � N A f I` �y� N O 3°id,� a cJ (q m,�, ' y+ �.�. ¢0 O Q Y . '�' m.��(9 I..J b (a �-��l m`@ � ''�^ e",� O P+'^�e �r`Ct r'�co ^t � � C k'� $y� C � �'t! A"D O�' �'n fi A g � •iPp' A� La'[; � r �' �R? yy y � Q �- � (a Q Cw'a...A :3�[T `� rL -❑�,r•� 9� �p O a .� [T . 4 A � �A•A.� �, � 'eY o.,y m O u ty c: " O `h a m �'.'� n�2 � A' -.� � o A n. �a trs�- �cs o ,� Y� s..ro � � i� S � �� ro.-°�.,� y�..,,� � � 0 3 � � « o o�--0. .�, m o � b c ^� c +� .� -t F"xvp. ^-N �.� o S�" F o�F''°N ' � O .m C 7� co v � �'" cn T �+ ' . p O '�w° � Y n "� `�' m A 3`fa �� m � � `3 O v'N tv A-r^ n O u 'T fl s.�i ' . X C'°A � G a �-m A '� �.�� � O�� _. c� � :c m �c�o � -�� �-� � � -"� � 3 � � w � A.O ° '"� � � � � Aa ° 53m p �`z°KwA��� w o ° � � � W °�. �o ,�y� S �s o K v � � � ��� ��o,u'O w � � �� `c k � 3 r+¢ c� Q Q � �,w w� �o o¢'� o �•�m s'ro+ ° . o a, � 3 � . � m �o o,�v��, � o �Ea,��w H 'n� `.�°. �o•� s c�i o�tEi�m N v �� m� C' gw N �� o u,-m �:,� o � R.40 �-c � : � o � a�`er a� �' ,�,d '`'y � � �:�.�N o� �e°.�'� `c` o � °��m � ° �'�`Q p � � e A a �`i ? 3 �- an A' �° o N 3 �"�•�°.,sa:n o 0 0 � �'cr n a1'A � o'°y � o � W� . � N . � �-, N si.��� es-�� o co �,'� •s�� n � m a A c o tl'2, m O � C ro �xo �•.� A. � .;,� �, ,�o m A.�v' F..u.. S n O f � �o o y S c a � o ���� � � �.� n ��p�oa�-.°,n � �� J' cr: t? � <<..,w c� N, `� �.si o c, � � °v,£� �a o 'o^„-m,o� � � 0 4 ° � 'Qs h �b' �-a � ��'°� -e ��.�m o �a ,,,,o o y �.. � w °,s �.'o` � m { -. � � � � A H'n' � ° � `-�a P s~Q � � �,"�"n'-V'c" ��."`'� "o' c�a °� c�s ��°'�; , n e�s�^�9 �y [�i O C '0 � !� �r�M.� O Q �. 4 N_ Cd'�y R � �n - � �� n(1f.�.. '�wr, � �+.� O �+A p a-T • �� y O t" � Q tp Q O �lp`-� "S . �- �•�-, s-� n � - -t 10 ._,,,�,..,...---^-'"" �„O c:- ,�,_,,...�-,_:,..-,-.,.-'_`� . N . � _"�-� • . +-_� _�...--�.�' �,�.r ` �,._.�..----„'_�_,. ._�. f ,-._"''-_ � ----^.'.""'...-....,.�-.....,---' ___��,,,,.,,��^���. _...�,e,,,.""'"