Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0790A
WrJRKERS'COMPENSATION DFCLARAT!Oh! I hx-reby effirm iFot I ho�e e certificote of mnsent to self �p�L��q���� �o� ��'L�pt�� P�ERMIT �I insure,or a ce�tifimre of Workers'Compensotion Insurance, or n<ertrfled copy ihereof(Sec.3800,L�b.C.J �� COUNTY OF LOS ANGELES BUILDING AND SAFETY � PolicyNo. Company_ j � ❑ Ce.titied copy rs hereby F�mished. FOR APPLICANT TO FILL IN BU1L°�N� � � 1y{A (� � ADORESS I 7J ta.h_='� �1_di ❑ Ce�tified copy Is filed with ihe counry 6uilding inspeo gU�LOING �/ /�//,�G'��,�/y�'�' ��ondeparfinem. AO�RE55 �,l���'� /J ,i i r �� Date Applicant CtTv " ��/`°� L ZIP LOCAti7Y CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need nof be completed if the permif is tor one ASSESSOR hundred dollars($100)or less.� TRACT BLOCK LOT NO. /�qp gpq( PAGE PARCEL 1 TEL. +� I certify ihat in the performance of the work for which this OWNER J -fL� ����(n�t� � Np��+ "���% USE�N� NO =�L„�7--� �� pe�mit is issued,I shall nof empioy any person in any on r qDDRE55 ( ( �L=� --C�`�� {¢�/-� SPECIAL Q' so as to become subject to the Wor C ns i ws. �7/' ,J� r/ CONDITIONS �j � l4Jate ����� APPlica ...r �- . ._.. CITV LIP `��/G3� � � NOTICE TO APPLICANT: If, after makin �t s Certific fe of �+RCHRECT OR TEL DISTRICT GROUP NPE fIRE PFtOCESSED BY � ENGWEER NO. ,[ONST. ZONF � Exemption, you should become subjed to ihe Warkers' W Compensati�on provisions of ihe Labor Code,you musi torth- qDottE55 �� ` � iih comp!y iih such provrsicns or this permio shnll be deemed revoked. - (,� 6 h,/ ' � � 7EL STATISTICAI CLASSIFI ATION APT. �CONpO. Z . corvrencroa �/ �C L- no�Z7-tit'_l� �j) —. LICENSED CONTRACTORS�ECLARATION / 3j!� t� :,�.�LIC ClASS NO._'^' OWELI UNITS— I here6y nffirm ihot I am licensed unde provisions of Chopter 9 AODRE55 f�(L`� d'�J Gf�''//i�t NO. �-j��1�� (commencinq wi�h Section 7pp0)of Divisioo 3 of the Business and � ��� ,) ��? SEWER MAP Professions Code,and my license is in fuil force and effed. CITv ...., �C�i'� CLASS �� �''� BK � VALIDATION „.,y��.j�jD r��A�� ) SQ.FT. NO.OF N0.OF CHECK -- I License Number 5 t� lic.Class�' � SIZE �-�rf� STORIES FAMILIES ONE ✓Ct��l�� ��a ��,�'� /�/i�G� t^��it VALUATION ._ Contracto� ! Date � DESCRIPTION OF WORK C.(,;J NEW S!� ADO ❑ s "_' �� , �I am exempt under Sec ❑ AITEft 8.8P.C.for Ihis reason REPAIR S - oaie_ ��;F oF oeMo� ❑ � �0 7 S,C1 A EXISTING BL�G. $ignafure APPLICANT TEI. FfNAt �' �, . OWNER-BUILDER DECLARATION PR�M) NO. DATE f�� 71 � � g e � � I I hereby affirrri thot I am exempt from ihe Coniractor's License � 4 - - I Luw fo�ihe followinp reason(Seciion 703?.5, Buslness and ADDRE55 p�y � J . '"�4 4'��'" Professions Code): PRESEN 8 1 . �;�.�y f:�1. ❑ BUILDING . , . ° � ` ` I, as owner of ihe property, or my employees with ADDRESS wnges as their sole compensation,will do the work and � � �' j�,i v p`�,� the struaure is not ir��ended or offered for sole($ection �OCALiTY 7044,8usiness and Professions Code). MOVING TEL �.. . � I,as owner of the property,am ezdusively conirocting CONTRACTOR NQ � wilh licensed contractors b conslruct the project(Seo- � qDDRE55 tion 7044,8usiness and Professions Code�. CONSTRUCTION LENDING AGENCY SET�BACD YARD HWY T�TApROPLCNE�R W�OTH - I I hereby affirm thot ihere is a construciion lending agency for FRONT . tha performon�e of Ihe work for which this pe�mit is issued P.L, (Sec 3097,Civ.C.�. SiDE . P.L. . Lender's Name . p y+— LOMA Ref.M Lender's Address �P.C.Fee S aermu Fee J . V , I certify fhoi I have read this applicatian ond stote thaf the Issuance Fee !��� LDMA P/C� 1 above information is correcc I agree ro compiy with all County ;�Inves+�gaso�Fee �,( � � � ordinances and State laws relating to boild�ng construcfion, to�al Fee ! "�� LUMA Perm.# � ' and h y ufhor r p seNatives of ihis Caunry to enter - q upo h�e�q ve- ne�" d property for inspection purpases. C� G'� . /�7��� SEE REVERSE POR E%PLANATORY LANGUAGE � �_ Sign of Applimnt Agent Dofe �.. ___� _ .� � . � ; ( � � d o � .� � �_.. � �_ ; � 3_ �._. _ _ ��_.� _ e � g rr; a ; r- r _ � � � � � t �U � r , g �� � _`_ r� - f� � ; � £ � ' "i �' .' t 3 E . z C € $ g � ,p. = 1 } � � ( t' � � z � j �. f (� �� ; _._..�_ '.�-.._( 6 f tt a �� � � � 1 E � 1 p � � � �r � b � I � ; a 1 o e�� s r � E � , i @ 1 � � � � { � � r � � t� � � j � � ' � i � g: I'� j � t � i �it � � � _� ` ,� a ; � }�� � r � ° r�� � �', :� . � '. t . f � [ � 4 p� 1 $ s�� t=. j ! � ¢ C � 3 . € 'o , .,� � � . ^^s � .� � a I 3 s� � , 7 € � . ] � � �� s ., �, :� a � -� � � d t " � �. � � � � _ � r [ g � { � � � � i d � 3 ' E 4 ) :+ � � j � f t � e j ,' �"."d � � � �. �� $ � '� <. `� I f & 3 ! � �,:. E ; � j � i _ + � � � � y : � � � i � '� j � � E j '� � � � ` � i � � � ; � i � _�, �'_.�_..� � 3 � � � , � � � . � ` � �� � � it � � � , . {.a__.�:. ..,,... ._ �.... j .....�._._,...�._._,.. � �,- i < , ; - - '. i �-:.; t ...'. � ? �= E 8 9 ; I � I: � - � ` � i ' j � ! � [ ,, „ ? i ' � } ! � E ( �, � �� � � : � i � � � ; , � ^---- , � _ ` .� —�..� ___.__.��. �__� � �..._ _ ___� —� �— �� ___. f g € ; � , �---- � ;; �w_-_i _-�-t~_ ( _-�--_--� �---- � ,, � �V � � { ¢ � � ! : . e. ...a-. I � e � S � rv _. [ � . � � 3;,�' � � i � € �'�S � I S �� ' i i . 9 ? E � . � , ��,' � � . y�.....�.�... j.� ,. 7 �...�.��..-_ � ..�....a..- �. �. E I ..__�� � %�� � € i j � .. . ; �{ .� ,-e � � ? �� �� � � � �, �,..._._ ._._,�___._�.,__,.�..� _�. ..-�__..-�^-�"�- � -.—,. �_ y `.� � �} � � -�a� � �»�.. � � ' _i . I �,. � � € � � 1 ' i � e�,.� li,-,� � �� fi E s � � � � f � , ' ; ,� ' � � � 3 k � _ � , E ; , = i � 's ; � �' � � , ! � � : � , , � { ; � 'i � ( , I � I � j, j � � �je.,,..,.. _ __ _.._P_,..._.�..._��- ..,,.....�.».�.__.._rf.._.�..� ._...�. ....—� ..s�,_ z : � [ ; � � $ Y . 1 � ( . � S r.. .. € � � f _..� � � � � ! : '� � �( �. � � �. � � � , � � . � i ; t ! : �I ," � t I i � 1I `� �...__.. ....� 5q-__� ._.._.A `s.. � � � i€ f � � � p � €� �.� � , � � ; ! � ; ��� � j__. j ! i � � � � # . ! � ' : i� �s � � i i � � � 's � � % � � �� �� � � � � � � ( � S � � �€� �, € � � � � � � � � �j � � � f � €� � � � � � j i � {� � � � � ! � � � s �� �� � . f � �� ta } � � � ' ` � � i� � � i � � � �, �� � � � �, � � • , � �� � j � �___..-�._. _ � i � q � � ',���� � ' _�_ � ��_�__ �___�.�a...�.� �� �.! __�-_�-_-�--� � g � � i � � � � �� � � � � i � k � � � � 7 t �jj ¢ � � . � � � � � � � � � � - � ! � � � p � � g � � � � � � � � � � � � ; i � � � � � � E � � � _ � g �' � �� -3 E � � i � j � � $ { � � � � � � 4 . � � " ( � � � � ; i m q! � � j � � � ! � � � � I � � � � E � " � � 1 � � � � � � � � � , � � ' ; � C , � � � � ' � � � € � � , I � � � � � � � � � � I � � � � � s f � i . � � � ��� � � � � � j � � � 9 � ° � I �� � ; '� � � �� i � � �� � � � ; 4 � � ; � � � : � � � � , � � � ,; ; � � � , � . ; � ; , � � ( t �� 4 � � � � � � } � g � € � � Ev � � �-�j 3. � � � � � � E � f � iro � � E � t � � � � � ` { ' ! I �� � � i � � � � i � � � i I i � � ; � � , , , � � � i �� � � � j � � i � � � f � . � � ` � i � ; � � � � � � � � i � � � � � � � � —, � � � � � ! � � � � � � �f ( {j � � �7 � '!E' �g � � � jj p} � i' � s � � � � I � � � Y S 7 1 F � 6 , k i E � ' S � � � � � { 3 � � � 1 � ( � 1 � 1- I � i i � � i � � F 1 � � � � d I I � � ' ` � � � � � � ' ; � ° I � ? � � � � € E e � ` ' � � � � � � � � � jE { ' ` ' 9 { � j � � � j ' � ¥ ( e � � � � � � ( � � �} � } ' ' 7 � € � .�� 5 # � � � E y t [ k � f � 1 �' fl 3 @ � � . � t g 1 p � 3 ) � � � & � � � � 1 � E � 1 � � � � I . I � � I � 1 � � � � � � , } � � . � � l � , , E . . , � I � � , � ! � � � � � � � n �� �.� � � � „,� � �� � '" '� � 4 -s � a' _ � � � � I � � t fj E J � � q' `t' ..... :`` ' � `-�`�. S`"` � � . . .�.. � ' �� � ` � � 4 � � � l � � � q � � � � �� �� � �- . ; � � � � � _' � :, -. ^ �.. �. --�� -�`w � '` �` � . '-' �s .��; � � - 5 ! � � � � � r � ^ � -, � ,� , -« �. � � . "�s . � �. �- . `�, $ ¢ i � � 1 " 3 � ^. ,� � �"s � ��' �� t � r �' s`" � r � 1 � � � � � ! 1 � � � � �. % � � � � K °�"a' ""'� � `,; `p $ � 9g ( �(( � � �f � � � �,. M fi � ^' ^' '� �'' ;a a .�„� .� . , r eq` . ' ip S � �( t q � - � � i -� s .. { � '.. a ,2 y-njn'� .. �� � "4 � .r . `i .. � � 9 j � I � � . 3 � 1 � v - ^"a w.. � � s�fr „�.� � .' ' Ci f�^ y � �` °.. i � � ( �� i G � �� � : w �% �* - � - � � � � � � ( � � � � { � ' � r� � � � , � s �� � � i s � 3 � � } a �� � , ...� �` � u � ,y -q .,,, �,.�: C:� � ^�. , b .. E € � f c ,„� � ,�, . , a � �a . � � �. �, `,., ,,^_-„ � � 9 � � � , �� � � � �.� � n � ,.. ` � � , � s�, � .� � � ; � � � �� � � � ` , � � � ? � � � ( ! °� � � � �, � , � , ,� �, � � i � C � � „ � � i ��� � � "° � � 0. ` =� �_ " � � � ; i{ . i � i � I ��:�� � � � , m �. =, � � � ,� �' � { � � -€ � [ � � i � _ � � �� .� � �� � ri `r � ��.? t . "�. } t "' � @ - Ig R� � � � i � ! 4; (' P � � � Sr�y' S ,� W � .�..`: . .,'. r � ..m, q" € � { € l� � } . �P e. , wq .: ' °`. .� ����.. } f ( $ . i � a '& 2t '-: . . -�.. �' � � a t" �' 3 � � j �� :f .� �� ' E k �� � . � �7 C7 . . <e C _ s^ �� � ...., ` �� �' � ) c .. � � � 4 I G - �- � ^ . . �: `� . �� .:,-t , � � � � , � � � _ ; � � �,. � -�, , , � � � ' � ? ' ` i � � � i � .. ' `; r . � s. s _ '% . . . , -� _, _ _ . r � � € E � 5 � � F� a ' 4