Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1007A (5)
. . .. . . . . ... . . . . .. _ . . . ' �WORKERS'COMPENSATIDN DECLARATIO� . ' . •� .� � � --'�' � ' _ � I here6y affirm�hat I have a certificafe ef�a�,e�„e,e�f �- � � -- �� APPLIC�ATION� FOR BUILDIN�G PERMIT � ��� insure,or a certifico�e oi Workeri Compenso�ion Insaronce, � . oIa cer�i(ied copy rhereof/(Sec.`.�'�B00,La6.'C.�) ��� � � " - � �� � � ' � � -- � -�, PolicyNo.�G b� �lCompon� ST'�Y_ i r�pJ�. COUNTY OF LOS ANGElES BUILDING AND SAFETY ��, �' �� Certified copy is hereby furnished. . —T FOR APPLICANT TO F�LL IN BUIIDING ADDRESS � . CerriFied copy Is filed wirh the covnry bvtlding inspec• BUaDiHG � � �tion deparfinenl. • . ADDRESS �Z. (i L L,..t�,v r/� Date7 • 3 U .�7Applimnt CtTY - �� -f- ZIP IOCAUTV CERTIFICATE OF EXEMPTION FROM W RKERS' � . NO.OF BlDGS. NEAREST + COMPENSATION INSURANCE � , SIZE OF LOT NOW ON lOi CROSS ST. � "� � " " - (This seclion need nol be completed if Iha permil Is for one TRAR BIOCK �pT�.�p. ASSESSOR hundred dollars($100)or less.) . NL4P BOOK PAGE PARCEI TEI. � US Z NE 1�1P � OWNER ��� I certify thot in the performance of rhe work�for which this C NO. NO permil is iss�ed,I shall not employ any person in ony manner SPEC�ni � so as fo becoma subje[t to Ihe Workers'Compensailon Law7. ' ADDRE55� �C CONDITIONS u� . 0 Daie Appllcanl' � - CItY 2IP � . U NOTICE TO APPLICANT: If, after��moking�lhis Cerfificale of ARCHITECTOR TEI. OISTRICT GROUP TYPE FIRE PROCESSEDBY 0 Exemprion, you should become sub�ect.�o the Workers' . ENGINEER No. � n � �pNST. ZONE F... Compensarion provisions oF tha Labor Coda,yo�m�st fonh- rc 3 � W ADDRES$ wlfh comply with such provi:tons or this permit shall be a deemed revoked. , - w CS � TEL. 1� STATISTICAL QASSIf TION APT. CONpp, � .. . CONTRACiOR S NO.r q�'{_ S`1 Z LICENSED CONTRACiORS DECLARATION . , ���. MSS NO. DWEIL.UNITS I hereby ai(irm ihat I am licensed under provisions of Chopler 9 ADDRE55 /� �..�� NO. (tommenting with Section 7000)o!Division 3 of the Business and ��� SEWER MAP Professlons Coda,and my Ilcense is In full forca ond eHett. CITY '✓G n r n.qSS � BK � VALIDATION ,/� SO.FT.• NO.OF NO.OF CHECK License Number��G��Ua Class!� 5¢E STORIES FAMRIES - ONE-� L VALUATION CoMrattorweS����.�/ ri�a �ESCRIMIONOF WORK G'� CLC► N� ❑ s 7i�) . . Gvf��/ ADD � C/C/ , . ❑I am exempt under Sec. _❑ - AITFR B.BP.C.for this reaion REPAIR � f � � . . — �. �_� O?']a pp+,: 7 • 3 a �,a�1 USE OF // exisT�Nc eioc. l oerna ❑ �)� . . , . � -Slgnot�re — . . . � �•�_ ." . APPLICANT TEG� FINAL � O NER-BUIIDER DECIARATIQN � PRiNi Na� DATE _ I heraby affirm thm�am exempt from tha Contractor's licensa - � - - - - � ' '�h f�S- Law for the followin reasan Section 7031.5, Business ond /+�OUESS FINAL - � - � e ( . . .'675r Profeeslons Coda): - � � �� - � - - pg N sy . . 0'j j(�_R'] , O � 8�����NG : 1, as owner of Iha property, or my employeas wllh qDDRE55 wages as rheir sole tompensation,will do the wark and � � � �- tha str�ctura is not In�ended or offered for sole(Section ��1LITY 704a,Bosiness and Professfons Code). � -- �-�- MOVMG ret.. � I,as owner of 1he properly,om eKclusively contracfing CONTRaCTOR NO. � � with licensed conlroctors Io consrrucl the projetl(Seo-� � - � -- � - - � - - . . ' . . � L� lion 7044,Business and P�ofessions Coda). ADDRESS , REOUIRED 70TAlSETBAIXFR I o7� '�k � CONSTRUCiION tENDiNG AGENCY ' � SET BnCK-- YAaD Hm/'r PROP.un7E WiDiii - ��� � O ' here6y afiirm that there is o tonstr�tfion lending agency far FRONi . ie pertormance oI�he work for whith this parmit is issued. _ P.l. ( iac.3097,Civ.C.)• SIDE /�• P.L. +nder's Name �' � � � � IDMA Ref.A +nder's Addrese � � � P.C.Fee S� Permlr fae :er�ify that I have read this opplicotion and stofe thof the Issuonce Fee �S .IDMA P/C M . � � :� �ave information fs cortect.I agrea to tomply with all Counry imeerigaiion Fee ) � � : dinonees and Stale�aws relating fo building conslruction, Totol Fee (p' LDM4 Perm.N � id hereby authorize repreeenrmlvm of this Couny Po mler � - -- . ' the ebove•mantioned properly far inspettian purposes. . �.—�f �(_ �_y / SEE REYERSE FOR EXPUNATORY LANGUAGE ' • s • Signafure of Applicom or Agent . pa�e �� . _ .. . . . . . . - Z � . _ � o c i __ - � � � , , .-�o "��l � ° °'_ ,° ,' �' U` ip� p � .o s. ,n ' '�^ . � �o 0 o m � t0.o o`� ^ .i c� c� 7''. � ' o ^ � n �J� .p ..SC .p n � � ��I .V p , , �� _ •? O n O 0 0" ...^» � Q� F. ,o � � �- m . � n� � - c < . � ,e� p O [J C �.^. C 7 7� p ,� ..��.,•� 'r' : r N•. �� � �.. �O Tn= � 7 " � 6 P �= a � g^'� °m ' � ' ; ! ' y ;; o o � � � 1 3 '` ; _ ; � z j � O 4° C O� - V� '" c O [ �� � O i o� � �c % m� N � o ,o � , t. '4 0 . O � co 2 � ° o c n. '" � �'' ' • y O � C � .A` � U" • . ,< ',. �•- m 'C 'P cC j 7� � ' � 3 �1 � � r �;�, � mr ';�" : � n ; .1 6' � " ` O o � O � �" �p ° p' �' C_ ° � �,� 1:.. �o . - � ,; � - . _ t , a- ;' . . ` ,.—. . J' ' �1 � Q � O. 'D . ' " � , i . A ' %I . � . J � � q` � +'�, ��•� � � . � ..c t%. 1 i 1 v � D W . 1 j N�� .,�j �' .. :�� '. . t -, tl-p, . . { N� ' . ,. / . . , ' , �{ '` � ;1 J . ' . . , �� �� i p � .. � . ,'( .' = i'1 0 -c 1 ` '1 ;1'1L` '1 _ , t ,' ,1 .' - . 1, . �, �' ..,' ,�,, = � � 'J' ., ; ;, _ - ;� � t, ,1- '�r- '•� � � � � � � ` ' � ,� ,� ,`� , i` .'� '. m '"' j , - -l , �1 4 } ��1 ^'�' i �+ , ,1`� 1 '� � ; 1 ' 1 , ��i . � ; ;_ O '� i i �' i y �. . , � �"� 1; . 77 , �� 'i ) � .'; ` . - � � u� � � � ,,�• �-! f ` 1�, �t l/ � � ` `'i_ -, '`l ,} `' `� :J �' `,, +, ,_1 y� , -,�1 �. ,�, t�t :: ,i j �! �4 1'� 'j :,f/ � 1 , • ' y '� � ' , � ' ��. � �.' '' -� �'. , 1 .. t ' ` , ',, ` I, .;, ,,`,; 1 _ rl �, . •rt� 1 . ./ 1 � l .'� / • '' •�' ' J*�1 1� . ,�, �1 ,� ` ' . '� �' `�� ,,'` �'. � '11 Y y ; –�',.�:' ' ' �.,1 ~�' �� `1 '{ ` ../ i 1' �, � . � + �1� ,�j. ,� � ',�. . • ,t . , +� '1 . . • ' _ . , , ' ' ��'�' ,/�� �.' `' - ', .' « '�{ � �.S,+�. ` . �l . 7 � °-�= :' �� ��Y._ } m[.._. . ,°� �` • y � .. c. -,'r "; n . � ,.'.; . �..,,�..'7:C 7.��Je �J t~�^+^'LT L..: i." ��I�. L!-' �, _.. c.•., t� `t�� � �.N`� `'�.'`� �.'c ""�•�.��''T- c -^'rt:i / ` .. } 4 ', ��l '�• ' �� F : .`+ �y �^ � �n ` �«n�.-a �...+L 3�'• �„'��i,.�.I. j 'i ,� �" �y "' i ,� _ a ��o _ ^.x;� �. .w•<...� .... , . _ � ,L� ` C;'y �.Y' `n�C ��{y �," y }a � � -.,y � � r. � :: � ... r A - = z � _ � � c � �.- 3 r 1 0 .•�. x M x� f � —�• "' ,_ = r.-S o - ^� = c `^ =-.�r � �r ❑. .�r .. �- :7•` "'7.:..^. ^„ _ ��N.�c � ..�.M �..^�� n .� •• � l, � , c ', `� �l 1'^ � �N" ,� y 3 � `�^ _�� « � ��^,s- � � ^ _ � � � j � ` p� '� _:k � o : ="� 5-� ^ :'°� .�;g °^ � ' � - ^ -, ±-:`�'„ ❑ � `'�"' '� � •; . \, �1 ��`t M "�`c.�N f�' :•~r . �',,.? '^ o' -:•�,', .. � f K'�y _ r,°3 .-. � �• � � a � N G c�".c�x a i " } : .� 3 m `' 3.�'^...L c _ y� - °! " .. � w . �' ,'�C. Y r r, ,' �� _ ' .. •. 3 ' ; =,s c..p.�.. = 'k'^,•�0'3 ^ � �o���v � c.`= _ � _ . ^ � 3.�. �o _ ^.� � = c-� a a' �l�o.� o K m . �_� `fl v_ �.' 1 .. .� - ` � C' r^�^",� �i p f� �. =.� -� `Lp a'7 i'.�.�' `� `r�-.7 f '- . �j ' ' , • _ � 1� 1 �:. G,,�,�..'�a�+� � � L" t- j O.p �^ L ' �^'t� ~ /^7 `'�,�.O 'x O n r' " '3.�.t � ^' � C'.� D _ . Z . . ^ .. •.+ -..- .O. .._L r,'f ► �< .a � . � . N1•, ��x.` -.�r ^� .L'y�� ^ C�' �=r�, :�.o �?�'��' � a' 4_a � � 3 y� ` _ n � ,' ' � '�.'W ^9 K � Y ! . � � ' ^ � ^ _^, : � i � i� �� •n � z _ �` Y r;c- 3 .c.t. �,'^ �c _•% . _ u,� C �:, ' � ' '� ,. ., _ � 1 1�L (;� p� _ �:w.= :',i�, - �O ��� t_�. _ ^�....��..N � i,•.�, X� n ["t`. w ' u� � � � �:'K ;-" � ` =.� "z-...c� - 3 ��1 � :� - r' -'..° n ' � O � ' ,;�--F."�� _. �-'' � �^_' :'� � c�o �°;�.= _ ` � :� o�. 1 '_ ,�� �� .� _ . . - � "�� �s c " `-•� � .i v+�4 .t •n^�w ^ - p - c j � . • .. . 1'�n O`� � '7' ��"`r l% � � �– r='i.'C.1.O m � .��i. �- �+^ .� f�' �, • , N. .�i`t� _p �M c� C','D •"'i 1 w.. Y .0 � =�_�F N � 'J� .�.N' � �. y _ � - � 5 � ' W;. �C. N'v - O .� �' » ~c "-.�. �K`�,.i-O C: � ';p • . 1�� � ; �l.' . � �� ..:.^h�,�', j, �� _ ? �`'_�� i�.ty 7 ~ � � ` �. ,. �� �� - " � �,a �^_� '�� ; � � , .. _ _ .�.:p'1`._-',. ^C �.�s:S'r'+:�', r ' ',1 _ �� : , . '' �(', �, -- "`� . :�� �