Loading...
HomeMy WebLinkAbout1096A 1097A (5) WORKERS'COMPENSATION DEQARATION � �hereby offirm�hot I hove o terfifitale oE�o�;e��,o se�f � � ��.�APPLICATION� FOR BUILDI NG �PERMIT � ins�re,or a certiiitota of Workers'Compensation Insurance, or a certiiied mpy the�eof(Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUIIDING AND$AFETY Policy No. Company ' � Certi(ied copy is hereby fumished. FOR APPLICANT TO FILL IN BURDiNG r ADDRESS �3 d V �• n`/ � Gen�f�ed copy Is filed with the munry buildtng inspeo- gui�oiN� /� �� � /J tion deparlmenf, ADDRE55 Dale�'J'�Applican � CiTY /1l�r/4� Ziv �OCntITY CERTIFICATE OF EXEM ION F` WORKE ' NO.OF B�DGS. . NE4REST COMPENSATION IN ANCE 512E OF lOT NOW ON tOT CRO55 ST. - ' --- -� - (This Setlion need nat ba comple d if Iha permil is fo�one TQACT- '3 BLOCK LOT NO.� ar-l� ASSE550R hundred dollors(E100�or less.) MAP BOdC�' � PAGE PARCEL TEL. f USE ZONE AMP I cer�ify fha�in the performance of the work for whfch this OWNER U/3 ,r� NO �_' �. '�—3a, permit is is:ued,I shall aot employ ony person in ony manner ' �� SVECiAt �' -- so as to become subject to the Workers'Compensation laws. - ADDaE55� _c CONDITIONS. 0 Date � Appiimnl CITV �r ZIP (�/A� �4s � � ARCHITECT OR TEL. NOTICE TO APPIICANT: If, offer making�this Certificafe of DISTRICT GROUP ttPE FIRE RtOCESSEDBY O ENGINEER NO. Exemptfon, you should 6ecoma subjecl 10 Ihe Workers' � ' �7� CONST.!' l� 20NE /, r F— Compensation provisianf af the tobor Code,you must(orth- � K.3 —1� 3 �Vl/I a wi�h com I wilh such rovisions or Ihis ADDRE55 py p permit shall be TEL. STATISTICALCLASSIFICATION � APT. CONDp. deemed revoked. �oritenaoR /�d G -v No. � _ � � q/ Z IICENSED CONTRACTORS DECLARATION .� . ,�,�j i��, QASS NO.�DWELL.UNITS � I hereby oHirm Ihol I om licensed under provisions of Chop�er 9 ADDRE55 y.�q. �.Y. NO. //�3- (commenctng with Setlion 7000)of Divizion 3 af tha Business and � ` ��� ��R�P Prafessions Code,ond my license Is in full force and eHect. � � -� CITY �l�//y2 �Y� /�/��7r �IASS /�- . . � V/LLIDATION Sp.FT. NO.OF NO.OF CMECK BK. PG. Li[ense NVmber Y��3�� LI[.Clcss h- � SIZE � STORIES - - FAMtlIES� �"�- - ONE , . � r Q VALUATION ConlroUo�v.T/�Dote'�';"d� � DESGRIPTIONOFWORK N L � NEW . s � �.-�—� .. . ADD ❑1 om exempt under Set. d f �- /G ' , - - L �v . AUER � B.BP.C.(or lhis reoson � . . ,-/j'I/O G.d a' REPAIR,❑ s � . oate: . - useoF �'�� .°1 G 9.6 A EXISTING BIDG. � a ❑ �� � e �7� - $(9n01urG . . - . . . . . .. APPLVKAM � U/� /fLl/GDG NO. �.•771f FINAL l I2P 6� � I-• •�2�I.G i] OWNER-BUIIDER DECIARAtION ' DATE � �here6y aiiirm that I am exempt from the Contmc�ar i Limnse � "� -- �}"f � '� • ° •!7,E'J= Law for the followin9 reason�Secfian 7031.5,Business and aDDRE55 N� �d ♦ /YZ � �Ad�: FlNAL ' - PfOfes5i0n5 CoCIe�: ' � '- ' - - - - - - PRE ENT � By �i� ��Q'��,�7{ ❑ BUIIDING I�• •�1�.A V� ' I, as owner of tha pioperty, or my employees with nDDRE55 � � wages as their soie cempensation,will do the wcrk and � - � �� - �' the structure is not intended or oifered for sole(SeUion ��`��TY � � f<<_���.` • • •t!,�i.Q 0�� 704a,Business ond Professions Gode). � � MoviNG - - � - � � TEt. - �� ''b` 0 23�3_a 7 'J.� � I,oi OwnGr of Ihe properfy,am exclusively confraCfing CONTRACTOR NO. _ wilh licensed tonfroctors to constrocf Iha projecf(Sec• � � ADDRE55 � � - � - � rlon 7044,Business ond Professions Code�. CONSTRUCTION LENDING AGENCY sE�BACK �ARD �+wv TOTP'pROP uNEFR WiDTri � I hereby affirm Ihaf Ihere is a const�uttion lending agency for FRONT ihe performance oi ihe work for which Ihis permil is issued P.l. _ . (Se[.3097,Civ.C.). SIDE � . � P.l. lender's Name � �� - � - r.e.F��s a � �3. P�,m,�F�s 3�.S� io�nn aer.x Lender's Address � � I certi(y thal I have read Ihis application and state thot the lesuance Fee �r SC� LDM4 P/C N obove information is torreN.I agree fo tomply with all County Invesrigo�ion Fee o�dinances ond Srate lawe relming lo boilding canstruction, _ Toml Fee •� v ' ond hereby nuthorixe rep.esenfotives of this County to en�er 3 LDI�M Perm.N upon�h bova• r�t�ed property for inspettion purposes. ' �f/ / '� � SEE REVERSE fOR E%PLANATOIIY IANGUAGE . � SI iuro ol Applim or n� - pole . .-.. . . .. . - . . . . . _ - � . Z "" 0 0 � , �.. = r_ � ..n :' A , � ��• � � n , � N 'f'� n �, m o ' :. :v 's o ° �� �� ��.���.� :v � `�' �. 9 i Q � ,. r f l7 n G .. � -� '� � "O � � t(�O D .- � G � r m O O � �Q � 0 7 N'. Q � O_.' l� .�h 5 � ' p ' �p m�, Q O O p �? � 5 V �� .9 � ��'i.� �0 t / . j '^ � . � ^O �` 1 � O � O Wy � � _ y'p' �^ � � ' . � �� m � , j �,. � „ ] O v� x � � P'� ° °p � a � � -'- i Z p 0 0� o . o - � •i _ , o � ? N .�.'. 7 j .0 A ' ' m �q .�..1 O �D . ,. ,. n G . O � Z ��;� O . _ .�, . .O G. ' � 4 � - ,�- rl . 1� I ,• • � � ' �`.� ,y � .. �`I � i� ,p{ - . . _ _ _ '��o O. .. 1 . . p �' � '� ' ' O:S,. . � . ' a�. . G.a'. . � y��, . , .' • , i �p � . � ' � ' , . . � � ' C ' . , � p �.. . ' 1 .! 'r ; � ; �. �, t. �' ' �- � ,�. � � (�, 1 • . ' . _ ' t i,' j , ` ;�' ��' . _ 1 �11r � �� , % -: • . � � �� rl 1�i , '� �'.� `+` ''�. . . 1 '� . ... � . �� `� �� �1 !'' '' ' • i � ' �, ./� .. - n _ `'�,.� �, �' ;1 '', t `.,, f`;� 1 ��•�.. A � � l ' ,1 ��'� ''• •� �i �'/. . ; + , � i,` , , , , r�� '; ' tt ' . 'i f. .',, '�, ,' , O � � . ` + ` !� 1 'i,, '�, ,. �1 . '� �; � 1 � . •, . ', � . '. ., . , ; �. � �., , � . �' . '� �' ' ,' � ` . `�./ . �; _ - . - ': �: ' � ' 1 j �,�. , i : - � ; . ;` ' 'r '��t 1�r "1 .' ,. . 1 '� , _.,i` -"; , 1 . ,` , '� �i� � '' ' ,- . � 1 .� � ,'� 4�'� � // J✓ � ,� ; � 1� 1�� '� � . �1 ' - . � � , � , . t � j . 1 . , . � � ," - , . �' � . ' � , _ ' ' y �r ,� ,� , . ^ .. 7 t c,�C'`�=.�+i, ^� � ��j :7 �. " � ' �CS£ e' ` "t3 � +�= :. �"��� . ' � � . . i �,' - �.� ,-.'y = � � N a f"'c �^ .=.+�^".7 w L ^ -c�,ri ' { , t '_ '..�X. F. h `• ~ _ i b+C`.� ,- ...C 3"^ 3�} O !_ _ � . 1 �7�J 7 ". �; L...". .C�n -� ... .. „ - �^•,J " � � - � . �: ��i•�;�a P ��� L^ .r'. - x" ^ ., .-..v, ' _ ', � „ � „c ,.'4 � � � �. Q +p � �—; �?' N�.� �i � s.�.� _ `_' � �c C�:r Y - F �.ti-.� 3'A.� = � �,�n .. , � .. - � ;O �� L_' "`V �fic G S`•..-�.r.�n „ c^ a �r,..� o �,�7 _ � � ..::,` :..� t '7 ^ -/: -:r.- �N ` v � �^ : ....%� cf _ ^=''. _• `l � � _�T�'G /1 . - �� � . 1 �� .F r f'� �s a c ti 7��' � 3 .�+�- :� n �;� ;. � '1 1 . . .' C� y���N N-�� A�� o-,� ^� ^.7�,.�.�f 0 r 7�>�R;� � ,,. �: � �;�� � . � . _ � "�� ^ .. � 7 � ":.�3 ' _? r :.= a= ,^:K"� ;+.� .. .`•, :./ r. _ . �• �c. � N c �`� ._% � t�a _ s c � L ���F �� � :.-, _ 'o r 7- i � �.! � ' � 3� :�_ w � �o'o ' �.. -x � la fy�._�" �- _ N '^� _ „ _ ;;� � �, � ,) �� C,�� q �•"• �� � ^' �C �-� �.. C'C"' �{`j.O'.�j p -, ���' ` C'�i'= - � .' , _ � . 1 7� �G ^�{� ��'� ' n �'^ � y ��_C � �' ^'' " 1 ry � .�,� - � � � z ,'� � a�� _ :. �� M - - _ �- � _ = � ��-� � �- ' V� 1 � ��j _� O- �C.L _ n �"O K a � ��"3 = _ - 'x T i �� 1 U,i �J'1�'w _N J �_ : c"� 'c� c.� '� �" �_�� � ; �"� .i i � '� .. - :"�. t "¢,..� ' ` n`. � �.' ..: %' n 1 1 m� �.�- .. o m . � :,�:� f ° � � _ � - ? ^ = ' : -� � � � ^ , �. �''.� �=` ` =_ zn ' ��_.�..'-:°-=3 �.�»�'��' ~ `.�°�^ : ; '�'C ,� �y ���. � � p � �r �,� �'c � �.G-^~s'�^� :°-o�'�� e�-."i_�.. � :..` ��^ � o� / �' Z, ^ _ a . r x � ' ^ ��� c �'3� a� --'�i -.," = n''- , 9 's..y�;, ,; � s" _ c. � n �3 �--�� L ._� : �` o 0 . � - ., "w c 7 N • � � �,,,,,`' :k-.. ' ° y = �/'�' ^'c ' � � - - m � " '.,y �,` � _ _ » � %n e n= ...,,� _. - 'n � !_ � 1 _ . N ��V ? 1 �- i���^ �1 �� fJ � �r..~^�1� �`^'.r i•N �� •Ji� � f: � � � .Y J' f� , .-. . . , . � `. t. � � Q �f, �.M �`-.fi ry�v� "� ..V� L. � , � � . � .: v ' -�• 11 �,b�. 'a ~n� �.(7 ► � K ry O O r'. .. '� ` � _ c. � , ..��~ .n p. . 3 . _`�,:.3 t� � � .� . . ( .C�� v � % `� ^ ' y �.-��" `L� -� ' . o _ y �M n � � . .. "._ - ,, i �: - N V