HomeMy WebLinkAbout1112A (5) �� � WORKERS'COMPENSATION DECLARATION �
' APPLICATtON FO� UILDING PERMIT
� 1 hereby affirm that I have a certi4icate of consent to self -
insure,or a cer?ifimfe af Workers'Compenstion Insurance,or
I a certified copy�hereof(sec 3800,�ab.C.) COUNTY Of LOS ANGELES BUILDING AND SAFETY
(0 PolicyNo. Company BUILDMG F�� �
� Certif�ed copy is he�eby furnished. FOR APPLICANT TO FILL IN no�aess ��1• � /�' � � ��'r ,.�..' <-�
� CerLfied copy is f led wrth the county build�ng inspec- BUILDWG % y�� f d - �
I �iqJi department .,, � ADDRESS 3 I���r i '�r� �'-�� �Y� �'•�: LOCALITY ��.�•5�i"j�'t" � � .
I . (+ .,��, "��_'�'�- ,�.,_:,_ : r . .. NEAREST � :G-'°"
i Doie / j+� °'1`.�,-Applicam� ,{!�'«�� +w 1 ;� � d'td%v i ziP � 1 l .`�S� cRoss sT (:?�l ri`i;§ � l.�'�-� 'T�o.:�a.,i 3 .
- . C RTIFICATE OF EXEMPTION FROM WORKE� ' . SizE oF�oi?;}C�� � f„�SS No.OF 6toG5. / ASSESSOR
� - COMPENSATION INSURANCE � NOW ON LOT t MAP BOOK PAGE PARCEL
� '�_(This section need not be wmpleted it the permit is for one _� �.. USE ZONE MAP / J -^7
'�hundfed dollafs'($100)Or Ie35.) TRACi� BLOCK LOT NO. NO. �f /�T ;}� . .�,
} } 1 �j TEl SPECIA� g,
�'I certify that in Ihe performance of the work for which ihis �wNER �j1.Y�}, 1�.�' y'°"� �-�'� � CONDiiIONs
-pe mit is issued,I shall nat employ y person in any manner j A j �ISTRiQ GROUP TYPE FIRE PROCESSED BY �
ADDRE55 {.i-�L� ��'�5��y�LF"� §"��"` 4.�I' CONST. ZONE �
�so.as to hecome subject to the Workers Compensa{ion ws. 1_ �'j f/.1 .��y �y.y�- �.-.-7- r����' '�_ �
C. tf) . . , l �j --.r�` (.. J �Y..- ..i-Hi. E\
r, T ! ( �. %- ' t CITY i.. �9 o1,e'4-'� 7I ���-3� W
'Date! �7 .Appliw�t� �`s'i� � STATISTICAL UASSIFI�ATION APT. CON00. � y,1
�-NOiI E T APPLICANT: if, after making !Fis L.rtificote of AkCHiTEQ OR �EL. � �
tNGINEER NO. CLA55 NO.�`-'� DWELL UNITS_ �
:£zemption, you should become subjecl io-4he Workers' hfD
'Compensation provisions of the La6ar Code,you must for�h- ADDRF55 S6WER MAP �
�with mmply with such provisions ar this permit sholl be �-
-deemed revoked � . . � � y M ••T�t"'� y�) VA4IDATION
CONTRACTOR ;,s �,��J��Y Y�� e2e'O /i��1 �� �K. PG,
UCENSED CONTRACTORS DEC:LAtiRTl97�„� i-7 � LIC '7 r �] ,/
�I he!eby a}tirm thot I om licensed unde provisions of Ch�rpter 9 _ ADDRE55�c�t���a'v k'*�i'"<�# � -��NO� /}✓�✓-�'^' VA�UATION
(commenu with Sedlon J000)of Div'son 3 of the Busmess arle� .� "� LIC. . "f �
Professi s Code,and my license is in fu�l force and effect. CITY�,,r f;�°��'��� �Y1S'4 {-""q CLASS $ ���
� f .-"' %� . � Sq FTt NO.(7F � NO.Of � CHECK �
licen�e Number��`^���, ���-lic.Class �- SIZE ^� �� STORIFS tAM)ILIES ONE
9 ).,. j) .�s� � . �..-s"_„�i-d NeW � $
Conir<actor�'�����rl-t 'j7 q��'�+'T�igefte � �j�` c�� � DESCRIPTIONOF WORK � d 1, y -3 � .
� �I'am e emp�from Ih,f cens ng requiremenls as I am a ��i�'1 �` �t�C% �\ Yd� . /���� ���
Ilcerts d or<hiteU or a rey�siered professional engin� . t �—)�- ALTER � FINAL
act' g �n�.mY Professonal capociY (Secfion 3f71, ! ��' �f.:��'� � j �"-���� REPAIR � DATE �{..�^`�� .
Business and Professions Codel. ✓�^ U5E OF � �
}-•'i,�� DEMOL FINA!
."'�'- EXISTING BLDG '�'�L'.r �❑� By .
I.ic.or Reg.No. Date . APPL�.CANT -' TEL ("� ��,�: � .
OWNER-BUILDER DEQARATION (PRWi) �i�� � �£' �� NO� ��J'j} I, (��
I hereby affirm ihat I am�exempi from fhe Controctor's License `. ADDRESS:at�'' ������2'�-{`���it `�'¢'}�7'� 4� �`✓� �� ;
Law for ihe following rcason(Secfio��7031.5, Business qnd
Professions Code): paeSeNT '� -
❑ �BUILDING i � _�.�� 7 � !�
I, as ownei-of fhe property, or my employees wiih ADURE55
woges as iheir sole compensution,wJl do fhe work ond - „ � � {+ �
the structure is not intended or offered for sale(Section �OCai.I�Y . .r}n m i� a��
7044,Business and Professlnns Code). � MOVING 1E�� � � - �
� I,as owner of ihe pwperty,am exdusively contracii�ny CONiRACTUR NO. a -� ���a�.r'n. ��
wifh licensod confracfors to consiru[t the project(Sec- ADDRESS � - �:�'�i=��n'�
_ tion 7044,Ausiaess and Professions Code). , � �
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY sEi RACK �ARD HwY pg�p.�iNE WIDiH ' $fl,� �`��
I hereby affirm thai there is�a consirudion lending agency for - FRONT . � �
the erformance of the wo( tor which fhis ermit is issued p.�. �
(SecP 3097,Civ.C.). I� p SIUE
1 � ?,L
Lendei s Name .�.�
_ " 9 e� /
�P_C.Fee$ Permif Fee .?(�r5�' �k
Lender's Address t$ � �^[�� �
I cenify ihat I have read ihis'applicqtion�nd state ihat tne . � Issua ce Fee '?�7� �
�` above information is correc!.I agree to comply with all Caunty .in�oes�igoiion Fee n � t -�
� ordinances ond State laws relofing to building canstruction, ic�al Fee �.:1d 7 d-�^' -
m and hereby auShorize representatives of this County to entor _ . ._
Wupon ihe 4bove-meniionqt�p o ty fo/r:�nspection purposes.
r J���4.., .k, f�,L.��.�, .
�¢ �,,� ,� � , ' SEE REVERSE FOR EXPLANASORY LANGUAGE . -
'� S�gnat�ra of ApplYconr c�C+genr Daio �s
�f'
���s
o �
� �
.�-� � „ � Q
� �} �p � O (D �
^,rn p 9 � 5
,�""' -o o � n� m W o a -�o a m � �
.---� n ' 1 �� <q `;�• `° 4 � '.: ',p �
�'--.•"' F � 1 �¢ Q 4 Q `n 6 � .
-n iro t 9 ¢, �� � a 1 �'
� - N O @ n � 3 N Q -c9 3 � � � a �
r � � ¢ � � �Q� � �� Q � a� � �
-ei C�� n s m � t �'� ' '� � �n_ ��i m,
�j � G � � R°' ' � "�,�] Cu �
� a � ,r 1 3 O � -L � > 0 q�'.
O ' �" � x Q.�� ` -p t N i . �
� 4°G � � g . N t O- +G � �
� o g a � O � 3 � � � � P�
? �o� � t � � � �c, c'J �ca �
; �
o.� �` ` 1� � �. >a
� � � �
�
r ���� � �
� � c� � �
� �� �
� � �p e
,� � � �
� � . . � � � � � �
� ^ � �°�
�i
¢R
� ,
¢
�
d
�
-�tl
e+a
�¢
� A
u'�
�
� �
� - �
'
'
� �q _r,...
' � �.,s'-°a ,a y � m
�' =e � _` � �
'� .� �o .we �.r`� p`U y y@ D
�,GSSQ �'r � ��o �� P �' ., 6O
� _.�os.� �' � � �❑p,b. c�o Q� "` � Q on �
�'na �
5` w a o o � � ~ N �z`r,� �t o�; z� �o sa.� '�'�
.�y' c-r`o.�e [`� �°� � '° u0'� c '^ c a ~ `-.'� "' P r,� � � y � o ° � �
C^]-t � c�✓ p A � 5'v ,��, P Q `� �„'� v� o`� r."�w
O 4 �j � ce a-� �' -`cr O n`q r a°v qP'P,�.�.� �^��.`� +�� A.�,n c' p v, 5 O C'i
� ur ' .R e� m tSl S- p'-+.e Q .ce,„�s. (`n -2 Q v�N �'c7 � � �
tD � �� ° t�H "4 m`� � w 9 s� �} o m o p � m �.� � ,�,�c,c��c o � n �
� o � �� c"o a o o"�' � m � �+q�'°"�� m o'�� 9� � " 'cr kr� " °3 t�t
m rs� ou �0 � Qc�o�':o m�Z w.� o g' p�`i�oQ��` �� °t�..�`cX�
N � n» °" `�°..�.� � ^t �a y � 3 co � c:a e,`-..'d, �. � 3 +� 'U�y
� LQ m ., N � a.o ° �,... aa �.-ac. � aa m�-a �„� � ma.� O "' o ��,'n�C�
� � o � K ? r.s-o " o�-�.�a 7 0 �`��-s co o • �, �''
c � � m'�O Q �' �"co ��m �..° A,o a N �-.�'��'�'���`�����-�e� p�tl '�'
_ . 3 tr A -t.�y''"'+(w'D. m p P+w 9 � � � O � � w¢'`�y m . `t�
Q,. � � m�er � o o �.�'`Y � _ ,i,�O ��� � o � ° g Q a �`� ?3 7+
x', m � o °�'� _No �;,� o �'-,cro � �c� o a,�•-..p �� .w �� ° sO
� � u'� �a c �. 0 � � f; m -�t c �`�"� Q-£. �5�,,4 m R.`^ � "v�"Rii m o n V,,`°
- "� � �A.� n� o o-�•��,`"�a.e'�i o � a o cs °a o�m �ia.�.w �Sx,H`-° � n ;�
� � � °� a..`•' 3 �.�"�`°t*.."�ace =c Q 3 ¢� � c•.�yaa°.:U °A"•i �y Q
v� � s'� !; c w �...'°� `" `° e+o '' ^ �'6 ,�„ ��P o � :��' m � � o ^
� `c� �°e q � � �•�o�'s.�m o o�cu �°�o o�, �o� ��,�.�u�
•,,. �` �' �'^ F N Q r, �-^ " � �w
� w � w g p o 0 o d �-'e a�—� s m �" _ �•a��, A� n
� O 4 ,..�L
'°,� Sr�a �».�� n o � � �:° �».�.:N �aa,.S� _ --"
} •� " o ,z n.ir` �s,��,a � �'`° J `�.�--�."--=
O O }' � -bt R ^ ^s Q° .. `..�-^.'
s^ 7 y.. J_�.-�-�-
`.t.o
? � �!r„
N
. .r^"-���
.i�..d�"'�_�"
�..-�..�'�..�
—�..�
l'
J�� �`
__—�.
��