Loading...
HomeMy WebLinkAbout0887A 2407A (4) • �: WQRKERS'COMPENSATION DECIARATION � � ��-- � � �� � - - � � � � � � � � � � � �Fe�hby afFirm tho�I have-a ceniiimre of�o�se�„o,e�� - � - - --APPLICATION FOR BUILDING PERMIT � `"��inswe;or o certificate of Workeri Compensation Insorance, � or a cerlified copy iherebf(Set.3800,Lab.C.) � � �� � � � � ' COUNTY OF LOS ANGELES BUILDING AND SAFETY PalicyNo. Company � Cernfied copy�s hereby 1�rnished. FOR APPIICANT TO FILL IN BU�L�ING / 33 � AODRESS (O � .Certified copy is iiled wi�h the covnty bvilding inspec• � � BU4�iNG 2 q 6 �, lion depa��menL ,. AD�RE55 J ,/� � I / Dote -Applimnt . .. . . CiTVD�A/710.✓c( Lv N� lOG4uTv CERTIFlCATE OF EXEMPTION fROM WORKERS . Q} NO.OP BLDGS. _ . NEs.REST �, ��S COM7ENSATION INSURANCE . SIZE OF LOT I NOW ON LOT CRO55 ST (This scction need nof be cOmplefed il Ihe permit is for one A )�7 ASSFSSOR � hundred dollors(E100)or less.� TRAQ � J BLOCK lOT NO. / / MAP BOp( - PAGE PARCEI . . . TEI.'�f USE-ZQ NE � MAP I certify that in the performonte of the wmk for whith this - OWNER � _ �� NO. $G - �,"/ / pp. � -3 a permit is issued,I sholl noi employ ony person in ony monner ADDRESS CG T �� ONDITIONS - � C.) so as ro become subjeU to�he Workers'Compensation ws. -� � CITY / iy! � ZIP / (�,s� .. O xUate AppliCaM �-�� ARCMITEQOR TEI. NOTICE O PLICANT: If, ofrer making this Certificare of ��y DiSTaICT GROUP NPE FIRE PROCESSED Br � ENGiNEER D . Y NO. Exemplion, you should becvme sub�ect to ihe Workers' .. . _ .- . -_ . _ . 9�7� / roy�/�� ZONF W Compensation provisions oF the Lobor Code,you musf fonh- qpDRESS [ r 9 � �3 J�� N wlfh comply with svch pravisions or this permit shall be deemed revoked. ' � � --TE�� -- ' STATISTICAI CLASSIFl T�ON APT. C DO. Z CONTRACTOR �J` NO. � — � LICENSED CONTRACTORS DECLARATION ���. �'ClASS NO.--- �WFIL UNITS-- -�� - -�- -- I hereby oHirm thot 1 am licensed under p�ovisions oi Chopter 9 ' A�oRE .Q '- NO. � � ��- � (commencing with Section 70UD]of Division 3 of the 8�siness and � ���, '��R�'P Professions Code,and my license is in(oll force ond efiecL �-� CiiY � cuss � `�� _� . VAtIDAT10N . � ' . ' SQ.FT. NO.OP NO.OF CHECK . ticense Number Lic.Class .. 512E .�0� STORIES . � - FAMILIES ONE VALUATION �.7 OEKRIPT�ON OF WORK B I � N� ❑ p2� /OO Conlracfor Date --�`- A� S � �I om exempr under Sec. � � � - _ O^� � a�hR � , • � s �08&7A B,BP.C.(or thie reason REPAiR . . - . � - ' USE Of oare: exisnn�c aioc.S� /t ��},,..0 QaS I.,.u.. oEnna #• • • •2 3 AP%IGiM N� �/ // TEL.7/ Signalure � PRINT/�Ll�/l.A� /}IGe�J No. G _ - F�NAL� ^�2 . I •2 2 8 b 5 OWNER-BUIIDER DECIARATION 7 DATE.� G � I hereby affirrrl Ihat I om ezempt from the Commctor's License - - aDDRE5SC+3J In0[�-.�T 5� ���+�5'''�� ��x3 fINAL • �2 C�''6 5� low for 1he following reason(Sedion 7031.5,Business and - � � PfOIBSSiOns CodOJ: , _ ,.. .. . ,.... PRE ENT . _ _ ` ' - . - - 6Y 0�� 5-8 8 � I,os owner of the property, or my empioyees wilh AD�DRE55� < Sr /.if�tl�A Ar . . wagesasfheirsolecampensafion,willdatheworkand - L�`-ry . - r�� ��.�- �he slruc�ore is not intended or offered for sale(Section � � - � ._ . . - 70aa,Bosiness ond Professions Code�. _. . _ _. MOVwG _. _, _. ._ . . _ TEL. �---�� ' -��• �� � I,as owner of ihe properfy,am exClvsively tontracfing CONTRACTOR No. � 2 4 0,7 Fl with licensed controctorz to consrruct fha project(Seo- . _ . .._. _ . . . ._ .- . . . . z lion 7044,8usiness and Professions Code). ADDRESS . If CONSTRUCTION LENDING AGENCY _ .. .. s[�aACK YARD HWY ��Tp'p�p�INE R WIDT11 � "' �, � n• L � • s } I here6y affi�m ihm�hera is a tonsnuction�ending agency for FRONT � - • � � •2 7 9.5 0 ihe performanm of ihe work for which this permit is iesued P.L. " _ � . . - . � . (Sec.3097,Civ.C.). � SiDE • •2 7�,J�� . o.t. Lender's Name - - - '- � � . �7 p p � LDMA Ret.4 . �Q� �J-$8 l6nder's Address - . - . P.C.Fee E �`�d'4 Permit Fea . . , . 1 certify thm I hava reed rhis applimtion ond srma tho�ihe hsuance Fea 7��`-rv tDMA v/C# � above informafion is correct.I agrea to comply with all Coonry �"-- invessgoi�o�Fee Q � ordinontes and State laws reloting to b�ilding constr�ction, To�ol Fee � /.�� LDMA Perm.N and hereby authorize representatives of this County to enter - upon fhe above-menfion d roperly for inspection purposes. /�'� � ... _.. . _ - . . .. ._ . . ...__ __._ ... . �.L-/�y/��/� �� SEE REVERSE FOR El[►LANATOMY tANGUAGE � ' �S�graN.e of Applimnl or Agen� te . , , .-._ t� o . ,. - -- o .. . — . _-,_ - _ `. _�:-i: --C+' ` � �' �� � 1 '� �� � � �� � � � �` �� v' ¢ro o a. O � � ; '� � F � °`o J� � � a � � ' ,� ! `i ; . � �i.- ,. � ^ n. r N p �� . � G '_ _ '^� �' 1:� p ¢ l,'�.< �'� i1 ' 1 p ',.,. '.. '� p C ^_P " 7 �i . p CG r- G � O � 7 D . C' `� 4 � �: -. "?. � ; .'n - . � a � a v � °'° ' o o ' " �l ' ', v !'t 2 0 ... 3 n f� � p � r j j o a : ' �p � , s�� '� � j^ ' 'D n� 1 � ' ', , � m p � � J p '� O W O. J'p�. �."�i� . '� ''t 1.' � , Z � r.�D m. r9-c 7 � .0 p . 7 ! p 1 � � f, • ^ �/' � a c �c °p � ° '" � z � _ - J'1 � ' � 2 . � p a o. o p� o � a• % � � , ,, .�� �� � � �m � ` 3 . , ,� �v . � A- � a; a 'i a p i � { � c n � � i �Q � D `J o Q ' � o- � ```; ,� �t, ° • �` " , , � • o o'' „ � ' �1 �'b r .�. � � A' ; . � ��� ''� � . 1� • � 'j � � n � 'f ..� . - . , �O O _ . � o D� .` M � .. . . , a a N 1 . . . � � - � . � � � O , � r ~ t ..� f . � '� � , i ��i . . y , � / � ' � ' y '� � j• / .. , . ��. �i. '�� �' �t'� _- � `,.1� �. . Z �' .. I "�� � ��� �.t1r: •. •, / ` �l '' 1. `• • . ..i . n ��' ,t �'. .� � �'` �/ '' ' I,r , Qi/, 1 �' `. '! + ,t' 1 : , �f ��� , 1��� /- • f�i� �I - �, v : � : .. . - � ' i`� _ 1 r {� 'i• � i '� V' � �� . � / N '` � . � �� .�, �� !- �i� ,� ! ' , '1� �, i l Ir - Y _ , - .. . 1 . '/ .' , L , �. ,` ,� r __ _- ' �1� 1�, i li� 1l(� y , 't -�� .. � �, 'j/ ��. '.w .. 1 . i �'/ ' `/ //' _ , � � , . . ' �� �• l• �` �'/ '' . , - t � , - ^ , . ' ' 5 � � � , y ' .. = ,�.� t f;=•c F��� �' � a . , �! � CS4 =•i �i s..s - ��? �.� � �-. _ ,,� �e�•: k � o � f'".c c� �-"�� :s w;�� u r,.�, �r, - . , � � `y� , .a-K'° ^ "' � _ ^ ''� .�i :^C"�.y C� :' ^ c ` y p e i . " � C`.? �';'�,'n �]`�c'�-� � �'� r'-N� o :' o -.� j.:�.���� ^"� =7- • o o a°.'N N... f � x°..: n � ; ; 7° 3 a s •`-=•x 's ;,= a _ 'U � � �n o ,� ' _ � G S" `=�:,�� y ..,,��. -,c.�.A f =.�'3 �C r �-�_� _ � 5 r ' 'i ' � ., � ...l, w,R � A� �"� n'1'� 'tiV' � o ? a.p 3•�'L �-� '; " =" �, -� ' 3 M �..�,�N N f `=,'�._�� y ��'�...��.�u o �� ►", � -�� - �.= N a a -� � 7 � 3 . J /i w �. ��'1^', ^ /� . �,r�. . - . . � .^ti,^ ~.c. M � p''o ?��n a�__ ., �'•. �c, O :S �'3 �^w�^���.= 6� x . t � s � M = c.o °. � x �,bz�,FN � � c� }..�_.. ^�:.� ,. �' � " .:. �� i ' , ' - - . : - .t7 � � `+, �: b? S '��.^�t « _ 0.3 n Q-� O'�.5,ws,��-�y � � .- :'L �.`� � �. ' _ C �. " L O N � .io"i � " 0 N F .. C.= � -� '� ,�� � � �, ;. - - Z � p c y'tr•.=,r�-o n -�.x �c �.� '.. C�, y ^�,�`�=" _ ,r_ c _ 0. n .s'O r_ � -i;:M '1. .- +�'• ' �. 1 " y. ,R C. � G t..���n � � ' ,�,,.� ,�"_ X" F ,^ip "�G x . . , `6 - � . � x '� �',+,.M 9 3.'.A.� 'A.� w.: 7 � N',�,� �• ' � �" G : ✓ . . � _ /e� N N. � fe � �'F'R C 'C C „ ..;.E1 '�..C.:j.�.. 3 3 L'+ r r ' . ' f� 'm ' ._x. - ?, o -� -�'m o 1 v.=.m m '� -�-'°-v;� � a _ �'.�^> _ - _5�'- f -� " �a o '{ :.o'� ' ^. '� (^a = �,c.,p�'� a.� � �.�n „ _ � m •O . ,�{ . A . , ;.� � C ��N p ,�-n:i�..c`z,= � O n_'t`Tr'7�n 3 �. 4 ���, � `.= t� /• ' v� .. ,...� G... � �' G„_ ti`.V'b~ ^ O :D �.�^� S G.a � C.��-' ^ i�'O _ a : cm "m '�_ c �� b=-3 �c � �r-�c.:,« ^ � � '1'� � ' F ' � ' n Q � y ..y r n �,��� _.C.S� f: O 9� �'�L .. �,C �~..'� � O P �,, - ` N ,t� '� a°`o o�. ���-'_~`'";:.�. i"::_i•n� o"`"= - =' - �Y '"�q - - . _ . `? .� � C? �,,.fl � -��� �..«,j _� ° ,9 -�F - ^.�^��= � —� i�'v� � , a .4� t� �b y O-[ �'r Q �.. = F %� O 6 f `' _.�.� ^ ` ' � - 1 � ��O � A 2 .. �N,� ^�' � y 3.n�+.".„ A 7 -:'� . � _ � � - ,o ,- ` � F ° n °J�.= :,'S'e. ..�+ ^`� P a� • - ' �,� _ _ ?. �1_' L�.p . _ . N / . . " 1 I �/ :' .- ♦ � �