Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1397A (7)
/ : _ . ! _ . .._.. _ . . .. _ _ ._.. . ._. ._ __..._..__. WORKERS'COMPENSATION DECIARATION � ' ' � : � � � � � , - - ...... . "- 'h°�°eY°";�m'h°„ h°°e°`e`';`;°°'e°`°°°Se°"°'e" APPLICATION FOR BUILDING PERMIT iniure,or a certificate of Workeri Compensotion Insurance or a cer�Hied copy�hereof(Sec.3800 labj�C.�.)�' � � � "--'.... .. . ..... .. . . . . . -.. .. . Poltcy No✓�S�y9 �Company �Q C.2 �� COUNTY OF LOS ANGELES . BUILDING AND SAFETY - ,,:-�-- - -.. � Cerified copy is hereby fumhhed: _. / ' FOR APPIICANT TO FILL IN BUILDING 3� �� S � ADDRE55 �' Ceriifiad copy le filed wBh tha caunty bullding Inspec- -�""- gUnDiNG q 3 v tlon departmenL � ADDRE55 .7 . _ ... . � �;,, ... . Date� 7.���Appllmo N� • '^v'�'�t Ctiv�•LdA+�trsw� 2iP � .. LOCALiTY ER FICATE OF EXEMFTI ROM WORKERS' � � �--- � ' �� -� ��� - NO.OF BlDGS. / - � � NEAREST. . . . _ . • ... . . � �� � � COMPENSATION INSURANCE � � . SIZE OF LOT - NOW ON lOT CROSS ST. (This section need not be complefed if fhe permif te for one �� � � TRACT �� " � - �- BtOCK _ LOT N0. ' A�M,pS�pK � PAGE PARCEL hundred dollars(�100)or�ess,) : � � . ^ / _ � TEL.��/30717 ON'NER�U�QA'n -�NO. ( USE ZONE MA I tertify that Tn the performance of the work for whlth this � (�� �� permfl is tesued,I eholl nol employ ony pelson In ony manner qooREss 33�/ SrEanl. . . . . _ . _ . . � so os to bacame subject io tha Workers'Compemotion lowa. � �- OQ [ONDITIONS 0 /}� U Date . ", � ..� APPlicanl . ,: . �.�,. . Cltt.KY � 21P ` . _ . . - . ... . . . . . a NOTICE W�APPLICANT: If, afler-mokin �thie CerFlficote ef AR�HITEROR TEL.�,_ DISTRICT GROUP TYPE , FIRE OCE55EDBY O g NGINEER �� NO. �"�'� �pNST ZONE U Exemplion,'you ehouid bemme iu6�ect ro'the Workers' ����- �-^ . Compensation provtetons of lhe lobor Code,y0U IltVsf fOtth• ADDRESS � _ ,� UN � u-� with comply with such provtsions or thle pe�mlt ehail ba -.� M p� , a� deemed revoked.� � � �- �� �� �� •. , TE�•(�p STATISTICAL ClA551FICATION . . APT. CONDO, v� CONTRAGTO A%J atl.0 NO.70 a . Z UCENSED CONTRACTORS DECLARATION�� � - - --.- � - �i� � n �CtA55 NO.�DVJELL UNITS � 1 hereby offirm Ihol I am Ilcansed onder provisions of Chopter 9 ADDRE55 S 3 GJ✓ .1�d�4�f�N0.3��Y`� � ��R�P . . . (commencing with Setlion 7000)of Division 3 of the Buslneas ond . ... . . .. ���, p �� Professlone Code,ond my�icensa fe In full forca and aHecr. dTY �• GV.55 YJ �-�BK;�-- � �-� - �� - - VAUDATION _' . " ' �p/uQ ' _. C 3 p _ S4EFT' NO.OF NO.OF CHECK � . �Ucensa Number 6 �Q L���•Class � �� STORIES� � - �� FAMILIES �- ONE - . � �- . nq �9,` p VALUATION � Centratto N-� �e � O� ._� .. DESCRIMION OF WORK... . .. ; - - - � A D ❑ S ���S.� . .. . .. �. �I am mpt vnder Sec. �. .. --- f . '�. . . ALTER � B.BP.C.(or 1h15 feason . � � REPAIR ❑ . _-.. .. . - .. . - . . . . . Dote:. .. �� - USE OF �EMOL ❑ - E%ISTING BLDG. . . __. . . APFIICANi TEL � . SignaNre - --- . �. _. . _..-. . FINAL OWNER•BUIL�ERDEQARATION PRINT No. . DATE - . . � �. I hereby affirm Ihat I am exempt from the ContraUor's Ucen:e , , Law ior the folloJ+ing reoson(Section 7031.5,8usiness and ADDRESS FINAL �- � � ��PfOfeSSi0f15 COdB�:� - ���� � � �'�� � ��� - ����� ��-'� PRE ENT 0Y 41 3 9,'7 A - QBURDING 1, as owne�of the properfy, or my employees with ADDRE55 #� • ��• • 1 woges as their sole compensotion,will da the work ond� �p�IITV , Ihe s�ructura is not in�ended or offered for sale(Section � i �(��b O 7044,Bvsiness and Professions Code). - -� -��� - MOVING � - - -- - - � TEL� � - � � . -- - OCONiRACTOR NO. � �� � � u I,as owner of ihe property,am excl�sively contracfing r- with licensed mmractors to construcl ihe project(Sec- ��- pDDrtE55 � � � - �9•� ��� � � fion 7044,Businens ond Professions Coda). � - � CONSTRUCTION LENDING AGENCY sE�BACK YARD� HWY - T�TApROP uNEF WiDTH� - � � . � I hereby affirm tho�there is a consiruction lending agency for FRONT � � the performance of the work(or which this permil is issued � V.L� - - - � -- �- --- � -- (Set.3097,Civ.C.). SiDE � . . . . . . . Rl. . � lendar's Nome � ' IDMA Rei.M � _� lender's Address � � � �-- � " - P.G Fee f Permn Fee� ' 1 certify Ihat 1 hava read this opplicaiion ond stote thot the . hsuonce Fee � LDM4 P/C M . - . -. _ _ _. a6ove information is correcl.1 ogree to comply with ail Couny Invesiiqa�ion Fee � ordlnances and Siaro laws relatlng to building mnsnuttion, Totol Pee LDMA Perm.B� _ � and he�eby aothoriza representatives o(this CouMy to eMer upon the obova-meMioned p/operry(or inspectlon purposes. Ln��'4./+�W-� � �- SFE REVERSE FOR EIf�LANATORY LANGUAGE � - SignoMe of Appliconr or Agen1 - pote. . .. . . .. r .. . . . . ; , . � _ z � . � _ _, _ � :,- o � -G� " � o. � r N `,l9 m� p ..{" O ty ..' . � - v a (i� �a o .,a, - r 0 o m �,� `o � - � I r m ^ cn �T �O � O n = y'�� ��. '.0 `:c p � 7+'y, � , �'p C ] O � n' � � ; mT (1S O � A � .,O" �? � �� �, � > j- n�j �� �� p : ' 9 � � 1� � . > > o o T s 3 a o ,o o �..., o',9 , ^ o; , ° c� c , c 3� K m -o ,r� 9 ,o o.c,,. o,� �� _ -�, � ,n < • '� � O � .^.� % /D� j- '.O W� O � O n'" 7 m � 7 �y� _ r; : � 7 � � � ,� �G N O Q [ Q � �O _ ^ 1` .,'1 • � ` �I r l 0 0� � ° ' a. ~ Jf. � t' i � q ? � m � o `L � � � i - � c� , - � _ , � a, � . 0. .' , Z � ' , o r O � , _ •i f � `� - ➢ � r , I �. 1 m a_ , � � � 4 ; � 'i � � � ,� ... � ��, ,., ,Z � O a�• Z , r, . ,.; � �.`1 '-- � �. � r . -' ��. CV � , � �l � - _1 �- i r . ' I M . ' �.J f .. O (� ' . . , i� @� �. y'. . � � I ''� ;, o' � `' •, - � %� �. � ;� N . . 1 _ .` 'o`'. ' 0� ,. � `:. �', ; - n.a. a i ,'c _ , k � `a, , � '' _ _ � ; , , .. 1.. . - - . .. -, ' `' t`1'` .II {` 1;I ,1 �i/ � .�,; 'Y �' , I 'I � , /_ ! � ��, ,� 1 ;�✓ `' � � �' , �t , . _=y _-� y f:"' 'f -' , rz ,: { - , `; y --'tt` 'a } ;,t 1 ; k ! t ' " z � ��� �� � �� 1 � ,4 '� - � � �t • ' ' i` � '� - ^ ;� V ; �i ;� � , l � i� � ' o ..� :f � '�� `1 _ �1 .� ' , �� �', N - ' �I ` ' ``� ' ` �� . �. , , �i M i� �� ' z <' +, '� � `i ;, ;�� ,4 ,�= � ,, ,. , a y i !' ,j tr . " i �� - ' ' m • � �. , , � ,�'. [� (� N ��. . .- ' _ - ,, . . .-: ^, � �, � t - ; ��, . . 1�; 1 �, � � ' - , 'i . 1 � �_ l i � � , i_ `/ 'I . j: 1 � I .. �- � � � ` � � � �t I � �• t � � ,t 4 ' • ' . ' .. j,- . ' � ' . '{ •1..� � '� •. , _ _ 1� � . r 1. 11� � . ,l �� � ''� . ,� ` �,�� , ,�'. . l� I 1 . i ' . " �r ' .. �'� ��.. �. .�� ' . -. � . �S .. . .. ` � � r : ,� � - . � '' '-� . � " ` � ���_ �'����,c �� �'7 .. . �. .. ��^S.Q '7S'I ^�i �'�S w G+� �•3 N � ; , . : .. s'� �.1 _ c� � � ;- ` �, � .��. � � �`•. . . 1 i ^J 'Y`p 7� .. n < t- " : � L.•- �-N ,. �� C,.3 v•�.p���" . 6 � ' ` • . 'i p�o� � � � +t0_�' C^"t � `��.� [. ^.a " � �", �� �� � � s r'D�i G .� ' . -,. � '�L ` .. � �'= Y ; . � o � � ^ M.4� � _ - i �� _ `� � c O �`� y c. ^ !i^�- ; �- -�j �' � � - - I � � ` A.h ^��S• �'.�n �'_ ��.n m.S - � � =�" M ti.� _ •i e-�'� 1 ' ' � �� t Q� ^ � ~:i. n.� ^'7 •'`. C'. ^�i'�� `{ '��� y ^ n C. ,'�,,, � '� { �N� .� .. � c: O. � w 7.'' C � C =.].N 7 'S ,"� .. � C.. n , S. � ' 'r �� . � I. C� C`4 C.. _M'j ~- n C 2,� ��O �@ ^ L��i� = �.fi C z . � �.r` �'. ' . �� fYD� i � : N T-i C^. �`}'.�7 .7 ...�1 7'n � � ,� ..Z " �M 1� � � � � �. ` M. 3-^. .i � '� ''S f Cj•0 ^J 3 �Cit � O �"� • '' _ , i ,D� .. �t 3 C p..0.,' �"` � ..p G ^ 7.3 � i�•� 7 ` � � � � .i ^ .�T�+ i � ^ - .. �-? , c �b'a c'�N�a9 a .. �.' _' � �. . . � � }' , � � � n �. �,� a ...q, .f`n.m v ��� "',. _ ..� --'''� � .. � - �'11 - � �,i ,; �t d�. z_.n.��`O'^`=O' � ' S a� _ _.;O.o�. � `s � =4 - ^ L � .�cc �•r( � m ._ o +, c.� � � �, �`'.. �O :- � ' � a �' .N c.� h � a � _ .. � � i , I. � ' � (DI �� j'.. � (D G..7. � �`G� 7 K '_ '� 1 F ^�b� ��^ � '� % � . . '� ' 70 - - '� ' ^' L..��.'H p'� - � 'S' `� ``e�''t7'� O C.7~C ' �- � _�. . . � /n 4 • ~ -��'C ' t f, �. .�7 C��a._ fl r 7 �-� �n .^, r ! .,.. f` � . - ,•' =r���'^ �� 3' ' 3`�-.L: ti.� 0 K. �'`^.� G' r� rr., �_'�� S' � . Z . u '1 � C .Pi � � i-L�"^J ^ .O(D �'`. "': a ^ `1 .. N:7-� � ,� _ Z. �"1 , .`.. .ry C�'�^ w�� �t.::i Cl . � I , 5"'; � :. t- _ � � c .. 3 �z_ - �_ � ^'o - '', i v� O, ,�.s �,`�-c ' �F'-�� ; ,� � � � e ,� -�w _ c_ " ; .n '' ,,,s��.. �' . O ` ...�,.. -c c �., „ _ v , � �. � . j 1 fA � C� �'4.�� s:� ,R_ M^p O �^ r"�.� � n -p� � !� - ��� ` ?°`° . �i 1«..� �p .� +` .r r, ..._ �,N r'G, �� O � " l:�0_ ', w N n � .�. L� � S�,V�' � � ✓ "�N 11 - �. , � 1 . C� . -._.'.�. ^�..'O' - . " ��^'0O 'f "'7� � , -..n `' _ _ - � \�J n � ni ^ � ^.���+..3'L' _` � . � . ' , , , i . O _ C � �fl �wa`� � ...;�.na . " _. - f•. y r�n.n :� 1: Q �l'� _ � r �±, . N �� ' V ~ l : I. . �- <, ;�� _ � �..�_..� .. ' t. ,_- ' f'/ ` , '