Loading...
HomeMy WebLinkAbout1038A WORKERS'COMPENSATION DECLARATION � � � �'- � I here6y affirm thot I have a�e�,,���a�a oF�o�,e��,o=a�f - . APPLICATIO(V FOR �BUILDING �PERMIT ins�re,o�o cerfificole of Workers'Compensafion Insuronce, or a c/e��(�ified copy thereof(Sec:3800,La .C.) � �OUNT OF LOS ANGELES BUILDING AND SAFETY Polic�No��a�^'Fompony__.. ��� � CerNfied copy is hereby furnished. FOR APPLICANT TO FILL IN BUIIDING �� �U O�Q�k � ADDRESS � Cerfified tepy is filed with the yQ ty building inspec- BUILD�NG f/� . tiondeparlme /OJ`r�S d" �/� A�DRE55 � �l� Q ,��uate�PPlicant,r✓���/� Q��S atr nr l7 iocaurr 1 - CERTIFICATE OF EXEMPTION FROM WORKERS' � - NO.OF BLDGS. NEAREST / '/� / - � COMPENSATION INSURANCE � SIZE Of l0T NOW ON lOT CROSS 5T.� I{�-�-K��/O GGL' (This section need no�ba comple�ed if the permil is for ona .7�p . a55E550R hundred doliors(E100)or less.) � TRACT BLOCK � sNLOT NO. M47 BOOK PAGE VARCEI � ' OWNER Sw�"`Ep, $E 20NE N�+P / !3 � I certify ihat in ihe performance of ihe work for which this ND• � } permit is issued,I sholl nof employ any persan in any manner SPECIAL ��� �� S� Q so as lo becoma subject lo the Workers'Compensatian laws. � ADDRE55 CONDITIONS 0 U Da1e� Applimnt - � Cltt ZIP a . NOTICE TO APPLICANT: If, after making 1hi5 Certificote of ARCHITEROR TE�. DISTRICT GROUP NPE fIRE PROCESSEDBY . O ENGINEER NO. CpNST. ZONE F— Exemption,�-you sho�ld becoma subjec� to.the Workers' / V Compensafion provieions of the lcbor Code,you must forth• qooRe55 L'v W with comply with such provisions or this permit shall be d �• STATISTIG4�CU1551FICATION APT, CON�p. (n deemed revoked. . � CONTRAttOR O. �2O' LICENSED CONTRACTORS DECtARATION. p�, aASS NO.�[DWetL UNi75 Z . I ere6y affirm Ihot I am litensed under provi71on5 of Choplet9 AODRE55 I•NO. ��R�P � mmmencing with Section 7000)of Division 3 of the Bosiness ond � ���, /� Professions Code,and my license is in iull force ond effed. CiTY �i{, � CW55 �7 BK � . . VALIDATION � 'M7l��xj///�7���� SQ.FT. NO. F NO.OF CHECK litense Numb� �Llc.Clas�� 52E .2['l/ STORIES � - - FAMIUES ONE- . C irocto��/y'e����fJate ` A D O s ALUATIO��s/� DESGRIPTION OF WORK �� I am exempf under Sec. 0 �"` ! � , � TER 0.8P.C.for this reoson • / � EPAIR ❑ _ - Dvte: �� /� r DFMOL ❑ � �1 0 3 8 A � SignatVre � � �� � APPIICANT �. / FINAL �` 'rj �I� �•• . s e � OWNER•BUILDER DECLARATION PRINT O. DATE �( d I hereby affi�m�hot I am e�empl from the Controctor's license " " " I • �[���� Law for�ha following reoson(SeUion 7031.5, Business and ADDRE55 �FINAL . � Prafessions CodeJ: � - - �� � PRE NT� 0Y • • •4 3.��� ❑ BU�L�iNG I, as owner of the properfy, or my employees wifh nDDZE55 woges os their sole compensotion,will do tha work and � � , ��C 2—fi B tha sfrucfura is nol in�ended or ofiered for sole(Settion ����Tr � 70a4,Business and Profess�ons Code). MOv�NG � iEt. - � - . � I,as owner of Iha proper�y,om exclusively contratting �aNTRAttOR NO. � with licensed controdors to construct fhe pro�ect(Seo- - - qDDttE55 � �� - � � � tion 7044,Business and Professions Code). - �� CONSTRUCTION IENOING AGENCY � � SET BACK YARD HWY �OiAl�SEOTP`I�FR M ypIDTH - � I hereby offirm Ihat thera is a canstruction lending agency for FRONT �he performance of the wo�k for which Ihis permil is issued P.l. � (See.3097,Civ.C.). SiDE P.l. lender's Name - � .�z• /� IDAM Ref.N Lende�s Address � � ' � � 7.0 Fee f Permi�Fee �� , 1 te�tify Ihat I heva read this applitotion ond sleta that fha . Issuance fee. �� �`� `� LDMA P/C N obave iniormation is conect.I ag�ea�o tomply wi�h all Counry invesrgm�on Fea o�dinonces ond$ta�e laws�eloting lo building construtlton, Toial Fee r v � lDhu Perm.M ond hereby authoriza representatives of this Counry to enter �_po���ned pr erty r in etliOn purPoses• f . . ... . O^ l�/ a ��A SEE RFVERSE FOR F%►LANATORY LANGUAGE gnature ol Appliront or Agem � pote i Z O / . - o .. � � o � �? � n ; �' o .v- L,y ^,�, p s (� � '. . :-r n � C � %.� . o r Cl� 'J N O � � �� n y '� I .� � . � � � n J^ ,p p C `� �4 . .../ � r 'f � ^ % j � 3N � ' N � T� � '� � � l 7 � 9 �O , i n' � .. Z, i � /� . N � T � O' . � � Q � � Q � � '�,� � O �, O �' '��0 , Z 0 r j P G G-�.f,7 4� : p �` �% , � p � � O � � p G' f ` � �' � . , � A r -n (�Z ? .D o Q°� i `'� �C ` ?O ` ,n $ '" Y. � p ��• ' � ^ T' �o Q. Z " � f G , O�r , . . F . . • �� � Q n Z � , o a �� � t: o a _ 40� � o �o �; .�� m :r. 0 3� o . o � . Z °� _ O .r tS � . O � � a� o , �, o . . D � ro. °� �o 0 0 � _ �o . m; � W y ;' � ' ' < ` � ro '� , . o-o- �1 m o ' �, . M ' N,; ' �p "� � ' . ',, � +. '` ;. �,l ^,' . . / .`t' . r . O � . . ` . �i . ' : � , - ' ' , r ' f . , .. � - . � ( `�� � ' �1 t . - ' • � � _. t i , i - V - \ . ' t. . � � 'O - � . . ' . . ' `�L.',, .. . p+ . , , ` '� J �� i,; �' ��' `�.�, \ . A � , . �. � �� M'' ���`•t';� � , O v t. ` �,: ; { ` ,,,� � ' y v1 ' � , ��i '.r_ • t ' • • ` •.�:' .. ' � �. '•i '' �,' }� � 1',-� ;�• '�� ,. '�i `' • t\ ' i. ,�.', � ! e i , . . � .i� ' , + .t + . ,' - • \ � '� ' _ " � �'�i` ' ��' �` • • .`��, ,` I\ '�� , + 1 - . .�� �'S � . . ; i;. ,.. .. .. �.c'�'r'. _•:c , . . " .. L ^��'* R L�f',� �. . .. '.. n � � L=�� �'� s. N . r .� �. . '�. . ' . � � �.G S'.40 f�c.L� `O V.� ��t, �'.� C C„/_ ' � L m�� �^'��p —� },,,y � �t �' � , ,, . ., v."^+ :5 �.K �.�.'M:v� �"t�?..� .. .�.-•��'' ... p= .r �, . . �•�--� ,, ^ K c. L ^ � � t"r�O � _�n� »�� ia �'.'.'~ � ..... � cr �p� �;;,r'. _^ �7'� N�, � S� a :..:� rs-G^�� ^ ?l� G .",{�`�,�'.� ^ r �'' �; " � .m fl ^'^Y.n ... � _ :. r � i � . , r ,p �� a� --t �-� � .. � Y�;..: ? =� � v�' -},'C v � S� p i , �o �c j: �� �c��-�.-,� �,� j �� v ,� y � ^.^ . _ 0 3. .. " ,� �o \''. � r.� .. �"' a '� � c '� co° . - >e:��.nc�-s � �^, oc� r i4.�.A 0- ,,,'.�^_ '.. ��� ee.7^ �...^T y ;t � ,,r,.e^t' K ,.'h "f;,, �c " � �, � 1' � o �'�'K + 7 4.."'_ . 3 •= 0 7' s ..•<� .. �� ? 4 c j� :. ` � �'o�C.-v� �y.7 •L y'�.L^n 3 j � �y .: C V`^e. ' » �p 2 �; .. � � � n .-.M 'N U G c=. q r Y 3 3 x Y^v' fd''�bN't� �C ' i• �''�~ - '•'__ '� i - � , 1 ' . " ' y :.. 3 f��Or =� Z �S.�' ��1 CY 7 O ^ .?..f.�n �%,~,—, •.i (L "� .` ' . . - . �` s��. � �? � .t. a �';r K ^ y,0 O N —i, ���n'a`. �' p j j. ` ' . � `` � . t ., 3,' µ-i'p•i� �� Y� " V� �:. O O � Y' �, �.� ~ c~f.•=.� 7 r, • , • ._ . � C�'' �.�' �,,.��O . '"�n n � 7 . 3 " : S µ -...� S r �, . ' . . 7 c. ..;. �: 0 p s..C < � L-. �� o :'::`��.: _ fJ..G '� � � - . . � a'� � ^'^ �i�...m'O c..,x, ° _? ��'i:,o t �t; '��.'�^ � `-�=: ^='�F C�f. 2 � ^ • j..a ^ � o:`^ � ': �� " � ��a c'�°' �3 '' „ �z �.,� � �-' � " °�„ ` " u�o `� � ,..c.�:r� n-� ' ..,� ;, _ ' ' ^ = o a-< c..-y+ � z� ,. i' :�.: ._, . ��i _ . . . � n i'L.� �7"O _ C '}.�-.,—.� "o .. �� 3 �C .. �s`7�'`��, a ]c� �O O _ ;y � �'-".� . .'"..� -�''a L"y_ y ' S'6� v ?."�q•�`. F' _ _ � i O .� :. �,_c: c �T c � ' , � A �• � ^ -� n C � L"'� F^'„'"`. '� _ '4 p�_in,� �--.,N T � ` �N �1 " . N . . k'. �' .. � . p ��.��+'� t�1�O � �L. - '+ - �� ^ � ' . Z � �' ' �,�''�_'� w, ;t ,. ...n '.F �r �n '. , 3 ' . • � � " � ^�� �'�' '� ���, � ?Nn O C ,� v r '� � � � . . . Y` ' :� Y.c �1� �' "'1t..'} ✓as..... • � .. ' . 4 �� .�'c, - n n � _ G k m . • ' � q�'- �=��;K~^y�n O ~^�'�ti..: y .r': (' O �'�` N �. . . � •Ii . f..� . � �