HomeMy WebLinkAbout1587A (9) � � - •
�.f
WORKERS'COMPENSATION DECLARATION --� � � �. -: -�- - � -�-' � � , � �
I hereby affirm ihat 1 have a�e,�;F,�o,e o<<o�5e�f,o se�, - � ��� � APPi.ICATION FOR BUILDING PERMIT �
insure,o�a certificaie of Workers'Compenso�ion Inswance, �
or o cerri(ied mpy thereof(Sec.3800,Lab.C.) -� � � .
Pol�c Nq��ompa�y S%�7� f?/f(/O COUNTY OF LOS ANGELES BUIL�ING AND SAFETY
�Cer�ified copy is hereby furnished. FOR APPLICANT TO FILL IN BUiIDING g • � t
aooReSs .J
Ceriified copy is filed wiih ihe tounty building,inspeo BUnOwG nc�
lion deportment. ADDRESS �3 L..� ���M��U �
��e � � JO � Appliconf � CITV /// ��/Q ZiP �7bJ tOCALITY
CERTIFICATE OF EXEMPTION FR M WORKERS' ._ .. . . r+0.OF BioGS. _. NFqREST ��' �y
� COMPENSATION INSURANCE 512E OF LOT NOW ON LOT � CRO55 ST. [,{,i[
(This section need not be comple�ed if the permit is for one n55E550R � . .
hundred dollors(5100)or�e55.) ' TRACT - BIOCK LOi NO. / ' /�IqP gppl( PAGE PAR�EL
� � TEL.g/I�WI� USE 20NE MAP
I cerlify that in 1he performance of fhe work(or whith�his OWNER O�yQf NO. 0 3 r,,o � � a;
permit is issved,I shatl not employ any person in any manner pDDeE55 .2�j�j2.� �s�t�/''��ND ,�1 SVK�n� _ . 0
so os lo become subject to�he Workeri Compensalion Laws. -- Q CONDITIONS [�
CITY ��D/�0 ZIP /�76� �
Dale Applicont O
ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, aFier moking this Certificote af Di5i2iCT GFtOUP 7YPE fiRE HiO�55ED BY U
Exemption, you should became 5�bje[f l0 1he Workeri ENG�NEER NO. CONST. �E
Compensa�ion provisions of Ihe Labar Code,you musl forth- ADDRE55 �-
ith comply w�th such provis�ons or Ihis permit sholl 6e � ' N
deemed revoked. ' �O C OR � ET�. mg �C Np. —7� TATISTICAL CU1551FICATION . APT. CONDO. Z
IICENSED CONTRACTORS DECLARATION � i��. CLn55 NO.��L�WEIL UNiTS , .
I hereby aHirm that I am licensed under provisions of Chapter 9 aDORE55��•w'SrA7C S7 �n10. ,r.r� ��R�P
, (commencing with Section 7000)of Divisio�3 of the Business and ���
Professions Code,ond my license is in(ull forte and effeU. GITY IU - � cw5�3 -� BK � VALIDATION
��'✓✓✓ SQ.FT. NO.OF• NO.OF CHECK
License N�mbe�r1�.�} Lfc.Closs C 3� SIZE � STORiES � FAM�LiES� ONE •
6[►�"'�" +�'•"'-'�+�Da�e_��� - VALUATION
Coniroctor E DESCRIPTION OF WORK N�7CVE EJ�S'71i✓(i' _ N�'`�_ ❑ ' = s�fs"�
/ AOD � ,
�I am exempr under Sec. ' ' _ r ❑
AITER
B.BP.C.for Ihii reoson � p � J � /�OS/T�'✓ REPAIR � f
Dole: O USE Of ` `� �EMOL
E%ISTiNG BLDG. ❑
$ignelule l� . APFLI�.4NT. TEL q�� �
ONE ER-BUILDER DECLARATION PRINT LA���'F NO./a/ 733� DATE �z C
I hereby aflirrrt�hm I am ezempt from the Conlrocror's License � �� � �
Law for the following reason.(Setlion 70J1:S,�Business and /+DDRE5�3• �''�JT����- � FINAL �1 5 8 7 A
Professians CodeJ: , . . . pgE¢N _ . . . . . . - By ' �• • • • � 1
❑ BUIIDING
1, os owner o(the prooerty, or my emoioyees wi�h nooaESS
woges os their sole compensa�ion,will do ihe work and ��q��TV , f � • •6�,7 J�
the structure is nof in�ended or offe�ed for sole(Section �
7044,8usiness ond Prolessions Code)., , . . ,, MOVtNG_ _. . . . TEL. . _ _
� I,as owner of tha property,om ex[I�sively[onfrocting fONTRACTOR NO. • � •6�.7 J c�
with licensed controcrors�o cons�roct tha project(Sec- - ADDaE55�- -�� � � ' � Q 9,� ��—II 8�
tion 7044,Business and Professions Code).
CONSTRUCTION LEN�ING AGENCY � �sEQencK vaeo r+wr T�TApRpP UNE wioTH � �
I hereby oifirm�hor�here is a construttion lending ogency for fkONT �
the performance of the work ior which rhis permit is issued P.L. . -
($ec.3097,Civ.C.). - �- �- SiDE �
P.l.
Lender's Name
'� LDMA Ref.N
lander's Add�ess � - P.0 Fee f Vermi�Fee . �
1 terti(y thai I have read this appllcation and state that the Issuonce Fee �. tDMA PiC M
obove info�morion is mrrect.I ogrea ro comply with all Counry In.esGgo�ion Fea
ordinances and Slate lows relating to building tonstruttion, To�al Fee IDMA Ferm.N
ond hereby outhori eprexntatives of this County to enter � -
upan the a e• � d � ert inspection purposes. .._ � �
. � �/ . . __.. _ ___...__. . . . . . . _. '. , : 1
� �p SEE REVEKE FOR EX�UNATORY LANGUAGE � � .
$i Wre of Applimnt or Agrnt pero _ __ _' _ . _ _ .. . . .. . .
. , . ..
>> o o c o � � o o" N c� _Q � ��.� �� rt 1 G, 3• -n �-r-- -- �--- --- o 0
c� c c - s '� a .. � o I r o n � n o ? �. o ..,`; � �
� � � I � o � „ � � , � � a� ,,1� _ � � ._, - �� F i I I
; �Z x �� � o F; � �n ° ==I ��'s n " `� �i �, r� ; ; � , :
o � n ° f c ' °„ � a • 'c�i o� , • o�� �` ;� c E-- v"• � � ,
� « Q o � ° o -< � � � � � 3 � c •:a i� j. i
c n o � o -� � •- •. i �
' �fD � _ � =� v ° _ '`� � o � i
a' o c � m' .. ? � ` . I o
, � ` o'I �: � � �� I o
i � I..':o.J� I�
o ' 1' ? � r' i � °
� � ' - - I ; , I
� - i I I ' � �,
t a • � ' i'• I ; ' ' 9
� � i'' D
. O i0 . . ! i : � ' ' ' Z
` 1 O � I � � — Z �
i .
� O A 1� 0
.. . . r- -m� D
' I /' . , 2 � O 7 �
; � '=� '` . ,o a m. D
� - z
� m n' y
i �o � �'� • •
, � �. . , , .
o. i . _ , -
� M �! �� • , '�: O Q`
I � � fl
� -�^ y,m '
I o ". �� _ . v e � • D.
n �
, � C . ' - ' ' " � � . �.
i -� a e <
. � i' - n. m -
• i . a
� / i . : . _ . � �. %': i /� ; �. .
' . .. � � ',�i �i '�`� �..1 r,l I ,
. /. ' ' ` ��' `:� - _ ;i �J '^ i� � , �
' ,f� _ � � � r. �� ,� �. ;'� r� (i - ' � .
i � � ' / � �. �il � _ ,
' � �" , . � i , _.:
. � i 4 + ;� 'J i i . ?�
' 1 i � � 4 �• - ! � , �f 2
I i i �, %� �; ' � � C' - � t
� . '' .._ � . L� " � .l �` , �•. . ��� .• y
' u: `.' V � ' ' `� r� �. Y O
. . i ,i 'f` r, ' + � . ;� . . ' � . N
' __'_ ' ' ' ' Il = y'' � � '� ', i /� ('{ _
' , � �� � � 'l .;i? O�
I � , , �� `�,� i• ' N
. � ' � • �„l ''i .� `• • i 'r: � , !�i/
, ---- • � /'. r. .. i ; '_ ,/ . '•-
I• , i �' " `` � , ' ��i
! I . . , ti � . 'l` _ i" �,:1 .i �� .
� � � ' - ' . � .�� � J ' . � ; �� i
, , i '
i
/ � � , .. � '�n '�f� : . �. . � : _ . � j � ' .
``, - v 'i : _n,_ti'�o-:�., - • C Q-'� ^? " ' �C T£ � � �n�,.; �� =� r.
, � - O �' . � �.�L.O � r `. C •a � ^.�i G � m O ,^ 'a..: ^ �``t r'+ � " '
�� ' N 'Ot' (J I y'�:+'�R�p� 1 1�' �7 ='.` � �-�` � �, tc � : C��''- �C a w �' R�; '^ ? �T
. , . "O.: � ^,�� (...£ .. •� ^ ij C 1 � O L 7 \\I V\7��r�T �
- _ �/_ � 4 .: �� � ti 3��;'�k � t'^ C _ "� � � . \ �,^ ? � T �
'� �� `:� J� `' J = o b n M n p � � �.. « ^'^ � ��' y�
''/ ' ' - �:� 3 �i ...� � —O `�� '.__ w a C O � y,, '�•ti G R c �'° .^„
i � � ti M
jj • • , .i M'F � �'� 2b �.e-� � ^ s �'D. m a � � ��'� ; ��LR L f �r
� m o . ; o - " „ � o •�
r .. ._ . . . ' �� N _'O � N - .,� �'�
j ,� ` M F �.„ a-.� .. � � � � z � ' � .
. � - - .. . _ I n L _ ,e (c o a�= ' `.o c� -7 ��� � � `�.�,�%� �i ' O� ?
, . ^ 13 S =.� M � ¢A n y' - a =�.T c o �c � M ^ ,rC'.e_^M , _.`
�"C � M 7 C�n 0 .f J C.] . C �� 7/� �/i 1
� �a ..•ti .. 0 � �.�•��� � N �� O � �, k�=•- [ � .. SC r
':. . . .. . N �, i j ,�, �^ b? t V �t � � � j `•1'J C T � r j ' � :,.1 ^' R. ^, �
1: L 1 . � � 7 �T� � � 3
- � .. T / ,d i A ��Y a O �7 y'� j',J C, y� 3 L �� =� .
a N '< w _ � �.
' i� � � A - ' I: ��� `�` "b�F �a 'L`-�•�;R � �,�"a rv C� � ::� r� � L :�"� � ^ G� C
L - " /i iani '!a � Np i� --� x „ � cna� � ay�� � � _'^ !
� ; - - - .. � � '� � ti�e C�� � � �[;`c..C` �e C�O � ' �- � ��; ' + � C � r_ ^'
_I . _ N . f� .. .�� � O �. '.i`i a ^ }�`�'. ` � .�: Q C ni -`�'� �'�; 't � �• ' .:. 'D
..c" ` I./ / [„ N n.� � 1 +� �`; O ;'+. '\ =' ��[ ` p, �
� .' - : - 2 �?/ - •;'�c crn� o ai'i :�� ��? <� ,.� `a � F� . `�- _ _
:i - , 0 ..� _ ��,�E.,�� 3 ��'� _ = �" �. f o. ���_ = .:� ^✓."" ✓ , �
m i�. � � �. c 6 ,�r c�� ., (�d_ J-� � c � $ t n � _
. � ' ;2 ^ _ . r 7 „ ���� � G _
�� i _ • ' ' N _ C.'� '9 ."..�.. � . � � Cf.` .a ^ � i..
i . . - ,�..= �'•�_ n 'i�ti �'• C`�'`' � � C•c �^� ^ C_M :. � �_ � _ i
� r - /' ' c,a`�.'N - ` ^•�� e � 4 0 �' `�} M1tj ,-�"��� ' . ��
w ,-�,.�� o i. �� � a s 3 ` .� y r; ,�
�l . . ( � �p, �z � l�v � �:s��� �.� c� �- -j ,"y�^_ _ t c. .c, c � %
" - _ _ ,v . � F+: - 3 ` �`.� o: h e 'a M ` (l
• ,�'j� . . - � - ('1 � � �c a-��~ :.`�' F �: '�.^ ;'�`z�� ,�� � o
1F � � n ���. e ,� o ,7�'h •�, �,c � •.
� . . . ' . � � ^ � O C �' q �:. '. N �� �-�, � v p
� _ • o c ''� ?� _ • � .^: 's'�o-_�: 3c� f `� '-^� : : � ,t - � �o �
. .. . - � .. t _ _ . _ , � � � +a��� �� � � ��' i„N
. ;,T. �e S^`ti n y•�n•n�-��ti w.; !'aS� . a.. ?/' . �
I.