Loading...
HomeMy WebLinkAbout1769A 3491A (10) WORKERS'COMPENSATION DECIARATION �� � � ' � ' - APPLICATION FOR�BUILDING PERMIT I hereby affirm thot I hove a certi(icata of consenl to sel(I " . � inwre,or a certificate of Worken'Compensation Insuranca, �•� - � or a�e�tif��Gc re c��3800,tab.C.� 0. J� COUNTY OF LOS ANGELES. .' - BUILDING AND SAFETY � Po❑licy No. Company � - � ..... � .. , . B(11LDMG.,, Certified copy is hereby fumished. FOR APPLICANT TO FILL 1N no�aess ��Cerfified copy is filed wilh the tovnly building inspec-� BUttDMG �l �) tion department. . AD�RE55- O'�� S-� � -/� -� -�O� LOCALITY � . � ` � ' NEAREST Date.�-3�Applimnl t �� c�T`/ Ail 21P � CROSSSi. � CERTIFICATE OF EXEMPTION FROM WORKERS' . NO.OF emGS. n55E550R � � �COMPENSATION INSURANCE $tZE OF LOT NOVJ ON LOT MAP BOOK : PAGE PARCEL �(This set8on need not be cample�ed if the permit is for one � - �� ��Z �P — � hundred dollars(E100J or less.) TRAtt BIOCK l0T NO. � NO. . � . .� -/ � TEI. . _. C�� SPECIAL �/j_/_ YYl � OWNER /{/= O�CT� R J/�4N0. �/-.2OY�-fJ . CON�ITIONS 4C+ (�� /'� � I certify that in the performance of the work(or which thie� ...._. oisreia GROUP n� FIRE SSe08v O permit is issoed,1 shall not employ any person in any manner �� '- -�- . .� ' � �-� " "-��� - - - - � �ONST. ,/ -ZONE /�` ' V so as to become s�bjett to the Workers'Compensation laws. ADDRE55 � V .� ` . � — � . � CITY � ZIP STATISTICAL CL4551FICATION APT. CONDO.. O . Date � Applicant � ' . . . ARCHITFR o TEL. f� �j - .. .U NOTICE TO APPLICANT: If, affer making lhis Certificafe of ENGWEER F•V.� ��Ar{� S� � "-NO:-. - S � CLnSS NO. �+�—DWEIL.UNITS ' - a Exemptlon, you should 6ecome subject to tha Workers' /� Compensaiion provisions af the tabor Code,yoU mVSt fO�ih- AODRE55� %;Q o�arD�; ��ev✓ SewER Mna � - � with comply with suth provisions or�this permit shall be �}— ' Z deemed revoked. �OMenCTO '71'f f'�J-,ZE�J BKE'iG PG,�� VALIDATION IICENSED CONTRACTORS�ECIARATION - UC. 7 � I hereby affirm thof I om Ikenzed under provizions of Chopter 9 AD�aE55 Gn! . NO. /0��{� VALUATION � (tommencing with$ection 7000)of Division 3 of tha Business ond ��/ ���. R Profeisions Code,and my license is in full forca and effect CIN W QASS !l � s/S��� , ' - Licensa Number���I l,l/ . � SI�ZEFT TORI�ES FAMILOIES CONE . �� Lia Class Q s CoMrocto � Date�-3 � DESCRIPTIONOFWORK C! iCt= TIff�CM N� � _ . . _.__ - .. ..... ._ ._ . ADD. �.. . . .. . �I am axempl under Sec. - ALTER ❑ FINAL �� 7�9� �. 8.&P.C.forthisreason '� �- -' � ' � � � -� � - - - -� -- ' aEpAiR DATE�=l —�� � + • ' � ❑ ... �. • . .?j - Date: , USE OF ... . _. . . . DEMOL ❑ � FINAL- - � ._ . ' _. .. . EICISiING OLDG: - By � • •9 1,3 R � __ Signature � �. APPIICAM TEL . . . . .. PRIM NO. .. - - : .� .. OWNER•BUILDER DECLARATION � • • .'��.J B� ' I here6y af(irm that I am exempt from Ihe Contrador's Ucense law for the following reasan(Setlion 7031.5,Business and ADDRESS � "-��"�� �- '� �� ���"� �� 8 j ProfeSilOnSCode): . � . � " PRE N .�.. , . . . . `� - �. ❑ . BUIIDING � . . . . .. . . .. _ . . - I,os owner of the properiy,-or my emplayees�with � --- a�oRe55--------—---- �---� - � � - ��- � �� '�!!9.1 A. wages as their sole compensation,will do the work and � ' ihe siructure is not infended or offered for sole(Sectlon . �«A��TY � � � --------� �-�- "- � � , �" �� wah liee sedfconhac ors b comt�udsfhelp ojecf($e c A MIR SCTOR � ' NO. � ..._ . _ .. ._._ �... _. ... . -l 4���.�q�u�. twn 7044,Bosiness and Professions Coda). . .__ . .� .. -- � . � � �- � - � � REOUIRED TOTAL SETBACK FROM EXIST. � . , �, ,., . CONSTRUCTION LENDING AGENCY � SeT BnCK YARD HWY PROP.lWE WiDTH ► .'���' � � _ ���-�- � -. �. .. ..,., I hereby offirm�hat fhere is a conslr�ttion lendfng agency for : ppONT - ��� � �-�-�---- -- - - � --� � ' � � - -� the performance of ihe work for which this permil is issued �v.t. . . � � � . �Sec.3097.Civ.C.)• � ... SiDE _ _ _. -.. . _ .__ . . . .: . . . . . � ._ _. . . . _ . . P.L � .. , . ,..�. lender's Name � � � � .. . ._ . ._ . . . _ . . . . . . . . . .'. _ ._ _.. . - _ . _ . , lender's Address P.G Fee E Permit Fee � � � � . . _..__.._._.._ . _ _.__. ... . . _._: . ... .. . 1 certify that I have read lhis opplimtlon and state that the � - ' � Issuance iee � Q� � . . � - . abova information is conect.1 agree ro comply with oll County Imestigation Fee � _ � . � ordinances and S�ate laws relming to boilding construction, - � ��- �� -- � � Torol Fee � � ond reby authoriza representatives of this Couny to enter � - � � � u e abavo- n ione oper for inspecNon purposes. � - �� - . � � � �� � � �, - -� - � � - �` - - � - -- - �-� � " -�� -�' " J �,3 p,� � SEE REYERSE FOR E%PUNATORY LANGUAGE _ .._ __ _ _ . ... _ ' . . -- .--- - - -� � . . . .. ._. - Slgnature of Appllmnt or genf Date � � � � � � � ���� � . . __. . _.._ . . �.. . . -. _. _.. ._._ . .. _.__.. . .. . ., . . . . . . . . . . �i z a _ -, o • .. _ _.� � o� `�`I `, ,li ` v �` O't � �` �' =�'�` � ��- �t N � � -��. ��. �q '` , o w�.. r' C9 �O- ��j'\ ,b �O '� 7 Cv O �-c� -'.� �tt �,', � �C O O � n ^ t0. � � �9: ^ lf.� �' /\` Q' C O �d n O -� . O, n. , o r,. ..��. i� . • \ ,;.� '7� � i-P O, �+ ai �4 /'� '�. , - �t ", A '1'� lP� l� � 7 � N 0 'O '� .�+ � (D �� �� M�'� •~�,-' ' . � ( ' ,^ N C � O ,�.. � e � O� O� �t �'.. ✓�,�,.��. ��.t,,� '� � ' N �n o �- 6."". 9_• ` o o ` -a �o i ;. f '� „� � � J � C cf_ P-- F.3 b 1 .. ` � p .'�.i^.., ��� J�1�., ,1 �. ;� ti � O C% x O ` m �• � O� • �� � � �� � � . O c� Q" c , � � ' � �O 7 7 �G ? ?O � � � + .G O� ' �'� � � ' ':^ �f: . `'r�f �O �o o m� �m �� N , � o N. � " ,:��y � �, � o � �2 0 °o � °��" - ` °� � / M i0� � �; ' `y ' 9 � Gu c a � - �� � '", G. .. �- 9 ��P.,� a o °3� � � � '�` -' o �' .* m 3 m^ � - ,y o' ;:' ` „f . , a\ � - � -\° r ,�: ( � 'o ; . (� '� �� ' � � � � r Di�c._ ,9 . � : ,{L� . '� .'4 � ��� '�. -�_�! b�0 . O� �1°� 1; , ,a n� o � � � �� � /`� ' � Q-O . 4 • � ~ ,. Y ' � � �= � e � . . . e �� ( � ^i O-C � , � ' r d„ O '(: �V �� �. 1 �.�' . OR �I � .. / �y . ` O G ' � � � �� �� A _ � � � ��• / � � � '� � ��' ��� ��a � � � 1 � ;�� _ , ��� '� y � � . � ' . '1 �� 1` i . '+ u� ' � 1 �� �. � '� n ' ... . . �,- �; `r. . � �y" �• `: r• _ � ; � , � ,i � \ � ; t, �� �, ,� ,,% , 7? . . ;, �,�_ ' , '',� , �, � ti ,- � . �� ; � , i � `1` �'` ��, 1 0 �i� i, l � . �. � 1 i � N � � �' , �'� ���' ' � • � � � �� � � � � ,� ��� ,` � }^ ,� ,�`� �1 , �, �,, � t " �� � ' �1 �� ' � . � �, 1 � 't �� 4 ,� t1 ,� ` `{ ` t , , V , ` �, .1 � . �1 �, ,, , �� ` •.,\ , � . \ � . �4 V - `` 1, , � , 5 � ., , ` ,i; ''` '` ��l `� - � , 1 � � ` '1` , �` �,`. , 1 I— / ; �` 1 , 1 . ', . `, \ �.,,-� �� ,. �\ ��� ,,��/ ,• `1 \� � t`.. , � ��. .. "� �� , - � � � ��.'d- '._ '? - �. t 1 \ i'� �`, . 1 �; � _ � ' � '� '� �`�" �� � � �. � + �� � � � � , ` � '..' , ',� `;= � - . cx �`5. � � ',� - � y :.�,c, � co ,� . ' � ,.. , � � . ,` . : - .� C.��t' O p�^4`�eav K'-..t.� N�6� . \ � i - m �.'.n A.�, �y,-b p N � .G.�': �i � � .. ' ' , - . . ` � C s� ' y' ."._"i.°� �+t�� U p '� .�`.' ` j ...V.�+�v� N ty��`C t�'.1 O C.,�'�,y F,Y'c7 M�O. Z `. � �',''� ,' ' � 1 `1 ` • \ ` C-� � ��C � r S'+.f� � C7 � O ��'f. .?'�.O� � r' �' .... `t p^� M . \ � \� � \,�, cr�"o�� ' i..'` r �'�..b � '�^ G � ° »� �-'' =`'„ H o=• x.o 's G., - : � '�, C��. x t;���K � ��-� � o�y = Q so �.:..� �C� a'+ �." N s° C , , � � o � o ..f � � - :' � �N c. .^.� o a t-',a x � � '" m .,r� . . . • C` '. O��p '� Q � �C'� j�,�!Q.�p �M �' �,.� rb; N? •'t Q .Y n�Z,'� F. �L...r �O N ' L7�G' ,- � � m .t o \ � n N C"t..�, �9 -'"ca-"�'��" a a o A��,.o �o ''^a .. r » H H °3 f', � ._ 1 � ` . « � A �'� O O oRi�� F �'s� �� p.„ � � j � ��(����„�=1�p- � �a � � o � ...,r:^ . �" � o� A. �z'7' ' �', �` \'�3', �-��'�o�.� c�a� Q w ?�'.o � ' c �� 31 m �_» M.�`P�� ^ =•''�^.`•='� 3 G' , , . 'l _ %�` f•L �.'. »� a Q .n�...� �c ^�,.V.p 4 '�^ f�i Oro �� � n L'� �y�C�.���••�Y . � 't m 1 � N c..o c•.. c x ,-�� c�a�, o � a-��. ",��,..,� A�.c `m -^'�> � � ..�' . ,'�1 � ," .�.�'? 'f '�'M:=i: � C C O O'O c •�C�-- �•-� n-9 O r - � / � t ��', =�~��,cn9 �� �'�.Nca `•'• o"0:2 � a�� ;•° oQx ��v'_;j37 ' `_ � 1• . , 0- G :.'l��' v,JiO` p� -Z...�� p,' .p�.�1 m-� p t-�_F`.�.t. ic '" N.in ^...' p '•' � O , t;� �� �\ " � ~-�o \'1 � u, y�� c'-�aP � �� �;. o '�^rono-£.:3 �"��t"o��° '«,c��� ol, � - m '.1 � m' �,c_F E„ r,-c � ::o m� "r `�t.^. o Q p,'� C?, C' -o U.^. �� ?- � Cl n y.��.:.(�.Q) p . ',6"�'� �-`''w t'�� C'b� � N ...;.� �t"�,,,..�,,,C.C`.,� �-.1 � _'` , � �� O % 1 ..�^• .F o.w�� c.:.eA.i N•rc�.t',"� : +n p ?v u�u�,..,-s��G�,� c�� ,,�t, •• �.�p. 1 " ' v+ - , c..c. �A �"� n � �'°..,;c 3'��in�c� �c w� �' f���:� '^..�� ,,��w. � 1 �', . c. p t ;i.. �.�`�m w •:_..:n.� ".C'o-'^� °r�, o�'v�'1 p��:;,�'" �u .� s cr, o , ' �' ^ �ti, �, m_ 'K. ¢ o 0 o .�'c � s�..�.� �o x� oa £'... �'� q �t, 1 . . i.'.. A ? - l - ^ . Q� _� N� } �O "•{r l i'w r ti Q ��_/��'�. �{ ''i "'J �t ,_l � (l� '. �`L ��7' ,'`-^n���-..., y . `, \ �` ' �' ' O �o � O ^ � _� � � �n � . �, . _ � , . ' 7 � .� C- 1�� , ' N ,, 4 � _ :� `. - . . ' '`." , — ., `. .. , - '`_ ..