HomeMy WebLinkAbout1594A (9) WORKERS'COMPENSATION DECLARATION . . f - �}
I here6y affirm ihat I have a tertifimte of consent to self � LS
��,��a,or a certifitata of Worke�s'Compensalion lnsvrante, �P P L I CAT I O N-F O R �B U I L D I N G P E RM I T
o�a certified copy thereof(Sec.3800,tab.C.) . COUNTY OF.LOS ANGELES__ ��'i. . BUILDING AND SAFETY
PolityNo. �Company BUiLDiNG
� Certiiied mpy is he.eby furn�shed. FOR APPLICANT TO FILL W - aooRess a09oZ
� Certified copy is flled with the cooNy buildi�g inspec- 8UIl0ING I .
, tion deparimeM, � . . A�DRESS � .� ,�,�p " LUCAIIN .
NEAREST /.' .
Date Applfmnt CITY W P ZIP CROSS ST. l�n�
� CERTIFICATE OF EXEMPTION FROM WORKERS � � NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP BOOK � AGE PARCEL
(This settion need not be tomple�ed if the permit is for one use ZONE nwP /aV..-� �� ,
hundred dollars(E100)or less.) � TRACT BLOCK LOT NO. �1 NO.
. � TEt. �n � SFECIAL �-
I certify that In the performante o/Ihe work for which this OWNER � Np. 7 C71. �� � CON�ITIONS 0-
permit is issued,I sholl nat employ any pBrSon In any manner ' ' � - - - /� �� DISTRICT GROUP TYPE FIRE PROCESSED BY 0 _
so as to become sub�ect to Ihe Worke,s'Compansation Laws. ADDRE55 y y I �� CONST.,1// ZONE �
. . . , . . �.. .. 1' `.J
Date -� � � Applicanf - ' � � CIN. .G �- .. ..ZIP / STATISTiCAIClAS51FIG4TION APT. NDO. � O
NOTICE TO APPLICANT: If,ofter making Ihis Certificate of ARCHITECi OR TEL. _9 � � � �V
ENGINEER -NO. � ��qu N0�-`/ DWELL VNIT$ W
�Exempflon, you ahould become sobjecf to the Worken' p,
Campensation provisions of the lobor Code,you most forlh- . .. . y
ADDRE55- - � �� -� ��------ �- -r SEWERMNP
with.comply wilh such provisions or this permit shall be � �
deemed revoked. - � �pMRAC70R .. NO. �� ��BK. PG,- VALIDATION
LICENSED CONTRACTORS DECUIRATION �i�
I hereby eHirm thot I om licensed ander provisions o(Chapter9 ADDRE55 NO. ��,VAIUATION �-
(mmmencirg with Section 7000)of Division 3 of the Business and �� ��� � . �
Professlom Code,and my license is in full forte ond effetl. GiY CW55 ���E�QQQ -� ,, . .
" Sq.Fi NO.OF NO.OF CMECK .-..._ . _. .
Li[ense NUmbef �LiG C�oss SIZE . Q STOR�ES FAMIUES � ; ONE '
. � . . - . . . _ . _. /. N�._❑ E - - . .
CoMfattof D�ta OESCRIPfION OF WORK . � - ' '
� � ' . c . ADD� . -....
�I am exempt onder$ee. ALTER � � FINAL - - ^� ����.a � .
B.&P.C.for this rcason . . .... .. . .. . . ... ...-- REPAiR � DATE�—�'�-�� ���.• . . a ' ,
. � . . . Data: USE OF . � . DEMOL.❑ � FINAI . .
ewsriric aioc. - _ _ ar I • 1 1 1.7 5
Signafure ' . . . . ' APPLICANT TEL.
OWNER-BUILDERDECL4RATION �WT S .NO.S � y ' -" - �
1 hereby aifirm that I am exempt from the Contracror's License � • ' � � �.�'S�
law for the followfng,reason(Section 7031.5,Business and ADORESS 1 �- - - � � �
0�.30-83
� ProfessionsCode): � . � vueSeNi ' . ._ ... _ . . . .. . _ .
\f"1 BUILDING _ __ .___._.. ___ _ _ . __.. __..
n�� I, as owner of tbe property, or my employees with A�DRE55
wages as their sole compensation,will do the work and . . ' . � .
. � the sfructura is not IMended or offered for sole(Setlion -- ����TY . . . . . .. .__. ' . . ..
7044,Business ond Profession:Coda). MOVING TEI. .. . .
� I,as owner of fhe properry,am axclus(vely[ontracting NTRACTOR NO. ' - . � .
with Iicensed conlroctors fo canstrucf the pro�ecf($ee- ADDRE55 �
tion 7044,0usiness and Professions Code). =� ' � � .
� � REQUIRED TOTAI SETBAIX FROM EXIST.
CONSTRUCTION IENDING AGENCY SET BnCK YARD HWY pR07.LINE WiDiH ,► . ' � '
I hereby offirm that there is a con:truction lending agency for . FRONt � �- � � - -� � ' . - - .
the parformance of the work for which Ihis permit is issued p.L. .
�Set.3097,Clv.C.). � � SIDE - " � �
_ . . _ . . . .. P.L - . . _._ ._._._. _. _._ . . .__'_. .. .� ..
lender's Nome � , __-\�-���
—.: ,..
. . . .. . . _ .. __ . . .. .
P.C.Fee E Permit Fee ��ar
Lendei s Address . � - _ � � �
..I terti that I have read ihia a lication and sfate ihat the . . . � : . .� .. - ---.. . .�. . �U. .�O. .•.. .':� � . .. � . . ._. .
fY PP Iasuan<e Fee � � �
obove informarion is correct.I agree to comply with oll Counry Investigarion Fee . �
-ordinances and Sto�e lowa relating to building constroction, -� � Torol Fee /��•�J �
and hereby au�horiza representatives of this Counry to enter ., .
upon the above- tioned property for inspec�ion purposes. � � - � - �� � � �- � - - � ��-�- � - - �
� ^ O.�� , SFE REVFRSE�FOR E%PIANATORY UNGUJICE .__ . . , ,
SlgnaNre ApplimM or Agen� pote. . ..m�
. . - ' . - . . . . . . _. ... . _ . .. .. . . . . /
__--,
_-- z o
. ._ o
I � ,. _p -9- '1
:„� c� ��� Q � �, `� �
� �' nv �a o a�, o �r• n, � ,� ', ,i
0
O 7 n n N O � ' V p O �y � .
•n N O -F p Q 9 �^. �.' � p -'� C � tf -'' a
-n N O (p fi • 9 O .i" P p'. •p' "' � � +.
�• � r 7 O p � O'O. t0 � � (l 3 ��' 3 q� � . p;
= p a m a' � o D a �i N o -o � e_ �� 1�
j 7 O O S � m O O j�� w � � Q� O O + ..� , O p � .
m p lp '" I �O '� O Qo� p _' j n. �m � ,? i N . ',� r
O 1 ^-° x `�'� � N -G ` ' " . �o -�'. � � I 9
N .n.. 7 Q 'I 1 H
7 W� (^ �p c O r ' 7 - � t,�
,n �3 0 4 ¢ , ;� �
' ,"�� ° � � a � ° �
a 1 t � � .� A �
1 a � � ° � r�� �
O N r, . t .
� n
Q � '.3 ' �
p A
� � � � � � � �, �� • O � � ��t � �-�
� Q., � �� ' , .. ,11 '
\
. ^'O� �' -..
\\ w • - " �� -� :'O
p • �I , �� . � �'4
\ � . . ^ ; o
�' ° s. `a
y1 '!�, . � ��� . Q�
� N `' Q"�
` \' • ' � � .. . � ,..
� \
r
f
\ . -- �` �I . �� . _
� , ti `
� ; '
'� , 1 �, � ,1 , . ' -- N
t �� , 1 . ,1 �
. ' . �.�� i ;� N
,i _ �
` :' '' . ` ,' ;1 . - ." �� . �
� ! I I
- " . '�" , • . � �� i � ,.
_•',,� . ',' �1 — ��,` - ,.I 1 ,` l.+ . . - .'� .
. � . , � . ., i .
1� , 1� .
�� . � '
� � , : t_ , �-•
' _ � } r-'
, � -} � � ,p n�- =. a- � � p �`S -
, � _ ' .. '. . �: _. „� p ^o p� »n; � �..• > m-
I » . '� •. - ,� n {�+C T$ _' w i q^0. .`�. p'? z n lp m , .,
� 'J u_"'r ^"z A M o R.�p. 'A �..�I O 3'b � N N �R'
' � � N .�.�C'�� � O"0 !'E �� l9 ti"J �6 O N��-..1 Q p O.�C' Q:
_ .. �� � ' .3.. a A ¢ x N ♦ .. -� C�„�T"'i:R x O �;
- 1 i � C`1 �t ^ �t:J ��-L�`.�' e� c �•� o N � Cl C �Y �.` •ti �� Q- £ 7
. � ' Q O � �N" � £ C"� .��.,cri-�.".~O.�f�„' c `� 4 ��c+ c� � o p e.u "'y ^.1 .
❑ N ti _ � '. � � ? �-� s.3 ��.� �,.. � � o.3.y-i,
. . . � � � i `b T• •' "� » L �u f+ ^ � r ^y`i a o . �.o
' . _ � - '. 1 ] ' ^ „ i .�O �� �.'1. � „' , �n O A..N ..� 'O � C ca �n y n ^ F 7�G '
i � �.. r. s+.
.. �1` - 1 ' �'' " � �•^ 7 � `��"�� �-���.Z~ O O O � C A � C ��'� n -�i �i p �,O �� .
��'J S�n j :. � �~J'N .p � �� � 7+ �� M y l0 O 2 q �...
,. . - �V � ' - '�� �Al �•aoNA0.,a� �?a .cn' '.n,x � '^'ap `'' fswnG�� " n�� ri:
. 1 � :�. � ^' c..o � ,n,-�r'_.�m �t, N a-3ro a n -,...��"«' " - =� �,��. `i p r,`:.'
j �'� � � � �" � � 'r z c�-= c'�a.�^� :.•� ° ��," � «:»^ a � t'�
� . �. . r >� z n �»..,,�',�p 4 .,'a ..�� `� Qp 4'6 �c.^ � o �Q,C .....�� �_�'.
a- n '? C ,� C:.^� p m .� L^n �-���"m r� �i? N fi.
1 _ . � -n'. �:.. J `� ..� ��„ � O .^�I ,4 �^..c. . !xi �� �'i.� x-C N ti"S ���-��. Y A .�..�
� t� - .1 � (1� .��. ^ j N � ` �l'- i O�k C Y H A 7� 3 - � O � 6�n �. • y� O .�.. t
, �� ��' "'� ( �.� �1 n h A P �., n� / R r�'_y� w\n A f-� �-ia"U��y 3 Q.rt�.i� .i'9 O � 3 .� �,
� � i ._:0... O ° ; �,�..o. n a!3 p,n'n � + „ Oc� ? ,t . O t.,..
c -, : " N � ` i '� �" �o' 3 � ����"�� ° ¢-� o�,o•Q a � � n n � � p,fi'�/:.
.�i 1 '^,p � c m ^ n ,.;.�t.�y m =a N o N ,.; �,3 M �.�,', x [� �O
� ~ f_ � � n n K ,t.��a: .c, .� r a 9 3 A A 'Y C y� � � p.� ,�r
- ; p - i ="'.,o � �.: � � .a w=�.,� « o p 9 � ;�� � F`�'L . +G y .
�'f �- � v, •. O'f . ,y'�� � � � ' i� ���K.N.��i.. O O� V�� W p R �� � fi L;,L' �'p.:
. 4 �
. - ' � ^ [P� .. n ^ p 0� S' x�S C IM'� 7r N O�.�`t �:�o e�l•e ._.L„��'
t � 4• �:a b •. -� a n •+ a C-� v C �" � ?,�L,'-:
j�' � � t: t -o� .,x r" n " �0 n � o r� C'n � e� O P � �"'e C�N'�i
. - � ...�w�t � � O ' � ,N_ � 3 a � �':;�C m
� � ' :'. , � y n^ _o y�% �,�� ,,',,, o: `',�o �;� �a„s -
U . . G I p:� . �O /p Q �' _`f q'ef� ',
.. t � r . ., 1'�^ � n �
_, < _ " � �- r � •-� �� �'
c �� �• �l. .� '
. ` . ' i,'' ... - -