Loading...
HomeMy WebLinkAbout1551A )1'ORKERS'CO!P.FENSATION OECLARATION I hr�rby o����m rhal I hevr���,,,�;�o,�oF�o�,��,,o,��� APPf.ICATION FOR BUILDING PERMIT � msure,o.a cen�lita�e of Wor4ers'Compansalion Insu�once, cr�o ccrr�lird ccoy�hercof(Sec.3300,Lab.C.� COUNTY OF LOS ANGELES BUILOING AND SAPETY Palicy No. Compony BU�tC'NG � Ccri�l+ed copy is hcreby fur��shed. FOR APPLICANT i0 FILL IN ADD7E55 � ,CrrGlied cepy�s f�ed with ihe counry huild+ng inspec- BUi1D�NG ' lion Acpnrfinenr. AD'J�E55 _���1/� DOIC Applicant CITY {JI��O/�I��,� 71V' �I/Ei l IOCAtITY .0 NO.OF BlDGS. N'.AREST CERTIFICATE OF EXEMPTION FROM VJORKER$' S�ZE O�lOi NOv�I ON lOT CRO55 ST. ti • �}[ CO1dPEN5ATION INSURANCE -�— �This seci�on necd not be tomplcied if Ihe pe�m�1 is for one ASSESSOR ' hv�dred dollors(5100)ar ICSS.� TRACT OLOCK LOi NO. /J�AP P.00K PAGE PARCFL O`h'NER C ��' f USE ZONE �N } I te!rlily ihot in ihe�crformoncn.of the�ork lor wh' i is �� n. permi��s iss�ed,I sholl not employ ony p son any nnn . 6 S°E�iA� U so as l0 6eco ,su�[t lo Ihe�'✓o�k i Om�rnsali n La �DDRE55 p� sV PCa�!ei��. �.� CpNDITIONS �) �d. aTr n� i3a, ziv C� � �/ Do1N Appli[ant ARCHITECTC+' TEL O J1 NOTICE TO PPIICANT: If, a(�er m ng this Ce�����ca of DISiRiCI GROU7 TyCE F14E PROCESSED BY �"' E.emp�ion, you should become subjen �o �he Wa ke�i ENG�!.FfR N0� CCY$T, . 20N W Cemp�^•.�'icn provisiars cf the labor Codr.,you mus�(orth- pDpRF55 • � �" wi�h comply w'�h suth provisions or Ihis permii sholl be TEI. $TATISiICAL QASSIFICATION AVT, COt+00. Z deemr.d revokpd. �04iRACTOR NO. — IICENSED CONTRACTORS DECIARATION �i�. RA55 NO. DwEIL.Uv1T5 I hereby ollirm thot I am licensed�ndr.r prov�s�o�s o�Chcp�er 9 A��RE55 Np. �w,���P �tommrncing wi�h$ection 7000)of Dirision�of the B�siness ond liC. Professeons Code,nnd my license is in lull Iorcr,ond elfect. CiiV Cta55 BK � VALIDATION SO.FT. NO.OF NO.CF CHFCK licensr.Numher Li[.CIo55 SIIE STO4iE5 FA.MIL�ES O�E VALUATION an DESCRIPi104 OF WCRK �,� N'w ❑ 3 CoNraclor Dalr. ACD = `" ��� , �I am ezempt under Sec. . � � ALTER B.BP.C.for ihi�reason REPn!R ❑ s . ' DOIC: �SE OF DEI.tiOL E%ISTING OICG. � :�� 5 J� l�i AFMIGiNi TFI. $ignalurr. FR:NTI NO. FINa e • • OWNER-6UILDER DECLARATION DAT �/, �' � ' � I he.eby aff�rrtl iha�I om ezempt from�hc Controctor's Litense law for Ihr.(ollowinp reoson(S^ction 7071.5, Businrss and /OCoE55 FINAL � • �U�.G; Professions CodeJ: _ .__ , a�ie_!n� B1' a . c — ❑ BU'LDiNG � "��^— I, os owner of ihe p.cpe.ty, or my employees with aDo4e55 .i agez as ihr.i.sole compensonon,will do�he work and �� � �1 0� ,i—";S the struc�ure is nal intendcd or o((ered for sole(Set�ion �aA�iTY 7044,Business ond ProFessions Code). fAOVING TFI. � I,os owner o(the proper�y,am e.cl�sirely contracrfng CONTRaCTOR NO. wilh licensed tonlractors to conslrucf Ihe prajetl(SeO . qD�RE55 iion 7044,Dus�ness and Professions Code). CONSTR�GTION LEND�NG AGENCY SEi�Bq�K Y�RD NWY ���Apppp�iNE� W!D7FI I hereby af(irm thar ihere is a cons+ruction Ir.nding agency For f RCu� Ihe performvnce o�IFe work(or which Ihis pe�mit is is�ued n.t. (Sr.C.J097,Crv.C.). SICE v.�. Lendei s Nome lDMA Rel.M Lender's Address P.C.Fee S Pe�m�e Fe. J I crnify ihot I ho�e read Ihis appli tion ond sro�e ihot Ihe Nwonce Fee � l�"M P/C M , above informm�on is corre .I ,�e td Comply wilh oll Counly � in.es��ga��on Fee ord�nOnCCS Ond 510�9�a s relati g�o uilding conskuction, To+nl Fee IDti+A Perm.M and here authorire r p.esem iive of�h�s County�o enter vpon�he above� nti f or ins ncfion purposes. ��q) � � _ 7'�Y(l�/ SFE REVERSE FOR EX�IANATORY LANGUAGF � naNre ol Apphconl�r Agr.M Dole i_.'_'T' �^ f _.' __ �-1._ ^ "__i"i ,,_,"`-_'i.-.__�_ __V'.I w'�_�. T �.__ _"'i_'__ __" __-.' _IIc i C_ �: ; : �. : �� -1 � �, I ����,-._ � , � �= - ;:T ;� � . =--1=—--�, � - �� i � : � �� -; , _' ' �? ci .., �� I �: �,:Ii z' � .. - I _ i _ c -i _ ;-= I -� I I. jl i ' 7 ~ -=, `= I = �: I , I � _ __ � � � I - � •: �. , ��� D . � � 'n'c n -, } M i a „J 1. �� ;.: �n� c: . � � `� � I _ �� ' c ` N � I' � I I `� L 1I � ' I I ' _ j � I, .v I L: P. n n o , r. � ' �= . b N I � � _ _�I < � I � � `: I, .< , il o� � � _. _ � � . � : � I _ �b I - II �r I ,, II� . II � � i • I I. �i I ! O � •I' , ' I � ti ' � _ _1__ ��_- ►� � � li o -- — --�-. - -� — � 1 I ' �� '� y I I ( �—� 0 O • — I � I • � ' 1 I�c � � I� � � � _l�' }I c 1 6 < ,I _ I I�ti � II � � I I � � n I . I - I I I�� ' ��c a Z � _.1 _ _� , �� � � � � ., � . - . ____... _ . , . � .; � � �- � . j; a o� ���' _!-_!i_ N � 1 p;. D(, � . � I 9 � �' D � � o c . I � , a � I i � I � j � . � 6 � O i �4 I II [ I � C I 1 � � I I � � . . . � Z N � ' � � n . . N . 0 � � N . . O � N T N �' . . I � ' v � n� a;�� - �Z-�^ ?7 : ��J f � c ;• _ � ❑ - C -'� ! O 7 C � •'G - �. '� - �'- - � ' - � � - ;�:.M R v� ��j �i _ ` � � _ _ _ .' r�. �� T C a' _ � c. , _ - �. �. � '� ; .. " �= ��0- L C Y _ `' C`` 1 v` f � p � � !t� _C �'`^ � j � `. S � �r - l: ~ ^ - C G -i . � `~' � r i.r o �� ] n � L " s t�� i� p ' a z �: `��� � y Y _� � � : �-. � F �=� z : �" '�_ ; 5 �� � _ 5 � � _ _ I � t• � �' - = ` ��r � - , ` �' ^ - ' - - � F c c-� ' � � ���- _ u � � � � �[ • r � , � _ � , � ? � •• 3 L G O �ti 7 a,' ' j q O 1� _ t,= = i =� . , L�' 1 ^� ` � �J � � ^x � _ � ` � ` _ �' _ : '_' � , _ ^ f - � T 4 L %i ^� � r' V y �� � T. + �, y ' t ,, ti �� �� w � . -ni .fn ` ' �w`C C '� e � :•� �.L � � �r �j L � ~ _ _- �- - O � �. � :.N r. _F+� c�= �: �e � _ - � `-. � _ _ :. _ �. . N � _ "` � o ; L a � <-` ? . - �.�'_ ' ' ' = " - '' - - _ ' _ - L= r� � -: - . � �� +�.� _ � �� G`�~ �' -. _ � � ' - � _ ` T= i j �r.�� " _ �� a ' ^^ = ' ^ � `� ^_N J ` ^ ^ � . �! r $ U ,�� � � �� � � � f' = .� � . N 1 � [ r y'4^ ''`' � C = , `'�"`_ � Y _ _ _ _ � � - ' � _ _ ';.'ti ,i, C�`"' ; � R.'< �� � � _ � _ . ., � i T. - . C 6 �'i . , . . r � �� ' � � i ' ��`�-� ~ :' � - ' - - : • � M _ - _ � _ ' �. p . : _ -�r � � ':.= � �,�' ti c'� � a` �=; c . = ' G fl � �` _ � r � _ � � ='�,�,.ii�. j _ � � �- ;�• � ���,� " i'1:/ , �� ^ � n ti ��, e , „ 'n � � i. � _ �. ` i � �. �,� ^ � - 1 ` � t �' �; �'� _ i _ ` _ - ' � i�-'c. I ,,, o. _ :. �. � n ` -. ^ � `� n r. } =�.J,` � � . �. � r � . �r �� � ; <, - � 7 l ; L`. 'i