Loading...
HomeMy WebLinkAbout0979A • VVORKERS'CO".1PFNSATION CECLARATION . �I hc�eby�,,,�m ihai I hove a cerriFicote e��o�,e�,,o=P�� APPLICATION FOR BUILDING PERMIT � �nsurr.,o�n cerr�f�co�e of LVorkrrs'Compensorion Insur�nce, o�o ce���l�ed conv�hernnf(Sec.3@ b.C) volP, � ��j�3'$'�m a�r� t . Y'�l COUNTY OF LO$ANGELES BUILDING AND SAFETY P nn Cc.rif�ed copy�s herehy f�rn�sheA. FOR APPII NT TO FILL IN ADCRESS � �v �. fY�+�'� �N � Ce�nfiad copy�s kled wuh the c unry buld�nq inspe.o euuoirre , (��� " Y, `� t�on depa��men�. 3 � nooa[55 l� � i Date ZS���i��o '� 14t���(lGt� uTv Cc✓Np� G✓' z�v :ocnurv CERTIFICATE OF E%E�!.PTION FROM WORKERS' NO.OF BlDGS. NEnREST CO�MPENSAT�ON INSURANCE SIZE OF(OT NOw ON!OT CROSS ST. /r R. ' (This sr.clion need nof be completed if Ihe permil is for o�e. �7 ASSESSCR hundred dollars(SI00)or less.) TRACT /S� BIOLK l0T NO. �fAP BOOC PAGE PARCEL '� iF �'i/'l �i/ U� ZCNE flAP } I cr.nNy�hai in ihe Performancr,o(�hc work for which ihh OWnFR �1� �- • /'� /1S NCV�(ovrC}� / �. �,ZQ�?y.C� d permil is issurd,1 sholl nol employ ony pr.�son�n ony monner � � SPECIAL O so as to bemme subject 10 Ihe Wor ompensa� Lowi. /' ADDRf55 � ` �/ � � r. C0471TIQN5 V Oate��pplicaM �Y, �2tc��„ arv � 2/'Tto�'�[ �� z�r p ARCHIfFCT OR �E�� DISIRICT GROU? TYPE FIRE PROCESSE�BY NOTICE TO APPLICANT: If, ofter making Ihis Cr.rlificnte o1 FhGiNEER NO. CONST. ZONE W E.r.m�tion, you should become. subject to Ihe VJorkers' Compc�saiion pro�isions of fhe lobo�Code,you musf fonn• qD�RF55 1� � ith comply �th such pro�isions or �his permir zhall bc ,� z dcemed revoked. L ' TFt ,� CC' STAiISTI�jS��IP.SSIFICAT104 APT. C DO. _ CCNTRACTOZ 1 1 G [� I(/N, � ✓� �/ IICENSED CONTRACTORS OECLARATIOY (/'� / ���, p c[ RA55 NO.�c�DWELI.UNITS I herr.by o!firm thol I am licensed under provisions o1 Chap�cr 9 �DDRE55 Q/� ` t ' NO. �/�/ (tommr.nc�ng w�ih$ecuon 7000)ol Division 3 of ihe Bus�ness and �i� !.� SEwER�nnv P�ofess�ons Code,and my license is in(uil lorce and r.ffr.c�. C�T � �S��a�. � C�ASS��/ eK � VAIIDATION S //�3� 50.Fi. NO.OF NO.OF CHECK �iCenseNumhP.��/ ��� LIC.��OS! `--� SIZE � STOQ'E$ FAMIfIES ONf /� � VAIU ION �� � � %� �ESCRIFiICNOf WORC �G�' NEW � N� Can�ract '� ate C`— �1 ADD � s � �I om ewempl under$ec. J `S v �xC � ALTER ❑ , 8.8P.C.lor ihis reason RFiAi4 � s . Da�e: USE O� CE",OL ❑ :Q�j�7.�i�{ FXISTING BIDG. Signalur� l.PPLICANT 7E1. FIHAL ' • • • OWfVER-BUILDER CECLARATION (FRINT) NO. DATE �� '�� � � �hereby affirrtt thot I om erempt fram thr.Conirac�or's litense low for the lollowing rcason(Section 7CJ1.5,6usiness ond PDD?E55 FINAL � � • •7':,?� Pro(essions Code)� RunD�N3 � By • • •7�.�v� � I, os owner of Iha propeny, or my emptoyees wilh a0o-FS5 �� ' wages as their sole compensat�on,will do ihe work and , ��.� Fy—�3 �he srructure is noi intr,nded or off>red(or sole(Settion LOfiILITY 7044,Bus�ness and Profess�ons Code). MOv:NG iFl. � I,as owner ot ihe properly,om exclusirely tontrott�ng COti1RnCT0R NO. �/ with licertsed con�roctors to cons!ruct�he projr.tr(Sec- qo�ce55 �""'" Tr�9 � iion 704a,Business and Profe.ssions Codr,). CONSTRUCTION LENDING AGEhCY SET�BaCK YACD HWV �U�ADRO�l Nf V WIDTH I hereby al(irm thot ihere�s a cons�ruc�io�lendin9 ogency!or (pUry� ihe pe�formence of ihe work fo�which�h�s permit is�ssued a�. (Se[.91�7.Civ.C.�. SiOE P.�. Lender's Nome � G �.7`S iorra Rnf.M Lendcr's Address v.0 Fee S � ve�m�r Fee �-y� , I certi(y that I have read this applicotion and slolr,thol the Issuonce Fee ��`�V lD�4lA v/C M obove information is correci.I ngree�o tomply with oll County Inves•�ga+�on Fee (� ordinantes and S�a�e lows rela7int�l0 6uilding construction, To�ol Fee !�� LDMA Perm.M and he y a or�ze rep�eseptaiives of this Couniy lo cnter u�� ah6 menS�onP Qroperry for inspection purposes. x // ��•��`. SEE NEVERSE FOR F%�LAHATORY IAHGUAGE S�gnolvre ol Appl�mn�or Agenl pn�e �� +�1'w' `°. , _ �--�' +' �o _ " � ' '—'.�..»� �i .,� 1 ' ----•-' 1� ._ --t.;• =.'�, ' � ': . �,. , ��_ .�:` (' t ,., i c'� r ', , . i ' • �1 � ` - '' •', J �:� (� � l,, f. I T* � , � - .. _ i 1 : ' • ^� - ': � i!t .. ^ " � � .f^ � �,�� . r. '7 111 �'.c L 1'' ,1' ,' ' t? ^ ''� 1 � , '' r 1 1 ' r �^ .��__` "1.. ♦ 1 r,t ' (, o `' � � ,r �� � t �' • r ; +� G'. � . �� � � � G 1 (•,1� G S� ` � '�' �O � ' _ - �: � � r 7 '; ' !' � 1�1 i!� •-�`' '^� o � 1 - � .c: �• 1, < . ° ' , �' 1� �" 1i 2 0 Q �3` ��,7 � o r �� J 'c � ~ <"+ , ' � � �.� 1'`�T .. j `� I o �° � � _ Y C .. rp ' '.• 1.� �7 '- --~` ' ' '.+ 7p •� � i�' C n IC'�.' �.n. t �-' ��1! � o ' � ''.o v :� ' 1 ! � O �� �� o, ,�4 a ; 1 11� ° ' fi�� y—. '' �o '. �', , ��-�'"' � � . ��•1 ' �. `� � . i" ' 1�� °o �' s ,' .. ' � �` y 6 �1 C �1 I , � �! q � 1'I p r ' q 1 1 s � 1' 6 S� • O� � O'6 �� � - . � v' 1 � ��° � � � � � , : : , m , .� . � ��. . . . . . z N . 'O � � . (1 � • • 0 ' , . A, . . N . Z _ O a . , T N ' . . .. `, C ".-.f �C.,.�..C. � '.� . -..��C �y'�• j_ �t`� �..�= � •• : y�, . � . . �..^� ' - k C � .. �' � �C� �.' c " '' i �'�� = ' ' ': - =r";. �` = - ` -- � � % , ',r- •Y• F iF �,-, e.:,.�C-�,- C�N ' _ �^ .,^... �'� ^ y � � '.^ S^U 7 � �' L Y • x � �;'' r : �:. ��� �_ � . 3 ' � c N : = .�-. =..� s � � c - �%- 4 N . .3:..M:� � f _ �� '�� � _ ��r. + p ��7 ^_'C' ^ y r _ � _ � , � �, �� ' _ 'c. �7 _ -«j �^ .. :. ..,`' j : _ %' i.'b : : �= � � . . 7 � S C •�? Z 'a t. c 'P : ' '• � - F _ ► o - �'- r � 4 -�.^_a C � ^ T� " � D ~i' � r. _ -- �� ,� y . .. ...> t_'�i - �'': �. � 7 _ 3 r � �, 3 ��� ,,,,'.'c.~ �' Ci � � � � !7 : G. .X - S"� = " G r'- � i l •� _ C.. � � �'.. �L y � ' . [' v � t" ^ ._x s -,. � �y t � o ; : 9 + � _ ' = �- .. j - ► � s �-� �, i: �`' a^? [,�'i,�"�-r `=e - :� " ` ' _ �s. �'�. � � - = = • =. .. '" a c' - a � .'-, `� _ ... � � � �. p � ' ��� = c " � .' � � � .... � ' 'I C .�4 _ ,n � .. � � i� - p _ ^ � Y_- L ^� � � ± r ' ` L ✓� p C :..C" .. .V. <' ' " : " �� � = c. . ! y� o � ^ � � 'C L 3 �".��r _ � J p C'.'...,„t S � t' �- � ' .�- '7 N ' ..y.• � .. 'r t^ r' ,. =t :� 5 i, n• ^7 �, �, S ` C. ' r" r` s, _ M c : a '; : � c : - - :_s. N .. ...y.';, ; � n'` ' '^a - = �-.� � :. s s � . � � t p �- C; ^ = ',G C L'+� � = '� �c � K ^�I. . . 7C _ C `y.. � ;� r =�^. z„`^ ^ r �� ^ � �i ' f- = -n .� �� N _ � � ,�� ^ s.M i �= y _ � �� - Z � � � t t:..�.` . - � � �' =. .. - � = r. - `'�'�i; O � = c .��^ .. r-! � •' £ '� '" = - =" ' _ � �" , G 'C = = � _ �'� C `� t, � � _ � .. 7 .. ' . � ' 4 G% = �� `o .1" - T�^ c•. �� 7 ; �i =� _ ` 7 ... ^ �; �� = o . ' . ' _s i: a.' ' • . �1 Z�1 � '``�� ti�.3 �'�,' � ' � c, _ T F n C _` � J f. ••, •' • '