Loading...
HomeMy WebLinkAbout0979A (5) • 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 _� �'�� r,? I a :� I ;i L -..�_�' --I� T I �--i-�- i��--i-�.''- �? - —;-.��-�- --- —- —�=-.-,'�.� o Q •3 :a c � - - C' K. ,-• ., �?' =I� : I I ,.. I I � I '_ ' ;'�' '�' �� � ` . I. ' I �I V ��� � < _ - �• -I v I � - .� �„O �:l t:: I 1'• �.• I! , �, j! I I '/ "7 r,, � � � y' ?. '�' O I i �: �; �T' '� y 'I j - �: A , I � ,C'.,r, - •-• j , a_ ' ;, p . I 'r. ' S' I �_ � rt ' U � j .. _ - � n : I � � o � � �� i�o • ~t y' � _ - .Jo I _ � I. r , I I" � I � � � - � . ) ' I; : i �� � ', n I � I I I - _�I .' I � � � I � � � ' ` I O � li � I �� � � — - "' ; e I 1 ��z " —�— --�--- -- o •=1 � � I ��r � � .�I_I:,° r �� . � � - � , � M;__�� � -� .. �� � ^ i ; ,— — —,--- o� i �� ; I I� ., a I.0 ' n , o � a � y � I . � _ _�_ _�_�__1 �;� � o — . � . I � � � � � � �_!: : � � . �; i ,� i� .` I �o �1 v A y �� ' � � � II z c � '- � � . . � ` �� ° �; � � a. . �� a �; a . , , . � . : � . I . 2 - N . � T ' . . � ' n . y � i A N � � . Z � Q --1 N I . C �, f�5 .l'�V � 1 T'� ^� �' �� � F � C t '. � ��:�.' - p � ^ ` U 7 � c L � � _ c F � C .- 9 . � ^�L c � ' .- : t'„ u. : 3'' � y V- � ' ■ F ^ � � � � :e .. c Y. �, ` [ � � c _ r w � L. � L ' � e �C' ' ' .� �,. +• - - - , � � _ z a � ^ _�c ti F c '^ _ ` �^ c �� ; = _ . `+ �F 7- � � �� n .. � � .. ^ N - �.. ti � _ '' � ., - n � � F., ; � � �C„ '�" �M ' 3 � � _ O [ >' �.` _ _ L G C . ^ .. , � � �'7 r ^ � � �� �c. ~ ` ^ r^ � � �'� " `� � `� � � .. f ? ` _ ``c � F _' ' _ c __ �� F = _ _ C `. ^ ; ' = ' � ^ L � � : �: �. � 1��- C r ? _ _ 4' '� C � n N = � � .`7� j' �a a - .� j � C ti +. � ?-� - � _ = . Z C ^. ' .`. ti� `� � ^ = C' ` ' � C •� ^ ~ a � �^ ` � i: - - T (� L, � `=' :� ry ` ,, 7 7 � G•N " y, i � � �.,�L�\ r- � h ,r � . _ '�i„ 2 � � . C -�i fn �� - C ^ ' - � ' ^ (1` �3 \~ � �� ' _.i _ �• Ci .1 _ ' 0 q sl^ � Z �C` C� ., � _1 ' C � [ ' � � � ^.` � _ � � �-[, C M C �'' C..`C� � �'� ` � .. y `^.� `�:� l `� . + _ � • ? � N � t ' 3 ; _ v �•`i ..� U ' _ � � ....` � L ,� _ � Z ' �.. �C � - = ; � ' .� � .. ] - � ^• � ' Q F i. ' - ❑ �, - � '� � - $ p C� �� � _ _ � N � ^ C r "��•s.^L` � _ r = _ �L`j _ � L _ (, i O � ti ^ �.' ' �` � � t-y _ ' _, � � � _ ' � �� = c _ ' � r ' t ° _ �_ � : ' j'': ^ � _ - . � o„ .'c � � � a � .��.\ � . � -� r. � ' �` _ L c _ r i.' ' C � � N,� •� K ` �_ � �'_ � � F �- ` � = _ ;i _ � , % . fl ..�� ;- � �' � _ _ _ ' n (` r Y: �,` ' _i. �• .. _ � - n � �" _� �. F. . � , C, � � ��C �� � �r 3 i. _ f _ ��= - C �. u(' I . . y . .. � �:�� . y . � �': � �.. � L a _ y . .. . . ti ' ' ' .. .-