HomeMy WebLinkAbout1749A WORKERS'COMPENSATION DECIARATION � �
� I"hereby af(irm thot I have a ceriificote of�o�,e��,e se�f - qpp��CATION FOR BUILDING PERMIT
insure,�or o certiFitare aF Workers'Compensa�ien Insurante,
or a c�rtified copy ihereof(Sec.3800,Lab.C.) � -
COUNTY OP LOS ANGELES BUILDING AND SAFETY
P:y!cy No. Compony �
LJ �er;ified copy is hereby furnished. FOR APPLICANT TO FIIL IN BUIIDING
OADDRES$ Z ,
CerGfied copy is filed w�ih ihe coomy bu�ld�ng inspec- gU4DiNG i
tion deportmenl. ADDRESS
Date Applicant CIN ZiP LOCAIITV
CERTIFI�ATE OF EXEMPTiON FROM WORKERS' rio.ov eio�s. n�neEST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRO55 ST. �
Qhis setiion need not be compieted if the permit is for one - TRAR 3 BLOCK � tOT n10. �ESSOR
hundred doilars(E100)or less.) AMG BOOK PAGE PARCEL
TEL. � _ �5E ZONE �P
I tertify Ihat in the periormance of the work for which ihis �NER p � � �
permif Is issued,I ehall not employ ony person in ony monner qD�RE55�� � CONDITIONS U �
so os to become s�bject to the Workers'Compansation laws. � �
at ziv V
Dote Applimnl � ARCHITEROR TEL. �
NOTICE TO APPLICRNT: If, after making this Cartifitate of , � oiStRiCT GROVa �NST. ZONE SEO er p
Exemption, yo� sho�ld become s�bject fo the Workers' � ENGiNEER No.
� Compensotion provislons of ihe Lobor Coda,you musl forth- qpDrtE55 ��� F//F�F�.�) � . � �''3 � 3 W
winc �omply with svch provlaions or this permit shcll be - E. STATISTICAL QASS�FICATION APT. CONDp.n n"
deemed revoked. CONIRACTOR f � � � �f z
LICENSED CONTRACTORS DECIARATION ���. CtA55 NO. DWELL.UNITS
I he�eby affi�m that I am licensed under provisioM of Choprer 9 ADDRESb1�� . NO. �yyER Mnnv
(commencing with Secrion 7000)o(Division 3 of the Bvsinau and
Pro�essions Code,ond my litense is in full force and effect CRy - OW Ne�S /LJL' gK � VAUDATION
5�.FT. NO.OF NO.OF CHECK
Llcense Number Li[.CIOSs SIZE �� SiORIES FAMILIES ONE
� a VALUATION p.7
- DESCRIPTION OF WORK N� /�3�a_
Coniroctor Dale AOD s �
�I am exempt�nder Sec. A��R ❑
� =� 7 l+.�a
8.8P.C.far this reoson � pEpp�R � � . .
USE OF DEMOI ❑ � • • �
Date: EXISTING BLDG. t .
Signature - iE. FINALn��q � 1 ° � � �p�
OWNER-BUILDER DECLARATION PRINT .� � DATE V�/J�
I hereby afFirm thot I am ezempt from the Contrac�or's Licensa � p�
Law for the following reozon(Section 7031.5.8usiness and A��R`-u FINAL • ° � � '' )U T --
P�essionsCode): p E tv Sy
BUIlOiNG
I, as owner of tha pioperty, or my amp�oyees with aDDRE55 �;�� �_n 7
woges es iheir sola compensatlon,will do tha work and , ���r
Ihe shocfure b nol inlanded or offered for sale(Section ����TY - -
70l4,Business and Prafesslons Cade). MOVING - -- --TEI. ' '�� � •
� I,os owner oi the property,om ezclusively cantmcting �ONTRACTOR NO. v-}� {i ,
wirh Iicensed mntracrors to constroct rhe prajeu(Sec- qookE55
tion 7044,0us�ness end Proiessions Code). ,��,j `���:����
- CONSTRUCTION LENDING AGENCY REQwRED IOini SErenCK r+� xi
$E T B A C K YARD HWY p{t p p.L I N E W I D T H `
I hereby affirm Ihot there is a tonstrutlion lending agency for fRONi �r( �C�^�'
tha pe�formance of the work(or which this permit is issued P1 . 1."!J��
(Sec.3097,Civ.C.). sioE '
v.i. - �'5 "�f,f^r
Lender's Name O�J, tpMA Ref.M `� ' �t�;
��.
Lender's Address P.[.Fee E Pe�m�t Fee /
1 certify ihot 1 have reod this applitation and state that the �ssuance Fee � iDMA P/C M � �
abvve informotion is correcl.I agree to comply with oll Counry Invee�igo��on fee p- p •
ordinonces and State laws relating to building constr�ttion, Towl Fee O LDMA Pe.m.M
and hereby aulharize rapresentolives o(thfs County fo enrer
upon Ihe abo e•mentioned propert fo i spection purposes.
�` SEE REVERSE FOR F%PLANATORY IANGUAGE
' S�gna�ure of AO ��onf r Agenf Do�e �
�
„ n S �n �n ^ � cn :;t=- C1 Gl T- S - .- - z -�
- o � o N o o � n� ,� � m c� � o 0
m ° a - - r. � ° c '� o � a ^ � °
� o ' � =' = . � o- _ �.� _, F p � ., ' �o ° a ° ,_
- a ,� : �o < � � � o D = c ” o � a ° _ � 7- '
a '=. m 1 O , �. tG _ �- .� � :O (1
� Z -< - �'� 7 �- O n O'
�� N of o � i c , o y� n� o � D
0 0 3 ' ' ° c '�^ -{ < '`; �v ° ,e � = �. - v ,
' '^ T O _ p O p p � p p _ '2 Y
��' o a " � o � � - ,:' .�-� �< o
- = _.,� - _ ° c
_ p _ r .
� ° " -
� � � ' ', � .� �� -. - D
I � � `D ' - Z
I � � _ �` �
� Q ' � ` IZ �
� � o
. • i �! ' m -o �
— -� � � . � '�v
' ' � �
' � - _ Q C
� � '�I z a ' -- 0 3 n
� , � ' ' _ �° ''` ° ' 2
i �• - • � � ~
� i 1 I �
i N � O . �
v+ _ y m
� � v �o ' y
n • - • v o
. o , �
� . . - o m �
t . c � o
. c , . ' aa , <
n. o
. , o.
. ' i . ' .
. , +r ,
_ _ � ,
. ��• ��,� � ,
, . ��" '
• i � � � . . . ; -
' � . �� � � / J :' f ' � Z
. ' _ , tn
. �
- _' ' '� . . . "' � - � - �
, " ' J I• � . ." � A
. i ' ' I � �% ; Z
� " •" J . - . ' ,i� � 0
/' ' - !i � ' . m
�/ - • �) ' N
�' �� ; I
' _ . i � . . . : . 1 .
� � o '� ! n� a- v- �... r� `� r.���F � c c �;� ; C.�= � =
' p 1 � = .O 7� �G T .�. `� l C � � `.` �'. � C � n �,�, � n -
' i H �� s �. '� "�_`� " �° ^ ^ � ^_ N �, r' ' L a � .� ` � `
- . • � 0 � �.�`. 'S "" �J 1 7 = ' N ,r L ,j `.J� �=1 � :
" - . ; � ' � �f _ � � �� �;� t•^ c' _ •<� �- -.t �., - ^ -;� �-
; � ' ' o ' � �:i ` S o � �� ' y `' ., �.� � o �� ? ., :�,'^ �z c � ,c .^.
, , . i _ I � N : � •N`. ., �. ` .�'�.N o-, � � �; � Z 3 � y� ` � s '� s C �
- � (�� :j ' �c] 0 � i` n G I.. : f"- 1 Q ti � ` � T �i +1. �-`1
. .. x � ti �� F \ C ti .'^C "" � \ � �z ` �
" �°� M o,� ' � � � > ti� , ^ � �._ .. .. � ,= _ -
- ' - - _. , 3 ` : a tl i ��. w �' .. ti '�N O o N : � - .. ti�i r �' � -
',i ' - z � N ` ~ � �� o �`j �h = a ' :�_oo �� �'' � �� �_ � ' � _ -
� ' ' c
�/ • - n . a � ` ����•n 3 �.� '� , ^.�.i�• �. 2� f'u L S ~� "'i-i i ti ^ N �� v
, O tn �' ~� 0 � '� � 5 ^ �a� o `� J �� ' _ � ` fi ^"^ ...
� �• L �• 'C t•F � '••� a O � S t;�; � 1 [� � r�_
N I ' � � O � �.� p' c`� _� .: �_^ cJ `'� • i ` ^ :] ;p •-•
= 0 ^ � `'+ L' v � L' ,�V+ ^
� -- �� ^' �_ ' . .� ` 1 ti-w y � ti` � ..
Z e ' �O c �5 i � `��� o � ` _�,�� `' ; �'
. O , ! t-� ^ � � r � �^.��' ,' � a � 3 Cc``a ~ � � � J .�..
' ' O _ _ ~ � �``� �-O a-< �`� 2 C , � � _ i
. � �� S . 'y n` - � �� n r ^.� l o � `` :. ...� _ � _ -
_ I . � I � ] y^� . �� - � � ��,� � o T 3 L�� �`` � = = _ - � �
� - P, . C n \ �� G -- ti C.\ C..}� •, iC �,� .� J .. ,�,_ � G ,: � N
• '�� G' a y C ,< +. ~� • w � 4_N{ O � '�'�l � i" '�" : `' O �
_ � ti�^ ` _ ^ ^ � ' �' _ .�'", p Q '�: � "^_ ...C � n �
o _ ~ � m�o ��� ^~�.fi`�-a �•° f `L L� - `r�i»' �"'
- N . .. .. �•n n � , n`: i �D i' a � � - . ., . : � � . �..._. v