HomeMy WebLinkAbout0930A 0931A - ! WORKERS'COMPENSATION DECtARATfON � I herebq affirm that I haye o certificate of conseM to self qpp��CAT10N FOR BUILDING PERMIT � insuie,or a certificate of Workers'Compensation Insuronce, �or o car�ified copy thereof(Set.38�0,Lo6.C.y ��• � �� � -" - . � COUNTY OF LOS ANGELES 6UILDING AND SAPETY Policy No�f 3_�7.ComPany�'i}[/�f/f�19T�Gi.S� � . � Ca�t�fied mpy+s hareby i�mished: FOR APPUCANT TO FILL IN BWIWNG � (J �� / ADDRE55 ,� �S� �Cadified to 's flled wilh the coun 6uildin ms eo- , . �---- py� �Y 9� P BUILDING 7 / p tipn eparl ent.� '� . .. . ADDRE55 �} (JDU � i�(� Dale b .� � appliconr (d cin / D • zir 7/ S � �prp,��r� CgRTI C111E OF EXEMPflO FROM WORKERS' - SiZE Oc�AT ��6�J�XJIS� NOW ON LOis C�5T. � ' � fOMPEfd5AT1pN I SURANCE �This aec�ion need not ba comple�ed if Ihe permi�is fw one � q � - - -�� - �R ' __ � hun�red dollqr4($70p)or le5s.) . - . � TRAQ d l 3 BLOCK lOT NO. ' Mp,P BOOK-� PAGE PAR�I - TEL USE ZOIXVE. M47 .. . .- I certify that in the performanca-of the work for wFich this OwNEa e pp. - � � � � ermil is issued,I shail not em lo�an rson in on manner / �p 1� �(/ � � SFEC�AI sPo as to 6ecome subjeclla the Workers'�Compensotion Lows. A�RESS (3 � �lf (.�U{1� (//(�� � CpNDiT10N5 � Dara " ' App�icant . ,, ... arr L/1 0 ��' ZiP � p...� � pC NOTICF TO APPIICANT: if, oker making fhis Gertificata of ARCHIiECT OR TEL. �ISTRICT G20UP NPE FIRE PROCFSSED BY O N INEER NO. [pryST - ZO� V Eaemption, you should �become wbject ro the Workers' /[�� I Compenso�ion provisions of the tabor Code,you must forih- qppRE55 �� � � d wi�h comply with such provisions or this permit siw.Il be - --� � - �� /� � y y I deemad�evokad. � � � - CONTRAROR � P P{t •LO NO. 6 -OpI ; STAT1571CAL QASSIFICATION . APT. GIXJDD. .L I LlCEN5E0 CONTRACTORS DECIARATION �� �i�, �(�y CLHSS i�.�DWEtt�tiNiTS • 1 here6y offirm thot 1 om licensed under provisions of Chapter 9 ADDRESS �f�d iY, /�' t�-9 Np.��T/o� �commerrcing witA Section 7000)of�ivision 3 of the Business and /� l�. SEWER MAV _ _ �� . � Prnfessions Code,ard my license is in.fuli Eorce and eRect. CiT�' L��✓/�� �'�'6� . VAi1DA7{ON I ... __ . Q _ ��i 5�.Ff. NO.OF NO.OF _ __CHECK �. PG. License Nymber���-��4� Lia Clcss•� �'��� 512E STORIES FAMIt�ES ONE ,/ �/'//�y� _YALVA710N co�macror � ��°x$ •��Date"7�T DESCRIPf10N OF WOf2K "FW � t ���p.� � ❑1 am exempf under Sec. i it/ �'J^/��O , DY. p`�. � � �0 9 3.0 A ALiEN � 8.8P.C.for this reoson ��R D . s - �• • • •'Z� Date: EX STING BIDG. � ❑ - I • �� �I�.S O � SignWure . �.� . .... . � .. � AVRICANT TEL. � FINAL = . OWNER-BUILDER DECtARAitON PR�Nr , . No. p __�f r7 / _ _ • • •� Z S O o 1 her aff'nm fhot 4 om exe t&om tba Comractor's Licanse / `/ p /7 ' -f ra -Q S�--- Law�the following reasor��5ectina 7031.5,Business and AODREu �r��'+ .'V[ �1.,t-!��'`A�n�"`f (--D✓���' Flruu � 0�b c 4�8 Jr Protessions code)' . ". � - .-" . . ..--Br-� ��� s 0 9 3,1 A � 1, as owner of the property, or my empbyees with Ba�� �` �� �\ _ � � . wages as their so�e compensation,will do the work and }� �-�M rhe structure is not intended or offered for sole(Section f� .._ LOCALITV ... �• • � • • � � 7f1d4:Business and Professrons Code).. .- .....__. . Mrnnr�...... ...� ._. .. .. T�.----..... ._ .. . �S I � � i,as Owner of fhe prop�y,om extlusivefy co��raCting CONTRACTOR NO. � � �3��5�� -with ticensed rnnhattors to ronstrutF Tha-pro�ed�(Seo- . . AooREu �-- --. ... - --_.. . . . ._ _ .. •�(�%5� rion 7014,Business and Professiona Code�. ..._ .REOUIRED _ OTAL SESBACK ���LONSTRUCfTON LEF1D(NG�AGENCV'.. _.-_ . �7 gqeK YARD "HWY � pppp.LINE �WIDTM D�L 4-E3 S I hereby affirm that there is a consvuction lending agency for FROPIr Ihe performance of ihe work for which thn permi�is issued p.l. � � � (SeC.3097.Civ.C�. SIDE � � � � � __�--� .. . ._. .. . -._ _ _ v.i. lender's Name ' ��� IDMA Ref.M Lendar i Addreu-'-----�--- - - --- - - e.C.Fee i - �- vermir Fee - - ...----- ._ ' . 1 certify.thatl have read this applimtion and.afole ihot.lhe iasuance Fee IDMA P/C N above information ia correct.I ogree fo comply with all County i��es��y�w�Fea � � ordinancea and Srote laws.relnting to 6uilding wnstruction, _ _ . . Teal Pee - -�- LDAAP.Perm.N- �� and hereby authorize representatives of this Counly to enter �pon e obove-men/t/i9Jj�ad pro e/r�y fw inspecti n urpo s. .. �(�f'� `�CQ,.�. . ����� SEE(tEVFiSf fOR El(P(ANATORY LANGUAGE .. .Sign „�.oFR IiJ mm urA�-.._._______-_.�s- . .._ .._. � / e�._ i /�. ��II�4�7 M �j Y, Y L 0� OI �ti - .0'� 41 M � Ol Ol \ �n Q..( pl '� ,O�:V'H � O�i C y O .�[.�O j� . C Q k'� O �� t�,� '� m�i.�C t�� , L . Ve� �. .� V�,. ��-Lo 3 0.0 � ��•M o � v� � y O U ..3 � Q�o�i 1' .yn O tl O ^ w�D d'L'v x m Pp � .�,� ,� O h r� O � y ��M� y` ? �N N��'a N�� 4 O.� � ��� V , �, � a'�K y Q L t!i O C � d iG V�s O•�'a E� O tl u�. O„��� � � N N m �'..B~, V !n � . ("'r � � i 4.�.a � R .� V�O N O �^ � o~i '.Z m M O 7 L„Li 0 �L ,1 C , , a E „ r E o •,.a � a K °1 n� a�� `o a o,e m d•� m:f X �[" w � ti' p xo , � "� h � F=.� o � �. `,..�-_ m ` �, „ . Q a '�,�_ � Q E e n�..,m y�. vUa,��o ,a oi o�e r+ , � � �� � �y'w y� C yb � 3.� � b � ��Y E N� � N f n ! 01� '!� � � � n w � m-G� o"', � � E.o o c o � 3 � O wEse`v� y���`�0 �-� 2� o�F' �'tec' c ? � � `oUtl'y+^ Z � y �o � � i•" � ,,�'°',';�,��C�o� � p� o b a•i d b 0.3 y a�w w � '�^ y � W E V �'� � e n o`�a ,",`� a d�U ° 3 >,�� ° d ° o b.,,?, e Z cn O!- Q o.� N 0.� v i+m q,�- n y a.o M �Zt: � w,t'�' a u`1 0. o�i � � y uui � - � co .ei� x �s� � �� � oa�i.oQ ° E� M`�' e r ° �°. e� �,� � vi �= - d " �+, g 4',.7'� M � a� � � 'c o�i� o � e� c ec.�°'. � �'ts a m i, G a Z [�il E o i� � c�g �%� m•= e � c ° °c � 4o�i � `�'� N c� ° d � � � � Z;� 3 � � '?�n,�v �C+-Ci ��C o .m 'in 0.y p y � � m Q'i� o y m b 0.Z'y Gl �o o k C r c�:=�-� m n � � �' a x c�,:� :;Q � p,°y' ": e.�''� • E � >.� e a tl.4 r'O k.�`'�. 0 ` tt a X V�o �- �,J �. � O p - � y y,1. ...� y� � of .. C _ 6 V '^ oyi O m w fY _.c _ m c .0'� +L n"Q'y� o�i �i tl" I- � N �'!t �y d y e � � 3� � O � � � 1 41 a^ 'Y i�. '+ iL a�i T,i.' IJ @ in .�'� i�. C ?Z Q�4 y ❑ OD V Cdi� C �+` ❑ '^ F — u `'i d 1.y.� y.,C,�y F C� �j � tl s.v w C d .Y y C p .� 4 C y O � � i C v ti V tl tl i`` �i �Q� O iy-Q T.�O '`. h J-0 Q V � � � ' 7 � I W ' �' Z � I In � K � � V ' W d N Z e il ', � y� ��. O >m ' m a b O � Q d. d t O a � y 0 O N 0 'r O ' L e a 0 M t C � � C u m = � � � ' d � Q � I Q � �. O p s � Z m Z Q � C J d � � � � 3 r � 0 Y C O C^ �... N N v'�' - O ` C O o `o E c �' a c '" -° °- d a u - d oo � o o a` _ � `o E a � a� �, � > > ° ° � o 0 a �� Q ° � �U c� � d � 'c ° � >� X 206 c V t p � _O « � p u 6 C Q O O � � � �� W y u � O � o m a o -°p' � m o o Y a� . � � E � .�c- s � � o d F Z . 3 = . - � � �lL �U O a O N l/ IA IL W J � =U LL W