HomeMy WebLinkAbout1653A 5379A (17) ' . WORKERS'COMPENSATION DECLARAAON , � � � -�
I hereby affirm that I.have a cer�ifiwte of mnsent to 5e�f � APPLICATION FOR BUILDING PERMIT
insure,o�a certificate of Workers'Compenstion Insurance,or
a certified capy thereof(Sec.3800,La6.C.) COUNTY OF L05 ANGELES BUILDING ANd SAFETY
P�olity No. Company ;
Cernfied copy is here6y furnished. I FOR APPLICANT TO FILL IN BUIIDING
ADDRESS
� Certified mpy is filed with the caunfy boilding inspec- BUILDING .q� " �
_ tion dapartment. ADDRESS �f[�Z �V►1 ��QE `N' �OCALITY t
NEAREST c�
Date /�pplicant CITY IAr„aup �- ZIP W116s CROSSST. -�`�J..tL\
CERTIFICATE OF EXEMPTION FROM WORKERS' S¢E OF LOT I O 300 �O ON LO7 - - MAP B�OORK PAGE vARCEL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one US ZONE MnP e�
TRACT OJ7 BLOCK LOT NO.
hundred dollars(5100)or less.) �, NO. � � o� }
OWNER l:.• L�VNCC TEL. SPECIAL a
i certify that in the performance of ihe work for which ihis NO. 'rJ- oZd CONDITIONS O
permit is issued,I shal)not employ ony parson in ony monner DISTRICT GROUP 7YPE FIRE PROCESSED BY V
so as to 6ecome subjecf to the Workers'Co olion La� _ A�DRE55 2 33a E. l��vnv+�� BAri (31.JA � CON57. _ ZONE �
�
Q` arv �qmc�� F3�9tZ zia 'fi�T45 ` O �✓ O
Date ��V APP�icant STAi15TiCALClA551FICATION qpt. CpNpp. - �
NOTICE-TO APPLICANT: If, ofte maki th' Cerfi i - ARCHRECTOR TEL V
Exempfio�, yoo shoold 6ec e zu e o the Wor rs' ENGINEER �.M- �I�CY.� NO. s4s�L3�iu ��� �/ DWELl.UN115� w
O.
Compensotion provisione of e lobor Code,you must torth- Ao�se55 �6�75 1sC.�n Lw• sewea mna �
with comply wilh such provisions or this permil shall be �
deemeCl revoked. [pNTRACTOR �bu1wYL NO. '� BK_O PG.5 VAIIDATION
� LICENSED CONTRACTORS DECLARATION - ��� . „ , . .
1 here6y affirm that I am licensed under pravisians of Chapter 9 ADDRESS � No. VAlUAT10N
(commencing wi�h Sectibn 7000)of Division 3 of ihe Business and �,�. g 1 6�3.A �
Professfons Code,and my license is in full force ond effec�. CI7Y CLA55 S �QQ QQ� �
- Sq.FT. NO.OF NO.OF CHECK �
Li[anbe Number Lic.Class 5¢E �'s� STORIES �' FAMILIES � ONE �� � � �2 3 �
5 p �
��ffOC�� DO1e DESCRIPTION OF WORK � _ NEW � I •6 2 O.H� �
� I pm axempf from the licensing reqviremeNs os I am a �ya� �y,. � �pd.o �C,�.. A�D � • �S L iS 8 C/c=i I
licensed orthitect or o regiatered professionol engineer AITER � , FINAL in �
acting in my professional copocity (Section 7051, aT�++ la� REPAiR � DATE `G' �f Q 2 2 Q-$2
Business and Professions Coda). use qF � � FINAL
EXISTING BLDG. �.IGUC• DEMOL Y '
Lic.or Reg.No. Date APPLICANT TEL.
OWNER-BUILDERDECIARATION- ���NT� � � No. 6�YFi-�37
I hereby affirm that I om exempt from the Controctor's License �1�.7s'Sy.,,.�,,�FL�tOG� Lu. G'
Law for the followinA repson.(Section 7031.5, Business and .4DDaE55 •e�\^ �B
Proiessions Code): vRE E
� i, as owner of the property, or my employees wi�h nDORE55
wages as iheir sole compensotion,will do the work ond z 5 3 Z 9 A
tha structure is not intended or offered for wle(SeUion �«A��T� �� � � � �1
rrtt�� 7044,Business and Professions Code). MOVING TEL�
UC 1 I,os ownev of the propeny,am exclusively coniracting cONtRAC70R ryp, I .�4��.O
�`"V with IicenSed COntfa[IofS�o[Onslru[f ihe p/oject(Sec- qDDRE55
�ion 7044,Bosiness and Professions CodeJ. . ••8 4 3 0��
REOLIIRED TOTAL SETBACK fROM E%IST. � -
CONSTRUCTION 1EN01NG AGENCY � SE7 BACK YAR� NWY pROG.LINE WIDTH
I hereby affirm that there is o construction lending agency for FRONi � O L C 7�S�
the performance of�he work for which ihis perm�t is issued v.�. �
(Sec 3097,Civ.C.�. � � � SIDE . .. . -. . . ,
P.L.
Lender's Nom { � � .
� �[� P.C.Fee 5 Vermit Fee � V��'�
Lendei s Addres � �C�i
I cerlify that I hov read Ihis pplirotion ond slate Iha�fhe ! issuonce Fee V � -
obove information is correct.I agree to comply with oli County �� �
a • Invesiigmion Fea _. �
ordinonces and State lows relating to building consiructian, I ')
� ond hereby aulhorize represenlatives of this Coumy la enfer � Toiol Gee
� on� bove-1te ioned property far inspection purposes �',
a ry� � j�'� : SfE REVERSE fOR ExPLANATORY IANGUAGE
� iqna�u.a o{Appl� nt or Agent pute ; ��
/ �
`..-A,
�
V d r
mm � oc �3 �� °
.-d� o �'�''" o�m c�`dw�o"' u
T, a.�-,W
u c�.�'�a�3 o c �,�i�-�e:� � �. ;-o c o' * °a c
� m '� t � � '� °' v � m ;
y�.�S 4 Oy.� �� �O �i U"��.5 w 1.��... � � a '�''�*" .Y � y� '
�g.� :a'�'a �V� v�-,�;, o� T 3�'' �.�et e.Q,'� ��s s c o a, r
c o,°' °' ",.�o"' o � a.� o��3 '� i-, �. � O
°en �,�a�o�p,.�ct�� E~$��3 :�� m.^ X°1rv� �'� � Z � .
s" cacmi'��e��7''�° i--°o ° o °szlom� ,`°„ D,pC°� x�� O
Om�' " e ��n° w � m a�ct E= �V �S,��a �.c o ^u e �,.� m v
Y,� � o '�.ty•� � de�,.°Daro c '' w-°'a°oa.° amt�� y ° o ° '� �' �
dE «� � `� ��'.�' �° " x c E+ �^ct n * 3'^�cs On�«�o .°�3 d �^
d•� uz�N��".o.�OG�..° m'� ma � ^de ��° dx� ° � °'povv �� � Z •
�`� � .R a. y � ��m 0-a � o o � '�$ y,M y " p� � x m a
W E G� ,rg� g .`d,«.�$� M'wa'., aQ��m���' eo �-�o u'� x d " � �
pmo'� � ° � t��,°�s�.a,�� so `��'�' ��'°' o� ?� eca �,m " � * °',.�a a
C�+ V �'+�� #', it u � Sr" ?s c x� S� �n G w 'H p.��e
WE.oy �"'a'�`� �Cc,01Om =�,�w� � � � 01 �Q,03 � � 9 � * o
p6 m � v X � A��•'.3 w Y' i�,,, � C '^ C C�i+d"+9+ C '� w �' �iy ot p` '"^.�.�. �`�ia �
�ps „ ; uy ? d� c '� 3 ` =^oo w'� r� u"+° ,y� ,�, � �. � N m
s :,,. o� m G1 s,c,r o c °1 m r� +� w-� x ,; ° �' � a��, � ❑ .a $
D�; E..��- �' ��""m�o� �'„ ��., o m � ���'� ��a°d a r� �,� w' � ° � m
W r C" m T l'.�,�.r `.�,,, 7t:a O ,� p i7 n W y p� �'tl t,.,l p"� ,'Yp .p V
Z.� �ts ca,x c--a o °'= ` m•,6 x � tl s. m ^r a
3n3 � d:.'t�,� c� .,�a,'�'' dN� � O ° ° °'��
� y� y m a~�'a,..a o�d °p�,X❑ o y�,�,E,�o« o,"� ?,
m m �„�, �a� i, x o:: � � 3
mc • � �. d�+ �°V es �
.t u � �L.0 w..
.^. � q a. p " .
�
� �.
N
0 � , 1
Z �
� �
V �`
W
� �
Z �/ i
�
t
"V I
� � '
7
CY O
'q c
v+
� a
; ` o
• u� o-
$, °e 4 �
a • �
ec �o
\ ~ �
0
• �
o �a � � �
o �
Q t � �� � �d
� � g o c o �o 0
� : � > l' � � o �a �.
O� � ' 1 .j� -�p � p N ?cp G�
Q o . 3 N o „ 3° % �� 1 °
O Z, ° c ' o y m ; >'m �" m � �
�' � ° pi o oif o r o� s oo °�
�n � ��- ' � o. c� •o °� rn s o =u ;..u,
6. � ° m °' ��;.o m d g o "° ,s+ o c ° -'
� M O/ C Cr� p-�G N'�Lr O � a �9p � 6 V- W
'i O � 41 ��F �V G✓ 'p 'P O� � N
� ` Y � E 6 P,'' 6.0 p �t �
o � m o a�'i � ° %� au ° o. ...--^"'.�_.--
U L p o —p� �� N-� '
m $ m � °_..�
3 = " � .�- �
6 � -
r �_,�.--�