HomeMy WebLinkAbout1528A 1529A (13) WORKERS'COMPENSAiION DECLARATION
1 heraby offirm that i hove a cerlificate of�o�,a��,o sa�f ��,� APPLiC�#TiON- FOR BUILDIfVG PERf1AAIT Il
inwre,or a cerfitico�e of Worken'Compenaation Imurance, .
or o cerrified mpy theraof(Sac:3800,Wb.c.� [OUNTY OF LOS ANGELES 6UILDING AND SAFETY
Poliry��956-10��r AEi'NA - . .
aCertified copy is hereby furniahed. � FOR APPLICANT TO FILL IN �1�tDING
ADDRESS 24234 SEAf.�2E�i DR.
� Certified copy is filed with ihe counfy building inspec- BUILOING
tion depanment. ADDRE55 24234 SF�IQ2EQ�I DR, iocnurr DIANK�ID BAR
Date 1�23 H4 NEAREST
f Appliwnf THN. j�[��] Q2(1TiU qTY ZIp CRO55 ST.
CERTIFICATE OF EXEMV�ION FROM WORKERS' IVO.OF BIOGS. q55E550(t
� COMPENSATION INSURANCE SIIE OF LOT NOW ON LOT MAV BOOK PAGE PARCEL
(This section need not be�complated if fha parmit is for one USE ZONE M1V+P
hundred dollari(�100)or less.j � TRACT BLOCK LOT NO. .'t.��,��
TEL SPECIAI
I certify tkqf in the perfwmoncs of th�work fw which thia �`�'�NER NO. — CON�ITIONS p�,
permi�is issued,I shall nof employ any person in any manner �ISTRICf GROUP 7YPE fIRE PROCESSED BY 0
w as ta becoma sub'ect fo the Workers'Com A���� CON ZON V
I pensatiOn lows. /a �� � � �
Dofe �. . ApPli[ant � . ��HL���8 .. ZIP.:�1.,. STATISTICAI C1q551flGT10N AM. CON00. O
� NOTICE TO APPLI�ANT: If, oftar mcking�this Cerfifiwte:of ENGINEER LJHVE.SZANY��.-� :.�...- T16. .. �'.QO�I3�- .��Np. �O. DWFiL.tlNliS�� Ivyi
aemption, �you should become��svbject-to�the Workers' � a
�ompensotion provisions of the lqbpr Code,you m��t forth- pppRpu314�N. ���+�,A�...��� +�� . . �R�qp. , . y�
with comply with such�provisions w Ihis permit ahall be� �_ . . . . ..- � . . Z
deemed revoked. � � � —
UCENSED CONTRACTORS�ECLARATION �7�R� �� — . BK.� PG, VALIDATION
UC.
I hereby affirm thot I am licensed under provisions of Chopter 9 ADDRE55 �10. YAIUAiION
(commancirg wilh Section 7000J of Diviaion 3 of the Business and IIC.
Profaations Ceda,ond my license is in fuli force and effect. CIN �VII� CU+SS $ s 6q 850 �
�
SQ.Ff. NO.OF NO.OF CHEGK
� LK9nseNumber 37�84 UaClpsf $ SIZE STORIES ]. fAMILIES 1 ONE
SCRIp17 1��� NEW 5
Contracto�mc� ntti,�r;u�T r_orvm om.]����54 DE o woaK CONSTRUCTION A�
❑I om exempt under Sec. ALiER ❑ Futn�� �1 5 2,8 A
B.&P.C.for this reoson ' � DATE �(y(8�
REPAIR
Date: E STING BIDG. p�p� � FINAL #�� � •2�
ey C�.�,_v--�
$ignafuro . A7PlKANT TEL. � •L 2 3.� 3 '
��OWNER-BU�LDER DECLARATION �t�NT �.�p, i
I harnby affirm�ha�1 am aaempt hom the Conhacb(s Licenae ADDRE55 1�74 pA� �� �r �a �a , � �2 L'A� `3� I�
law for the foNowing reason�Section 7031.5,Buclness and r � � �
Profeaaions Code): Prte 0 2 1 3—8 4
" � I, aa owner of tbe r BUIIDING
! p aperry,or my employeea wilh qppRESS
l wages as their sole comperuotion,wiil do�he work and
the strutture is not infended or offered for wla(Section ����TM
70M,Busineaa and Profeuions Code). MOVING iEL . c' V���
� I,as owner of tha praperfy,am exclvsivaly coniracting NiRACiOR NO. -
with licenaed contracrors to conatrucf fbe projea(Sec- ppoRE55 #• •• . ��
lion 704�,Business and Profeasions Code�. _
REOUIRED TOTAL SETBAIX FROM EXIST.
CONSTRUCTION LEN�ING AGENCY SFT BACK Y'� H'� PROP.UN WIDTH . - . I •3 8 5 5 U
I hareby offirm thm there is a cons�ruction lending agency for fRONT I''
the parfwmance of the work for which this permit ia issued P.t. Y'" �� ► • •3 8�5 0 c=i
i5ec.3097.Civ.C.). S�DE
— '` S� /�� 0213-84
Lander's Name
`� P.G Fee S q-�-3 �J Permit Fee 3�J� �� .
Lender's Addreas '
� I ceni4y that 1 have read this applicntion and state that the issuanca Fea /O. �:U �
a above information ie correcl.I agree ro comply with.all County Invesrigo�ion Fee
� ordinantea and State lowa lating ro 6uilding construetion, Toto1 Fee .j p.5��v
lY and hareby authOrize repr entalives of lhis County to enfer
� upo obove-mention properfy for inspection purposes.
�/��� /1�- SEE REYfYSf FOY EXPLANA70lY IANGUAGE
' Signawre App icanr ar em � po�a t ��
,.- - :.
N ' _
.I�'y �. V � u�v S t . . . .
v 0/� � ...'�'" x�``� ° � 3 '" o ° _
T.." t C� .C y C � �y .� • . ,
w .a o'� � Xc�, '��'co"� 3 °o ���m,,i+,M:x °' p o � ��, a,�� � U
_ ,,n
M.h � � C� o � u O h . M a, cs.: n w � " � i�n- `,
. O f�I "�D �� C1 u ti"Cti M�� O O O�n S�{. r' i. «� T d 4�.J w :W � -.tf: � G : � � . , •
�? � _ � ,,,�.-' r"'�C- ` O 3�o �.k o`��,ti ..��, a� d �^ . , � 3 � , �
�. ; '«� c �:.,� � �� x 4 a� ` � L•4« y � `c . y s .�c K �. � t O E?. �
Y � o t4it�,p e� a � G . '� u ._�• � • �.._
O U �.VJ .� ZS 1: ti �' .V+.r £ �Ci. p f.�� .C> ti'�S�� x . . �, .. . '1
Z V ✓ a `+ q� ��ri�-Lc�� ^ t o ,01c,,',_'C �j" u 7. c � '' , .
.ia C � F � p � �i ;� �,-C .0 C C v��M.R. r � ,` � f
M= m �-r E_�- s. � . U C
O s c �•:n �•. � m �"' �, � .3'd�,,s..�. •; <, z. _ ��',a �Z= . ��.. .
E o ,t_� � c s �... o y y �,� � o �� i.. > .; n �;
<S � `' '?. •°•: �.,$ .�. £ � r j. C•�-I-� �•:: �t.S .y �':^+ ' e' - ° .�.�. _ `�e
. . ' m �'� ,�'�,ci t�`. ,c, i:,,. @ �O e: � � �' C � �. .� . �. ._
(� � G `�� � ��,, "'� �" y�� .i.; R 6 O'L � r� 3 c3 4 C ��R �C , , .
� c..� � ,C„ .,,, � � �^n,', a.C ..` p C-C` � �� c y' g (. 'L y ... ti.
�:] 'y .� '� �'� ,a,�w n�v y. �� �; i �
w � C _ ° � c p . .. L, Y e> C_-r, �, 7 IP <�. � - +' c ' '.
e�,'M^ � C:7 - i- e ei M{`%�,': � �: S � a „ ^ � � c� ;E
`O G,c..:` r F. i. � y' '� C � m f'.
G - i`. [ � _�. i:. ,• � �c. vc a. . .N' .
' L_ .� ^ i: � �,'� (J C � "Y ': >,,;''„ . �, � � r. •
. �� ._ �.y y . � _ �. •,,_ ^�i „ 'ci , ; _..�„ + �;
�. �� � � � *.,� _ �, , � � � o :a �:o �� ; � i ►
c�.� ,y � � � c � '�a. 's �. �- � ` � , .. . c � i
. n„/ r p.` . i-YC v�. e'v.!Z.�!+�. : �ip ° "ti ' ' � : i� .�i. C ' _' — _ .
{1W � '('1� �.. t 9..'�� $ �F _y 5 V 7V°. e � .L' i. V t' � . y ` �i r V C � � - ..
j." �i � �� fi'y.^a��s�'.. � 'C C C u • j ; �r.7. � a a . � � �,: L.-4 �l p . • ' .
,i a J y i; c: � . � . .. , 4 m-3 g. " ,p "�1 �:. r v'�� .�` , U _ � . .
. �i A w ^6 C t� Q C �y � � t ^'`�, c..�. ,
. i O G'. �s, �G'_., v.^w Ci � s,��'J j� E� ~ tl S= a' � .. - . � ..
OI C fi � 4 C F; '� C C`' '. �� t ��~ G~ �" � �
'= O �' T 4.��.�! y',w V C c G.,
V C �
_J � �` . . . . .
1
� ' � M
. . � �` � : �, ' I
!
� '
� +
� , 1 /
� �
� ` � , ! , . 1
�+ '� l I !� ,`'� ; ! 4
_ � i � � � . ; .„� �
;1 ;�� � ,, i't k I
iI ; � , � . j � _._.
�I 1 � ` �' ,__ - - -
� � .'I� � .._ _1 . �-- -- I �
. , _
. . �_�'�" ' . � �7 , '
, � R
tl �
�ro � � �
b ' ; ; .. � • ����✓
O v � ! �t+ �
a � d � � �
� �d � �
� o o : � t �
O r
i �_---
` O � � , � � �
� C � � Z � VJ
,1�� �
�� � � � . 4 __ 0 1 '-
a � � � � 1
� s Q< Y �� i..�--�--� - ,1 _ --.-—
a� �
o�o `, i- ".. "'_� ' ~�' i z . �� , . -o
X _---� �' i� s � ��: l c a
� � y , o d
' � �` i t` L � � 'i? % • o _ o �a o
�Lu �' 1 �i ° ��- � ': o � � ° o u �as c
.` ( j, �,i M � c � i ��,. "'a � o ` '� `� � o c i-'m �i v m ` O
1 :Y G� � O O O N C) � . :�: � I • , A 0 C I N p 41
im I 1 � c � u5 ao h� o cs• �oo -°o E °' s � oo �w
n�+ '� c. " Q, � � .'o t� —`v., ` rn d �0 9 a o o � j J s u �-
� C C Q �y W
� f �' L. 'U o �' a� .:4, •�u a � p Y o� � '�
EC � o �U o ' v � aU J nD.
i, �; o m p d '� a� ,�....
1 �' _ � v � � �
� 3 = --
� _.�.�_.__-�---- _ _