Loading...
HomeMy WebLinkAbout1376A (13) i _ ....__ _ _ _ . WORKERS'COMPENSAiION DECLARATION . � � - �� I herBby affirm thaf I hQve o certifiwte of�a�=e�;,o 5e�f �� -- - --�-�-� APPLICATION �FOR BUILDING PERMIT � irtiyire,or a certificate of Workers'Compensation Insurance, o�a cenrfied copy ihereot(Sec.3800,tati.C)- " ' COUNTY OF LOS ANGELES BUIID{NG•AND SAF�TY , _. � ❑ yNo. Company . . _ . . . .. . _ __.. -. . � Polic Cerrified mpy is hereby tum�sMad. . FOR APPLICAN7 TO FItL IN euuolNc 4 � ADDRE55 � Certified copy is filed with tFe counry 6uilding inspeo- gU4DING �� � r- /� , lion deporlmeM. AppRESS L 3'Z �• �` /Z�-�J ✓k, . . Qafe , . Applicanf � CtTY ���.t.��a �R � `}/76$ �pU,utr � CERTIFICAFE OF EXEMPTlON PROM WORKERS•.�.- .. . ... � . .. . NO.OF BLDGS. � - NFAREST. ..� �` . � _. ._ .�_._ . : : � � ••� � COMPENSATION INSURANCE 5¢e OF LOT wOW ON LOT CRO55 SL � (This sedion need nW�be completed if tbe permit is 4w•.one •-� -�q- .. ASSESSOR � ;.. . ... - - .:.-._._. � bundred dollors(;I00�or Iess.j . �� T��T BLOCK l0T NO. S J Mqp gppK : � �PAGE VARCEL OWNER" �l�.i� -�/irttl`'.+�—N`o.��� g,�'- use zon� n�av i certify that in the performance of the work tor which this �p 1 NO. ' 1 Y permit is issued,I aholl nof employ ony person in ony monner ����ry�, SVECIAL - -�- - so os to become su6jen ro fhe Wor i Com� nmtion Lows. ADDRE`''S�2 25'�� �' ��-'-� ����� �� !���' �X+J CANDiTIONS Q �� � , � �` ziP 9�z�aS .. u Date�� � APPIicaM - CITV _ �CAn.9Q � � ARCHITEGT OR � TEL. NOTICE TO APPLICANT: if, offer aking lhis Certificate of DiSTR�CT GkOua TYPE FIRE PROCESSEp gy O Exemption, you should 6awme ubjec�to he�Workers' �-�--�-- ENGINEER NO. �� CON57 Z ' Compensaflon provisiona of.the La r. � ou mus1.forth- qpDRESS . �a W .._ .. _' _ . . 0. with comply with sucb provisions or this permit stwp be .. . __. � " dqemed.revoked. .. - . . . - . ,,- CONTRACfOR Q h.� T� -. . . . STATISTICALClA551PICATION , APf. . _ UCENSED CONTRACTORS DECiARATlON.---... . . . __ �K. �CLA55 NO.��D4VELL UNtTS_ _ I hereby offirm iMt I am licensed�nder provisions of Chopter 9 A�DRESS NO. (commencing with Sectbn 7000)af Division 3 01 ihe Business and ...... l�C. ShwER MAP � . .. . . Profeuiona Cade,and my license is in full force ond eMect C�tt CIASS - VALiDAiION � � � . . . . - . .. SQ.FT NO.OF NO.OF CHECK BK. PG. � . Litanse N�mber � �'��� � Lic.C(ass� � ���� ' SIZE � � �-STORIES �- -FqMIUES � ONE - . . - . - Q . VQUATIQN.._...:._ � � DESCRIPf10N OF WORK �W OO . . . . .. , ConMactor� Dare � � s � . �I am axampt under Sec. . . . . � �. . �aT��. ........ . AITER � � ........ .. ��. s . . B.BP.C.for this reason �� _ . .. . .. . oara: us�a EXIST�NG 6LOG. �Ma ❑ Signa�u�e .. . ..... . • APPtIGnNt RVt-..... TEt.�7/'1C� �"' FINAL � . . . . OWNER-BUILDER DECLARATION PRINT ��KL� E� NO. _DATE I harabKa££rm ilwtlam.qwmpLfram the Cantrxtar�'s liconse - . .. .- ��. � Law for ihe followin reason�Setiwo 7031.5,Bosmess and ADDRE55 �° .j2,$ �. �=n� � -- -� . � . z�,.,. 9 ( . . FINAL-`=`.� . . .,._... .._ _ Y _ . . �Rof ons Code�. ... . _.. ,.,. . E . ,. . . . 8 . ... .. ._. . . .. . euaoir� �1 3 7.b A ' 1, as owne�of the property or my employees with AppiE55 . - wages os their sale compensatmn,will do ihe work and ithe strudure is not intended ar offered for sale(Section ����TY ` � #�� � � �� . ' I�t 7044,Business and Rafeuions Code). n�pvuvG TE�. ^`1 i � I,os owner of the property,pm exclusivaly conlracting CONTRAC70R pp. X J . � • �4 9,2 S , � � witk�licansed controctors ro constrod the�projee�(Seo- qDoeess �� � �� !��Y � �� • •4 9.2 5 c=i `; tion 7044,Business and Professions Code). � , \ -��� � CONSTRUCf10N LENDING'AGENCY �� " ..REpUIREO.. . yA� .MyY TDTP.l5ET6/� � � ser ea« PROP.UNE WIDTH i 5,� _ . 0 Z 1 6—8 5 i.hereby affirm that ihere is a construction lending agency for pgp� �1 .. � tYw perfwmance oi�he work for which 4his permil is issued �� P.�. : � (Sec.3097,Civ.C.I. SIDE .. . v.i. ^ Lender's Name �..- . - . ... . . � '- �, m - P.0 Pee S . ..-. . Permi�Fee � ����IDMA Ref.8 � � -� : = Lender's Address� � � ' ' � . � t cer7iiy lhot.l,hore read_thu_applicotion and slate.lhal the . .. . - Iss�o�ca Fee � :IDAM P2 k - - ' - - � abpve information is carrect.I agree to comply with all Counry ���es�igation fee : � W ordinanc s and State laws relating to.b�ilding construction, ;o�o��._ _..�'..� � � .��pMq parm,k� � � �� � � - ...._. ......_.._......_....__. � and her y authori e representaiives af this Co�nty to emer . . � - � upon t bove-me �ioned propeny for inspec�ion purposes. �� _ � _ . ..... � . .. .____._.__... ._..... ..... ... .. . ' . �'�� Q �(1G � SEE REVERfE POY EX►LANATORY UNGUAGE � - - � �� 5�wwre of Ap limM w gent pole .... . . -n� I � i i m �n m ?,�".. L�, m in �. .0� �i. . y p y+ 0� vl . . - . - `OrC�..Y.� 0�1'ChO �!Iy�•y0 '; aDOy�i��•~� ��yO �O�'y3 .y� ' . t eh,. . O 0��.R C O�G y'@ N O,ti C O �^•.V.�D N-Q�..K, d .'l � � y 1, y .� � • n yp�j�4 'C� ��~M �� NOu'� O �' .�tti� 9 �t .�Vyw�'i �.�a. u . . Pu. p'VO �.�� w°.�oV` ..o3�n^��-Q '^ • �rzy —'''oo �". tl a Z v.N o d�ts � X 0.''o K s � a v m ° �at e`1 y�� i a U i d a � �F�v �. � �.�c.odn+Q'«�o mo � * m � �'�i °w � O —'�-aca � m � . d c � jY R y.� °' N ZS m 0.� �.'�Y`p_ R C.,�[+'� o~i� o�i y X E" �, c°, C' . Q ., . W^ o ° "�''_� � cs F � o�, F`' cse� E_ ° ` c, °'"�� m : d x c a �' a.� v �, . �.'°. jyo•� �c-a� 0 3 m� �h�°d�'° � �b �'s � �' V a e � �`�d` � o � � R m-e c m � � �'� c ° o V ° � °' 2 , w �.�e v 'y .o,��m`�•M ��.xi+ �.`g o E" o�.i'S! `�',� a �� �o " ��:: ,� y, °' ; b � ` ' '� ���o�^$ a � °b3.°t' �b43'e� Q" � � �� d � y E�-U �'i � e o c �a.N`� a- �d U ° � a,�� ° m a° o•?' o o'� 'n u Q °'� � � �'"��"�V"^ �e.�y��, s E� e � �.c1'R p'w n s °�v o�i t��.,�°•, .c v�•i � . m .,Q c�, �-Q �'� � �+ y � �-y � d ., k -y c 0. 0 �"�„ K � � Z mr� y y � M t.v.:c ye �i ° m ���� r x�.c o�•�°'. � �� � o, � X .a y �. � �,d ' � � p a�o `o 0 4�, e n a�v � d a d E zE W {. y O N �' V � O C C N C i. 0.Cl `3 Cl 3S`' �^ C � C O.'w y .- y~mKti,�,. Q�~c o � m'�YC! tl� � dmC'io a � �'V0.-C'„ m Q. �,'� � e� C t�i�'�►1 O+"�,. � � � o �, 7 a t A_.� t +, �"�C �V " ��� � o O � N M.6\'��b O 6 �'r�- O U M Ci C„Q 01 i. C �L '�� �,i � V ._ ' �.� •�'.� �y�'i+ ,o�y `Y°`v �y:ro �. .�t a ? *� 4-. �� u.�'�C C u�i G� ,o L J� •`! d w w,� ►�.,O O� T ❑ 0 L � O 4.�ti Q O b �.�(i L� C�,O"u� � 4�. C � O ' ' ct� �o � ti V cs o � 3 �,�0� c aS,a a.�e �� n ►1.o r.�U a W E � . " . . , � I 4. _ . N . O � v • d N Z , � • kr. r. � � e 'O i � >�� ... � � . 7 , 6 ..� ' � 6 . � - � � � . o a v, � M p � � �. � ' 6 � � M Z � v � � � Z. � � � �� o � g � , : � : z m a w c z d . � . , _ d � � _ . o 8 � �Q1 m , m �' G � M �O � � 7� 'c a c m .� u � N . p o � o o '-O �p _ � C �a � � 6 E .,� q 0 ,p,0 � Q > ..c � 8 � �a � 6 d � �b C V .`� O d i a8 O C � O Ol 7� �L 'v p $ U O�' ^ C C. G�[ ' >'y tt Z C ' d c� p 'k d 0 �' � C a �� � 7� . pTi �C I n y � � � u F. Z o � m o . � m� o-u o `o o u� o 0 0 � o J o o �c 3 .._. ;� .�� .�.. �._ �� a � � ,., xu w