HomeMy WebLinkAbout1425 1519A � WORKERS'COMPENSATION DECLARATION
i hereby affirm thaf I have a cerfificate of consent�o self APPLICATION .FOf� BUILDING PERNIIT ,
inaure,or a tertifimte of Workeri Companstion Insurance,or .
a certifed topy thereof�Sec 3800,Lab.C.) � COUNTY OF LOS ANGELES' BUILDING AND SAFETY
Policy No. Company �
� Cert'rf ied copy�s he�eby furnished. FOR APPLICANT T PILL IN ���o�� 'y .�f
❑ ADDRE55
Cartified copy is filed wilh the counfy building inspec- BU�LDING ,,•s�
�iOn d0partment. ADDRE55 �OCALITY m'�•�/
NEAREST �
Dale ApplicaM Cliv • 21P CRO5557.
CERTfFtCATE OF EXEMPTION FROM WORKERS' � i 5 /'�� NOW ON`IOTs MAP BOO�K PAGE PARCEL �
COMPENSATION INSURANCE SIZE OF l0T
(This sec�ion need no�he cnmpleted if the permi�is for one USE ZONE MAP I
hundred dollars(5100)or iess.) reacr ioc� ior No. ,�� No. U� '�3 .
TEL SPECIAL a I
I certify thal in the performanc for wh�ch fhis OwNER NO. rZ.C�OPO CONDtTIONS O
permif is issued,I sho�l not p oy any per5on a y ' oIStRICT GROUP TYPE FIRE PROCESSED BY (�;,+
ADDRE55 CONST. Z(JNE
so as to betome subjecr ro he Worke�s'Com ws. ` Q ' � / O�•
� CITY ZIP � ` G,��
DOtE �-"�- �pplican � STATIS�ICAL CLA65lFICRFION APf. CON00.
ARCHRECT OR TEI. V
NOTICE TO APPLICANT: If,-efter making thls Certificme of 'n ui
ExemptiOn, you should become su6jecl fa ihe Workars' ENGINEER 2f� NO. CLA55 NO.��WELL.UNITS_ p,
Compensalion provisions of the Labar COde,you musi forth-� qpDRE55 � � �..KL 4,7 SEWER MAP z
with comply with such provisions or this permit shall be -
deemed revoked. , � tE�� - �3 VAUUATION I
CONTRACfOR C'�1.�.�' Y�.?Ll'�S NO. �BK. PG,
llCENSEO CONTRACTORS DECLARATI�N q �/ � �iC. . �E l.���/
I here6y affirm that I am licensed under provisions of Chnpter 9 AD�RESS e� C. O.c -[ VAIUATI N - {�
(cqmmencing with Section 7000�of Division 3 of the Business and ��� p ^�� ������g�v
Professions Cade,and my license is in full force ond effecr. C�TY i�i ..CLASS !T g j 8
SQ.FT. NO.O / NO.OF l CHECK ' Z
License Number��f�� � Lic.Class� SIZE STORIES ( FAMIlIES ( ONE 3
Coniractar ��"'� �r��^') . .. � DESCRIPTIONOF WORK NEW g � � . .a _/
�ote�'� I_�Z ADD �I!.Y�0'
� I am exempl hom the licensing requirements m(om a � �� ��-,� " , - - - -
litensed architeU or a registered professionol engineer ALTER � FIHAL ��3��y
oding in my profesaional copacity (Section 7051, � DATE I a� ,�'3
REPAIR
8usiness and prafessions Code). llSE OF -
EXiSTMG BLDG. .v L� /�' ��. DEMOL ❑ FIN
LI[.Or Reg.No. DatB APPLICANT TEL BY 1
. .. . .. PRINT _. ._. . f..._. NO." -J
- OWNER-BUILDER�ECtARATION -- `
I hereby offirm ihot I am eaempf from the Controctor's License � � �_ /'� �� 1n�-e_�.N�`�
Low for the f011owinq reoson(Seclion 7031.5, Business and A�DRE55- / � -�-� y' �
ProfeS5ion8 COdB)' PRE EN �
❑ . . _ . . BURDING .... . , . . ����
I, as owner of 1he property, o� my employees with A�DRESS
woges os their sole compenwtion,will do fhe work and
� rhe strucrure�s not�ntended or otfered for.wte(Section iocAurv a: dt.--
7044,Business ond Professions Codej. MOViNG iE�
� 1,as owner of tMe properry,am esclusively contracting � COnl7aAC70R No. � � � � -
with Iicensed conhactors to construU the projact(Sec- qDORe55 • - �
tion 7044,8usiness ond Professions Code). �
REOUIRED TO7AL SETBACK FROM Ex�sT. �1 51.9 A
CONSTRUCTION LENDING AGENCV SEi BqCK �ARD HwY pgnp_�iNE wiDiH
I hereby offirm rhar there is o consiruction lending agency for� � FRdNT #� �� ����
the performance of the work for which this permit is issued P i
(Sec.3097,Civ.C.). 5� I •4 0 6 5 0
P.L. .__ . _ __ _._ __ .
. _ . . . .. _.- ..
tender's Name /II �i4— .nJ •�4 p b 5 0�
� lende�s Address P.C.Fee E � .Q Permii Fee . �I/
�� 020.4-82
I certiiy Ihm I hove read this opplication ond sfate thai ihe Issu re Fee
- a6ore information is correct.l agree to mmply with oll County �,,,,a,r�goroo Fee �� `
^ ordin s and Slo�e laws relating lo building construction, �y �
� n ere y itho7ze r tatives of this County to enter To�ol Fee �lJb/S
�'U opon the abo d proper�y for inspec�ion purposes. � „
� ` _ G. (f�.J-.�J� .SEE iEYERSE FOR E1L7LANAlORY lA(iGUAGE_ - . .... _ _.
� _.. _._ � .<—�= . . .. , � �
Signo�ure oF Appl�con�or Agent Dote ��
N
� N s
.�
� d o 3 � o W
m�� °,�.v Z:c" t�.
.".�.�. ��+ o� C J`��,«-,� O. O
t�p d f��� � m � O d tF L,y `i etS t '�
G (O.S.\"'m` + ? �'p O C � .9 f0 �j ys .
a,• ': o o �� � y'� .`�n'a, m w V �,;* � Y
u�."a,.a°�o „�+'� a o b �,�+'3 � �, m o,o� .xa. C
'3r ov�� �v: ap oo � y.a� .,�°-.'�'�o 'sF * "'�s Z � � `,
� ��•i�` ,�v��°1 V s y�,e~r+«�. p 3'� .*.�.T� �"�...'�s �°n � m` y � ° m 'N,a
° O Q�Q`�� o':ttG- � �, E=% `�it+ 4� d�'� �,. o V3� �i � \
r .Q"
�� � Ol M � 1. d � � � Mbl -n d � � � o e �y `,
o r �,o, „�•,eow.c p, 4.,K t .;
�a.d o O � m c'�O � '�O O 1� O �',� o ea '3 _ v n �d�.. C� N
G f '..l'."O� ��.fi'� 4L'ti >�,.�'V�f'.w�n `'� y, �.D Y � o f, ,�^ N
'�uv+ � � � �ogd �,�� m� �:�� �c o�'�„° o�-q o.���033 � Z \
p d-' � �+•a '.��1 1� m e�.-..a-cs ° m'r '''� � '' "� ° ° �y-,""a.'�- 7
H� c ��� "'�Q�� �� � � � °° m '�3.°a �w K�� 01 a °,� " �`��
do ,°, . °' S��.� � � ��� �'00� o3 ?`'w�aw sta' ° N �'� E
dw O T� '„�t 0�O�� �d�,�r, � d N .n �K 4""' d0� w� � V � y p ey� � .
�'..+ yu .a O an""' p' 4'O d � 0.' � 'O p 5.
� m� �" *� "' o°wa,~ .`�ut� �°,z,c01 ��'w��-,3 � d3 �� o °
A m3�o����sM � ��++ o m�,,v.,,c,01 � iscrp ° °, �� a�.� � � o m
�t, v o.a�t?o o,� ,,,�c� o o@.�.�n� d c, �, b,°� o � d � �� C o $
pow o� 4'a�3' �oa. €. � � �o" c �-s�� $o'�'� ,���� oo m
.� m eS • d..,
� „ p w ,�.n�'� d c�.v•• ;�•.'�L �'�h o .i o� d�y x r-- " x �,,v
5 o d `� � p,� ,� x N � m � ,�'� d �,��;,J �$•a.a
A t o� .�',�°,��,o v d '��--� °_o" v$4''x a $ c� �.e
ti.
� o � � «. @; � � x " ° -- 2 � �. � o o �,a .'
tz1 E" R` �'�:�.�j o s, �"'a,� d m• � �,�a,-� a'
3�;���`.`2~`o o�+a dQ 3'�� o �
p9 � � *ao^� Qo�� a,
m „ p � Fva`� �„V `J
mG 'y � w.a�� p
�.,�-� �`' ° �' • V
� c� Z,
�1 �' '' �' �. �O
_ �
� �... • ;: f;• ,� ..� .
, �
•� • ," �'� .�1
�, ��` T i'� /i ^� � � �
� y� `` y �
I
',i �
�Z � ��'� i r � ,
� q � a'✓ • •/
Oi' � � � //;
� �<{� v) , 4�
W �+ n'.
0, !,�. w
� \\ " ryf
�� __ � 1
.-r ����' "'r �
� � _ f • �� r
�� f.� ,� , '`°.� �
p0 J ' `"" �.. f °c
3 ��j 1 ,fn ,� po �
�
a �
ds • �
,� o
� v 6
a
o p�
o, p o
4 �
0
O '�m
o c m o °
Z o \ 0 9E n- u`- cJ1 ""
e • � rn � �n o o d� y°n `o
r �i° +� i s �° e o ` '�°' �'\ �` c c
ZV � 00 > � is 7 � r•���- � o V'u.u+ - ���
J � .� > d5 � '@ � t O Z
� � %•r QT � O O � D �6 y j
Q Z . 4 4 @ 'n � � U y O i/� W
r g° °N'.°� � a+ o�.' ".�
N " 0 G G�rU „G,-� •� G
p� � p r �
P G�
J �pj. D p � � �,..�; '�`V L � O�-
` a .,�'- G `p¢ '4� 7 J G1 � j
y O
� � �C> �"'i
i 6• pi � m %� �O �;y�
a � u s m ° � i
o = ;�, �"'
. 3
o •
m Z �� .
r