Loading...
HomeMy WebLinkAbout1644A 2187A � WORKERS'C0.4".�ENSATION CECLARATION I' /� � I he.eby af�;,m ,�a,� �a��a certiFica�r.o<<o�,��,�o,P�� APPLICATION FOR BUILDING PERMIT � � ineurr.,or a ter��(ico!r.oi Workers'Compertsai�on Insurance, L� c�o tert�i�C'�COpy ItiC�POF�SI!C.�QOO,�Ob.C.� �gir1C��J�Pt (�IlYT�O�IAL AMEQi� COUNTY OF LOS ANGELES BUILDING AND SAFETY o��cyNo. omPony � Cc�tif�ed copy�s hcrr.6y furnished. FOR APPLICANT TO FIIL IN eunotn;G nooR:ss L4�-{�CO E. STA2.. �.-r-• Ccrrlf�ed cepy is filed w�!h�he eounry b�ilding inspeC- BUIID:NG �Y e �` IiOn dC��rimenl. (� ADGR[SS aJ�� l��• oo�e q � �n�Pi��a�� CA-riO �ihC� aTr�! �AM R_ z�v �l"7 '� iocaurr �iArYl �AR CERTIFICATE OF E%E�1.PTION FROM WORKERS' n+0.Oc BLOGS. NEn4EST ' CO=M.pENSATION INSURANCE SRE OF LOT NOW ON lOT � CROSS ST. (This settion need not be compleied if Ihe permit is for onc $� o�aK lOT NO. ASSESSOR h�ndred dollors(SI00)or lefs.) TRACT MAP P.00K PAGE PARCFL ON":ER��4l��D l-ASS� NO.,� U ZOhE /�P ��Q I cenify ihat in�he performonce o�tha work for which ihis � h�. permif is Issued,�shall ncf employ any person in ony manner ADDRE55 � C. S"�11 Q. 1 5����A� n- so es to he:eme su6ject to the Wcrkers'Comper.ecticn Laws. • C CONDiiiC':5 0 atr��Atr1pt10 Q ziv 9 l'� � v Do�e AFpliconf ARCHiTECiOR TFI. � NOTICE TO APPIICANT� li, oiler ma4ing 1hi!Certificala of �ISTRICT GROua TYPE F;RE P40CESSEO Bv O E.emp�ion, you should becoma su6jetl to ihn Wcrkers' FNG!NEER NO. ^v CC'��;1 ' - �pwt� 1- Compensation provisions of fhe Lobor Code,you mus�forih• q07aE55 �� \\ v�— �V � lUil with comply with such provlsions or lhis permit sholl bc TEL. 1 STATiS'iCal ClAS,'S��'.C!�iON A?T. CCn��O. u) delmed revo4ed. CONTRACTCR �� Np. t `']�t�-� �\ IICENSED CONTRACTORS D'.CLARAiION p ���. �1n CLA55 N0._LD'h?lL.UNITS Z I Feroby oFiirm ihot I am I�censed unde�p•ovisions oi Chapter 9 ADC:E55 '1C,��Aid�ty � NO. 41 1 b� (commancing w��h Sec�i�n 7000)cf Division 7 cf ihe Busiress and '.` ��� SEWER MAP Professiors Code,and my licensr.is in full force and effen. �iTY �J�LIJIY� CLA55 C� �� VALIOATION r_L(. (� SO.FT. I� NO.C' NO.Of CHECK BK' �'' Lieer.se Number����`�' ` lic.Clase -`�� SiZE �T STOQiES FAMI�!�5 � OhE P��O�� p (y�[�� VALUATION Co���ac�o� �n� Do�e a 3� `' • ��KR!�TICN OF WC4K $� T -J6�S ^� ❑ f � �j S� ADD ❑I am c*emp�undcr Scc. Q-� LATT1 -Qr AITFR � ='1 6 i;,4 r'{ � 8.8P.C.for ihis reoson REPA!R ❑ s ". • • .�J F Do!e: USE CF ` ^� C�:�_a E%I571\G BIDG. - 1�nt� ❑ Signa+ure ACPLICANT TEI. FINAI J • •J 7�.J� OWnER-BUILDER DECLARATION ��x:4T� � ( A'NNO. 'T]r{- � DATE + � ;�.;(j�; I hereby affirm ihal I am oxempt from�he Contractor's licenee e� �IAI,LGY-�'H-V�I4�.*1 UT Law for ihe iollowing reoson(Seuion 7031.5,�usiness and ACCaE55 FlNAL G 9.1 9-��E Profeestons Ccde): 2 ti By � eu•�o�N^ I, os owner af Ihe preperly, or my employees wi!h AC�RESS wagr.s as Iheir sole compensa�ion,will do Ihe work and ��a��Tv � ihe struc!ure is net in!ended or cffered for sale(Seclion 70<4,Businr.ss and Proirtssions Cade). h�Ov�vG TEt. � � I,ns owner of the preperly,am e.clusively conlracfing CCNTaaCtOR NO. w��h I�censed tonn�c�on to co�s�roct ihe p.ojrtcl(Sec. qDD".FSS i�on 7D44,Business and Profess�ons Cedn�. CONSTRUCTIO.J LENDING AGENCY SEi EACK �ARD HWV �V�AFRpP.��ti��V,� WID�Fi ' � 2, � r 1 I hereby affirm Ihot ihere is a[ons�ruction lendinc�agenty ior {kL,y� r• • • . • � thr.pe��ormance eF the work ior which this prrmit i�issued P�, (Scc.3077,Civ.C.). SipE � . .�C J U P.L. londer's Name � r !'''� lC'.�A Ref.N � •�`O ��% � lender's Address P G Fee S S PP�TiI FPH I Q �d IG.GS-&3 a I cerlify that�have read this applicalion and stale that the Issuonre Fen �Q ID.'�1�P/C M obove informolion is correct.I og�ee fo comply wi�h oll Counfy Invesiigoi�on Fee ord�nontes ond Storn lows relo��ng to building consnuciion, iorol Fea � IDMA P�rm,M and reby auihorize representailves of this Co�n�y�o enter _ up hn ob�nyr.- iianr,d prope�iy for inspec�ian purposns. 1.•. A1, qqqrrr��� 'L p�ct ` (Jg�� �T 1.� SEE REVERSE FOR E%PLANATORV LANGUAGE a_� S�gna�ure ol Appi�cen or Agem pe e a a `1y� . �f��� � ` ...� � � �c' ,L /rn �� T' \o �^ �: � �\. � 1.o ,- r� ?Y �:' " , l ../ � � � �� S} CG � �C '��.G � ' " �\ i ,;\ �. � -.? '� ^ �� • 'J` t/ ` C..\`, ' '��T'. (^(f \ � �• � t_ � `�' '• � .. �< �� \ � y\O � r' r^ j " � ,'r•r�\ �p -�.(C � � . r �p t �'I. � : ii � C 7' �� ° ` t . `/ � '= r��� .� ' � A �f '^ \ �•`r °; ��� '.,\m t _ ..,\.\ � T . '?f� n ''L ;� �i � �•� '/'' �� , �_\\d y .� -u�= o . & � \�� ., . �: o , �.�.�.. \ ��� �o � � +� ✓ • � \� o /', , �` '�� 'r. \�\ 7, \ y , ` � � v \\-.��� �\ �� .l/ `! �G ; '� /� \ ��. ` \ � �r _ \ % �p \ � �/ \q n \ 4 ` ��• �-�..� ,i O C. /' � . t ` i � \ ~ � �� �� � \ 'y \`N , ` � ii � 4� � i . P - - /, '� • \ y, �� �` / � i n / r , �!� � 1 y � . . {/� � � 2 . • � . � ._ . ;• �i�. .' J . N .. � �.% `� �` � - .. ` '.. � J . ' . ` ' ' � 'f _ � " � c. �••_:' :.G :.j:' ,-, ' � �} �•% �,�, .-�:s ' =.c,,r.�~'` f � .�. t t. 4`� .. ^` c• ?� . . 'I ✓ -' . —'n'4.T C • L� `f•N,'^_C��� ` �'Nr � ^ ' '! '�,' , �., �_-= r `f� o = -_;-.� � - r.:. _ r; C:i ' V'� ..'L S. ,� �:. A O ► n"'a'� C-y` ' ' f. ..i . C p ';, `? GY ' : _� '^ �:'r� �V_ c - ' �'- ' r. C. • �• � � 'r'• `C'''t'w � � n p •~ �� .-,S-4 _ �'V7 '• � � ✓� �= �'i ' e. � . � _ '- (�+ -' �- •i _ s. - � _'` r: i � �..7 G-Nt. C:�r%, t 1' -`� ^ ^C'� `� , r:Y y~ ���^ ��i y � i � C. v _ � �. _ f. _ 2 L '�^.�cy �� ` 4^ _ _ � ,r ..f �` �� �.` i• � ...��^F {""n _" , .. 7+..'���~~. ~ _ '.. � .�. •'�'+� • • .�� _�^' � G .. �'_ i' . ' ^ O^C%� r �..�.. �r"' �' L..= .. f,.r�. � ?_ � �.^� o „ s:.- _ ~� 4 � L�. � �i = c _ �•:.- _ �,n% ✓ � N �„^a - `� r, = _ - �„C �� . s. � e. - i• c� t � s.•�� ^'•�� � w � � ,4 G-�_ - � i..H � ? � �n �^' r� �.y� G�.� ^ V � r ^ .�. /'.N ^ =• l � n � ^'a�`. .. .- — ' � _ S a i,`� �^ s. ; �� a'� ' `✓. 'J F S^-� .. �i � , :l 7 r.^t � t ' F � - -.C..- (, L� ' � i `f�r � ^�F w�_.. .l'_ V ` . O O Y���"�iF�' '`+'��_^�'^_~(�Y,�,Y _•% - "'. � .. 1/� } Ct Y � � G < � � , ' � ,s^' ^ r �7 , �' .'4 ' � '- - �� ^ �f `, 'f f r .. � � ' I ///•�� �,1� /