HomeMy WebLinkAbout1419A 8919A (8) VJORKERS'COMPENSATION DECLARAiION ^
I he�eby•offirm ,�a,� �o��a«,,,�,�a,�of mnsent to sel( APPLICATION��FOR BUILDING PERMIT LS
".fu"�e,,ar a��rfifica�n of Workers'Compensaiion Insuronce,
• o�acerlified cepy Ihereof(Sec.3800,�ab.C.) COUNTY OF LOS ANGELES eUILDING AND SAFETY
PolicyNo. Company
B�IID�NG. ry O ����Q
� Cer�ified topy is herr.by furnfshed. FOR APPLICANT TO FILL IN n..eR,SS -1
❑ Cerjilied copy is(iled wilh Ihe county 6uilding inspe[- g�IIDiNG I/
li0n departmenf. ADDRE55 7 � � �C QU n� �(�J4 LOCAL�TV
Date Applicant CiTv � 0/✓� /7/�/% Ziv y� ]�s CROSSSSi. J ���C
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.Oc CioGS. ASSESSCa
COh1PEN5ATION INSURANCE S�ZE OF LOT n r. NOw OY tOT ti!nr AOOK PnGE PaRCEL
(This sectian need not 6n compleled if ihe pr.rmi�is for one Q� u 20\'E MAP
h�ndred dollars(SI00)or�rss.� TRACT �Z l P.!OCK LOT NO. � NO. I O�
� -�7,iEt. S%'ECinL }
1 certify thot in the performonce of�he work for which ihis OwhER O �/Z - � f}-�u h0. ��.� CCN'JITICN$ o.
permil i5 i55uBd,I Shpll npl employ any e.rson in ony nne.r , O:SiFICI GRCU? IYf'E FI7E FR(KESSEU BY 0
so as lo br.comn subject lo Iha Work C mp ns . Laws. nCCRE55 . . � . Q. L 1 O ^ CCNGT,r• ZC� ����� V
�/' � - 1,� ��T� � ��)��7/� (,(•� I�)/1 � '� v "
/l Da'e ApPlicor �Y=�=`=�—b�I�-! Z�P $TAi15TICnL CIl�S$'FIUIICN AP�. CONDO. O
NOTICE TO APPLICANT: If, after making Ihis Ccrtificatc of ARCHITECT O TEL. V
Eremption, you Should betomc su6ject fo the Workeri FNG!NFFa �A f� . 'Q � NO. CLA55 NO. d� DWELL.UNITS�I �!1
Compensalion provis�ons of Ihr.La6ar Code,you musl forlh• qDDRE55 � '
y?. Q SEWERh•.AP �
w��h comply wiih svth provisions or ihis permit sholl br. 7_
deemed rnvo4ed. -�y�E�� � VAIIDATION '-
CONTRACTO4 �s 1WI�IUNO. � �IC1 PK� �'•
. LICENSE�CONTRACTORS DECLARATION /� ii�.
I herrby nifirm thot I om licnnsrd undr.r provisions of Chap!er 9 ADDRE55 � l� l}7A-/] �Q;'O. �L VALUATION
(commencing with$e:tien 7000)of Division 3 af the 6�siness and /�
Prafessions Code,and my license is in full fa�cr.ond e.f(ect. CiiV 4.� v�C2 CLA55 5 Q�d
SO.fT �/•, VO.CF �1 NO.OF CfiECK , ? � /� � ;v r� .
Licensa Num6er lic.Clasa SIZE 7 STO4!ES /� FA!:.!LIFS OKE � �
1 5 �! •• • ►'z� �
COnlraClol Date DESCRIDTiC,�F WO.% V (�./ . h��v+ ❑
�I am ezempt unde�Sr.c � � ACD � � .f���j`
nliER ❑ DA EL 12'�.f` "/ � :� i .
8.8P.C.for th�s reoson �/� t-N� � '�' f'�-
. a�rnie
Doie: USE OF FINAL ��
F%ISTiNG BIDG. ��"'�"• ❑ B ...:C`.� .,..
$ignOture APiYIUNT �,r� y
OWNER-6UILDER DECLARATION IPR'NT � r`� � . � � �
I hcreby affirm that I om eRempl from the Conlrac�or's Litensr. �
low for the followin9 rr.aeon�Sect�on 7031.5,Business and ADDaFSS .
^ P� fesslons Code): oc�_tti;
���o�� �a�i.�r�.
I, as awnrr of Ihe Arepnrfy, or my employees with ACC4E55
wopn.s ae�heir sole campensaiion,will do�he work and : � � � 1
the strvct�re is nol inlended or offered for sale(Sr.Uion �OCALiTv �r + •
7044,6�siness ond Professions Code). M.OwNG TFi.
� I,as owner o(�he preperty,am e.clusively cantroUin� NiRAC10R NO. � •C� Q�(1
with licensed contrac�c�s ro consrruct the projeU�Sr.c- qeDe�55 �'��� i"�,Q^�
�ion 7044,Business and Profess�ons Code�. �� ��-
kEQU1fiED TOTAL SET9AIX FRU.•A F%iSI,
CONSTRUCTION LENDING AGENCY SEl BACK YARD HWY ekOa.uNE wiorH• , 0 cz�8"Z,I
I hereby aFfirm ihol ihere is a construttion lending ogency fo� .,,faUN� . .
Ihe performonce oi tha work for which this permil is issur.d P.L. •�
�Sec.3097.Civ.C.J. Sipc
m P.l. �
� Lr.nder's Name
� lender's Address P.C.Fee S �� Permi�Fee `�•� '
� I cerliFy tho�I hove read this applicalion and stale Ihal the les� ce Fee 0 �`��
Obove inFormation ie correct.1 a9ree to comply with all County inves�igo��on feo a
� ordinonces and Sla�r.laws relatin�to 6uildint�const�uction, p r Dr� �
�7 and hereby o�rhorize represenro�ives of ihis Co�nty to entr.r TD�OI FP9
upo e above-menti0ne properly for inspe[tion p�rposes. 1 'l\M �5
� �� �✓L 6(� - -�7 �� i.s � . � ' .
SEE REVERSE FOR E1(PLANATORY LANGUAGE �
Signorure o!A�,icant or Agenl pni� 'E'�/
!
�+ r r m T (A � L� ^v � (,� -r� T � I . -i
�4 � j � 7 O O L7 O 7 � n C �O � O O (1� fr 1` f. �; . . ' t O C
K. C� i� i �- 1 V S � 3 � � �� ; T' O � �� � �," o '4 �' {: � __I�_ ..
4. � � � � � ! �� �'] .. c:. �� 1 � L . O '� O _. _ i . 1.
� �, -t� .c L: ii 7 _ � c ; v: �
� n �'' H �-� �' •. �_ `� ' , c': T; n (1 I
h J a'c � -'} � , �` �.;J t C` :'? (l:i C �' �� )+
� �?�;� 1�a . � � � f' c �;.:� c: _, — '; ; � _. ,
C � N: - { r . �. _1 � �C _ 4, "�
W � 7 f� (: _ O L) ., — - ', ( �
c� I o ` �� u I� � G
` ` _ u � V� ( _ c ti, ci► ;��
� ' __� �p _ ^- "� = ii h�
� � —I� � � •�.
i �
` �..�-�� � � � I �r� � • ' �. ='�
v � �� -�• �
� �(� l/J}�� � �(�I, [ti �1 I' C �__ � —�' I_'_ � —�—�— ' V;
� vl � � y/ (1 V� � � '` ` O �1
,� �; �` Q,` J' I I M T� �' O
L 1: 1�— —I` „ �� �
� � , _ - _ _c � � �
� —�`�� 1 � I � ' �' ^
P'�� � i 2 n
� — .v � �
c ."G:_ � � • o n e
6-�J�L�1 / 1 r � i �o' � =,
i � �
«' ` '\ Q o
w ' a; .
i-.� �
e i.is e �
� j O i ti
� , i °a e �
- - a o
. a
• ' N
_ �
. �
' . ` n
N
' �' O
'jl
' . � . ' N
� ' �
\. . �-!
I � ' �
' N
. � - _l:� _ :
. ;�� � �
: ' '� � i �
f i I I . , I
, , � i � , � � . � ^_ : _ .. __ . -_ _ : �. �. �. _ � � �-_
. ; . � � �=� � :.. _ , �- - _ .- - � - : r -� . - .�� _ _ � _ �:�:
� ; � � ,�: . _ .. . _ __ :_�� _ _ `.�� � _ . �� _�� , _- �, . .. ���
' I � ( I I ' . _ . _ ' _ _ . ' _ _ � C
i I I � � � - � " - . ' _ � - �� - ' . :. - - _ i
i � � , j � I i - . ..._ - �: _ y _ � ,
I � � , I � � 7 i � � _ ' . ; . ..-. � .,. J - ` ,'. '; _" - - _ .� ` _ -
I � � I � � I � i' � ' _ .. ' �' .ry. ` . - <. - � . ��
� � i � ["• ' - ' r: " ^ �
I � I ; � i.. ' ���� � __ .. - ' =: c .. _ ``.. t;" , - ° - .
I • i ' �' � , ,. . - ` .. r . `� ` � � = _
� I � � I I I I ��'� . I I' ` .., . 't �� �� ' " '` ' � " `
I I I I I I . � I �C, I , .. - r �; .. _ -� ` :' � ` f � � �=� � „ _ ^.
I � � ` r' i ` t. �, .. ; . �—~' ;._ _ �._'^C` _ � �.' �:
I . I i . • . ' = - - ' � " ` - ''> ` - .. . �� � - �
j I I : �' C �:�. ., ,, f . 4�\ ` �� ' r p L' G;�C L +� M `� - _ e: �
I � • I � `. � .. � " :' �. _ ` _ - �. ` �:;:-''` �' ;'.n l
�1 l n. H f.'1 f � 1 � �M• G
(1 �.`^ ,� � ` f� f_ Gf , lw ` _- 1
Y i �� [. 1 r�� � l.� �� � \1
ry r: — Co � r-w O t. C �f' ,. n`•
� � . N . . : r� ('1 �� ': = �'��.�.'.` CJl; i `� �~ p`•(•.?1 � = i. �..�
� � f' Q \1 -• �•• l n`7 y L� `.�^„l+L~7 �..� M �y `i