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HomeMy WebLinkAbout1407A -_ � _ -.- --.. .._-- ___. ..._____._----------___._._ ._.__. _.____. ____ __ . .. _ __.. ` WORKERS',COMPENSATION DECLARAiION . - ��•��--�'�•'•� � `+ � '� � -� -'` • ms� ., . . , . _ . . .. .. .. .. . � � - 1 hereby affirm iha� t hare a cerlifica�e oi<oount b self � �.e,oracertificateofWorkers'�omPe�sa,,a���=�.o��e, � APPLICATION__FOR BU.ILDING PERMIT �; �� ior a cer�Hi d copy;erQ\(se�:aeoo tob�c.) �� ' ' � � COUNTY OF LOS ANGFLES BUILDING AND SAFETK$�S�:p�I4 (gf�� Policy No. Co1 pany . �...Cer�ified copy is hereby iurnished. � _ . •', FOR APPUCANT TO.fILL IN BUi�DtNG � • I . . , . _.., ADDRES$ ' { ❑ Certified copy is filed with the county building inspec- -- �- BWL�ING �/` Q �7 �{ Q �tibn de t!9enl:� . . .. . � r. ....�...� .�. ADDRE55 /!. /�/U� C'2l�5.y/�� �. ' __..'_ .. __. / )� (/ . ..,,,�///f/) /�.^.,' 7�y� . n _ _._ _ . p. q r ` Date t�V� � 0 � APPIic(Ifi�Y J� . V G V c r}-!V�L � C�tv I!jl��/�! ��ln�. .. ,G�Lv l�! �l ��-- IOCAUTY. .. v77 � �". " rC� � -' � CERTIFICATE OF EXEMPTION FROM WORKERS' � - -� " "' '��' y ,�/� NO OF BiDGS:-� -- -�- tafAREST��. ..-. _- _. � ' - �. .. COMPENSATION INSURANCE..- ..,..:.. SizE OF lat Z•(S �`f'L �. NOw ON LOT �� CRO55 ST. DI� - Q✓j 1Z' Q LV 1� '. � Qhis seclion need noi be comple�ad if ihe permit is�for one ��������� -- '� � - � -� '�- �� �"-� - ��+ ��R ��� � � ' � ���� ' ' huodred dollars(5100)or,tezs.). � . . . � TaACr ' �j��J BtOCK l0T NO. Y � Mqp OppK"" �" ' PAGE PARQI , : TEL ' I certify Ihal in ihe performance of 1he�work far which Ihis OWNER""� - � '-"� ✓Z-�----�N0.7� •� 3j USE ZONE � �/K � � permil,is issued.�I shall not employ ony person in any manner ,---_- _ /�l.I - Z UI---.. � � ��l/' � �ECIAI. _. _ � �� ^�' - ..��,,�.� .O � so as to become su6jeci fo�he Workers'Compensation laws. aooae55� -0� r�TNF .D,E {� � CONDITIONS �r. __ V , ... . .. .� ..� . �... , ..�,� . . , ..... CRY. ��J A. ..21P . ' 7G ' _ . _ .._.. .,' "" ....._. ._.. . .... .. ._ . Dale:. . . �Applimnt' . ., . y . . � ARCHITECT OR� n iEL7�Y. p;$TR;'�7._ _G � Ti ri .FiKE i�icOCtSS[l]BY_.. '`�' jr"+CE i0 APPIICANi: 1(, aFler moking this'CartiFicole of ?✓�.�S T �j ' "�J� NO. -SY�t�� ' � . ,'�j i � •ptio�,,yau should become subject-10��he Workers' �- � fNGiNEER ) NST. yA� ZONE W � Compensmion provisians of ihe lobor Code,yo�musi{onh- nD�RE552 � f! � �+'y GU«✓"'�f/�` Al`"'� -� r �"" � �--- - � a i wi�h comply wilh�such provisions or.ihis.permil sholl 6e �--- ,-� - � . , TEI.�� � � ' STATISTICAL QASSIFICAiION . ' APT. CO . �Z : deemedre�ok0(I.�� ... .�. �.�..�.. .. �. .._�..�. ._ CONTRACi00. � S FLtaUJ.i�`( No. � . - _.. . __ . - ��, LICENSED CONTRACTORS�ECIARATION�..� �� �-- �- /_ - UC.(� !Lry� C�NO. �� OWELL.UNITS � I hereby affirm that I am licensed under prov sions of Chap�er 9 AOD (�/f7 � � �~ NOU � '�/V ��R�P � , (commencing wiih Section 7000)of Division 3 of the Bosiness and _ .... �/ �r'.._ __ __._ . ,�iC.--�- -.-.----�� ; �� � Professions Code,and my license�s in fuil(orce ond effecL Ci Yil(��L �c.' /.55 ----"gK: - pG� ' .-- --" - � ���VAUDAiION ; . � . . _. . .�. �.. - CHECJC_i . . � I ' ' . __...._. SQ.F ,J, NO.OF • NO.OF .'..' � License,�bO��Gr ����� Lic.Closs ��-� S�ZE �J STOR�ES FAMILIES ONF V . - - �� . . _.. . . .'�'.� .r. .� , . _ _ . / �7n -�/' /��,/ ._ ALU/JA/TION .f�._ .. _ .. �CQnIFOCtot' O�i V f��-YI"` �Date�_'��. " DESCRIPTION OF WORK_'.. .."""'_.. ... ...... ... AEDWD � S OC W 7 II/ `.. . ' _ � ... . � .. . _ .. _ � � �I am axempt under Sec. _ .._- ....- � _. ..._. . .q�iER ❑ , ' � . : - -, ,.,.�. ;.. .. . . , .. : . . . _ _. .. . - S -_.... _ _.._ _ __. ... _..---- � B.BP.C,for this reoson ._. RE7AIR��❑ � �_ . . . . . ._..�,� .,., � U5E . . : : : � Date:� exisrw�stoa. iV DEnno'. _. . .. . .... . ... � � Si nolure �.- ... _ ..- �--� ' .�... -�- '�� �IC1WT � . TEL.7 1 � 9 aRiNi/'A(� .�/v 9 � NO. �- ' j FINAI • ' : OWNER-BUILDERDECIARATION .._._. ..... ._.. .--._.. _._ ... /I- --.-- -... . - -- .. _ _•.DATE.___...- -'-. ...._. ,.__ . � ... .._... ... .._.__ ' � I hereby atfirm Ibat I am exampt from ihe Contraclor's licanse qbOR455ZI�U S� ��{r�7 �JL f�f�t -�Z�/ � •�• `•�• • � Law(or Ihe following reamn(Section 7031.5,Bosiness and FINAI � ProfessionsCode):... . . . . . ._......... .....•-_- -. . E - ._ su�mwc � S(�lLgr!` Cfl(/SS/NL . By . /i � r �._ I,ns owner of ibe propeny, or my empioyees w�ih __. _ . ADDRE55 .._..... .. . ._._.. ....... .. .._ ......._._._...-'__. ._ . .. :� 1 <t �tl -. wages os the�r sole campenwlion,will do�he work and �«A�in,� fl��J���� � , the siructure�s no�inlended or oHored tor sale(Section , ' � .,___ ,°1- ' . �-7044,Business and Professions Code)... . ... . . ..-�-` MOVING.._..__-- . .._.. ...__ .._..__.tEL: ...- ... ..._-.- . .. '..._... - '--� --" . .. , � I,as owner of the property,am exclusively contraUing CONiRACTOR NO. � _ . � .'. .. _. . . . �_ wlth licensed conlmctors fo mnstrucf the prOlett(Sec- '.. .. -.� "�""". . - ..- .. _.. . . . _ .__.. ._.._ ___.. __ ...__ _._ . . ..:-. . ,- 1 � �G G I 4 ADDRESS ` � � tion 7044,Bosiness and Professions CodeJ. ' i.U�� � L t,c. . "'_' . _REOUIRED_. .IOTAL SETBA ''_ .. ..._._. . _ .:._ . . :. . . . _.. ... �-'� -� -��� 'CONSTRUCTION LENDING AGENCY�'-�-� � � SEi BnCK -YARD HWY- GRO�.LINE WIDTH - I hereby affirm Ihat ihere is a construction lending agency for fRONT ���L y� �C- � � ihe performance oF tbe wark for which Ihis permil irissued . . -P.L---" '---- . -.-_ ..__. ..__. __.._ .. ...-� -- - ._... ...-'-. - _ . . ..... ._-.- - --.. . . -._ -I C.3097, iv.C.. SIDE $ � ..._ . ... P.L __`___ . _....... ....._ ... . _._ .. ������� _ _ _ . . ._. . , : ' _ , - - p IOMA Ref.Y � � _.. .. . ._ . . . ._ . .. . . __. ... .. .. . P.C.Fee f _. . . _.'. 7ermit Fee '-��:JG•��' . ._. ..... . - lender's Address � ' � '� � ,.'. ' . �Q.�l� , � . . rc I te�liPy Ihat 1 have read this opplica�ion and stole.lhal.ihe . . - -.-. .'- '...._. . - . ...... . Issuonce Fer-.- -- • IDM.4 P/C k.... -. ... .. . . ^--.. � �...., ... ¢ obove information is correcL I agree ro comply with all County Inreiti9ation Fea �/ ' � . ;..- . � _ordinonces ond Sta�e lawsftela�iQg to building wnstr�ction. ... . ..' ._-_-'._.__. .._._.._..._ Tmal Fee--.�"'j 7��� �. -LDMq oerm.� ....-.-... -.. - .'_. . .- .----. -. ..'� .... u ond h eby au�horixe re seNohves of ihis Cou ty�o en� r ' $ Po bove-ment' d property(or�specti �purpas s. _ ���� "�S Q� � .____ _ _.... � . `.. . . .__.. __. . .. . - '--' ---- --�-- J _.... . ... ..- - ,-_ " ' a �✓ � SEE RFVERSE FOR EXfMNATORY IANGUAGE � ^ _. _ fgnmureofAp mnlorAgent _._ .._. ..... 1e'.' �_. .. _ . .. _.�'.__'_ _." . ' '. ..... _ ..___ ._. .. . . -. ___ ..__.. . . . 1.. ._ .. . _-. '.. _. . �O �ri I i `... ... .+ 'M' ' N O1 T� .l'p .W V 01 Ol l .M C V C . .N / 1 p�""�+'�.�` G C tu C ��..W �.1 . C Q.1`'.y� � FJ\F� C O Cl �� �' ��.. � . � .... � _ � V�_`� � :U r.;.N •�n �O ; o� d'�ti'. - . 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