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HomeMy WebLinkAbout0918A 0919A (4) , .- -..._._ ._... .. ._._ . .._..__. -- ---�- - - --....._. _._..._ _ ... . ........ ... _. . ... . ._... ._. � WORKERS�COMPENSATIONDECLARATION '� ' ��''�.��� ". � ' � -. . • � � .1 hereby offirm ihal I have a cer�ificate of tonsent to se�F -� - �� � -��APPLICATION FOR��BUILDING� PE�RMIT �---�� � insure,or a certificata of Workers'Compensation Insuronce, or a certified copy ihereof(Sec.3600,Lab.C.J .._-_ -._..- ._... . . _ .__ -- - -- - , - . COUNTY OF LOS ANGELES BUILDING AND SAFE7Y P❑olicyNo._61WFTX7Q�2mpany I-lar�fnrrl (;rn��n_ aui�o�rvG Certitied copy�s hereby fumished. FOR APPLICANT TO FIILIN ApoREu oz� �� �• r7 Certified copy'is filed wi�h the county building inspeo- � -� BURDiNG ' UU fion departme c�' � � , � AODRE55 24438 Edst T d ' � 6�,� � Dote��; -� ,.�� � - .. . _-' _ . .__ .._.. ._.... .-...__... . , ApplimN GITY � Z�P LOCALITY ' CERTIFICATE OF EXEMPTION FROM WORKERS" •� - � � -�� --�----� ' �'" NO.OF BIDGS. �--� - NEAREST... . . _.... ._ . . ...... �-.- .'- . ... ..._.. . ... ' '� COMPENSATION INSURANCE � 54E OP lOT tiOW ON lOT CRO55 ST. (Thfs section need no�be comple�ed if the pe�mit is for one - � - ��� -�� -- � ASSESSOR _ - hundred dollars�51D0)ar less.).. . TRAQ 42568��� ei«K �� ior Ao. ✓ MAP BOOK � VAGE. PA�� . . .- TEI. �c�{��� h1HP 1 ceriify thot in tha performonce of�he work for which this OWNER "' ""' '� "--' NO. �SO��OD� 'Y p�p � ��-3 �' • �, I �� a �iermil is issued,I shall not employ any person in any manner . . .� � ` � S�ECiA�.� ��-��� � � - - � so as to become subjecf lo the Workers'Compensation Laws. �- A�DRESS�- - - �� -��� �-�-v CONDITIONS . ' � CITY_ ZIP __ _ __ ._ .. ._ .. .. . - - - � � Date� �Ap'pliwnt ��� ARCHITECT OR TEI. �� DISTRICT GROUP TYPE FIRE PROCESSED BY r ICE'TO-APPLICANT: If,�aHer moking lhis Cerfificote of ENGMEER �� CONST./ ZpLJE V I �np�ion,�you should bemme subject �o �he Workers' - � /��j �� �� , ... . lompensatton provisions of Ihe Lobor Code,you must forih- ADDRESS ' �� -�� ---'" �- � �� -��-� �N with comply wi�h�such provisions or �his permi� shall be ... tEi. 5TA7i5TICAL MSSiFICATION APT. CONDO. � Z deemed revoked....•., . . . . coNrxnaoa • No. _ _. �- IICENSED CONiRACTORS DECIARATION .. - - � --- ��i�.� CtA55 NO. DwELL UNrtS I hereby otfirm thal I am Iicensed.under proviiions of Chap�er 9 ADDRE55 NO. SEwErz n�a.P � • . (commencing wi�h Sec�ion 7000)of Division 3 of the Bus(ness and _ . ���. � ._. _ .. _ .. , Profession:Code,and my license is in full(orce�and ef(ect. CITY C�n55 � --�- ���BK-� ��- � "�"`� -�--�- -- VALIDATION - ' �� ' , � � � SO.FT. NO.OF NO.OF __ CHECK - '; L�cense Numbe� '4O9b�O . ' 'lic,Class` B" size STORIE$ FAMILIES, ONE' ' � / VAWATION_Q, y'\ -C.Q i�.<3 fi--� Bramal ea CC1�l f' • ' DESCRIPTIO F WORK '�J- N� � ��S` C�(�v Confractor Oata . ADD S , •.•. .. . �I am eMempl under Se[. " ALTER ,f� a L, � . . . ❑ s , I.^��_1..10 8.8P.C.for this�eason __ REPAIR ❑ " " --�""" � � ' � ' USE OF Dat o�a "'��J� 1 i fi� �'nn�j— E%IS71NG BI�G. � � - - --- - ' SignaWre . L/C.[__ -.. APaicnNr TE�. FINAL G t�<[fl"C C � WNER-BUILDER DECLARATION PRiM NO. DATE �� � -� - � -- � -- - - - , .I hereby affirm that I om eaempt from the Contractor's Litense . -. law for the followin9 reoson(Sectlon 7031.5,8usiness and ADDae55 FINAL � Professlons Code):" '' � ' - ' ' - e ni Y � ' ' � � ...... BUILDiNG .. . . . __ ., _. _. . � : . I, as awner of the property, o� my employees wi�h AD�RE55 ., - . , � woges as iheir sole compensation,will do the work and , ' -`` ' n C the strocture is no�intended or offered for sala(Section ����tt . �•��G' �. I{� '- - 7044,Business and Prafessions Code). - ' MOVING - - TEL:� - . ._.. ._ . .. . . _ . ._. � n I,as owner of the property,am exdusively convaning CONTRACfOR NO. . �l e a • o • � . y�'� with licensed mnhactors to cansiruct ihe project(Sec- �� � lion 704E,8usiness and Piafessions Code). AD�RE55 . I e�„ �.Q p. , -"� -� CONSTRUCTION LENDING AGENCY " - '- " SE�BACK�' YARD� Hwr 1O1'4pROTP uNEFR -- WIDTH o o�.��,���� ` I hereby affirm Ihat there is a tonstruc�ion lending agency for fkONT ' ' -tha performanca of Ihe wark for whicb�his permit is iasved --- -a.L. - - --- --. .. ..... ... .. . ... ..... .- -' . .. -:. . _ �; ___.�.� .. ' (Sec.3097,Civ.C.). SIDE � "' `�:'Y 5� � � . . .. ... . --"---- _. _._ _ ._ .. _. ..... _ _. : lender's Nama TOPOfItO �01111 11 1 0 11 B011k �prnq eef.N s ]44 Sansome.St., Su�te 700 --- p.C.FeeE -��I./J_ P�,m;,f«- - 4�v;�.-; - - . .. = lender's Address • ' �7 _ ` ' '� � .-I certify that I have read Ihis app im�ion and sia�e t at Ihe - - /S,/ll. Issua�ce Fee� ���U tDMA PiC I� - ' '`� � � - -� �� Q obova informalion is torrett.�agree fo tomply with all Coumy Investigaeion Fea r/ v i ._ . ' g ordinantes and$tote lows reloting lo bvilding tonstruUion, ,,.__ _ - Toiol Fee� v /'� LDhA4 Perm.M - . - _, , ' � and hereby outhorize representafives of this County to enler � - $ upon Ihe obove- ntiane proper i i ection purpos s y � _ _ , - _ - - - -- - p_�--�- . � < / SEE REVERSE FOR El(iIANATORY IANGUAGE � . .'" "_ n u App en - . fe _' _ ' . ._ _ . ... ... . _ . . _ . _. ! . . . .. •. .� 1 _. .Q� � Z o . - o . T- Y�, 'q � .�_ -O� � p N . �� `� �,.. '�a =• a' a 7 ^ iY O .o ; o� �m o� a v d _ q o Q � n. �� �D, O 'D =:. 'O.. O s: � ^ ° o 0 3 ° 'o �• � -o in a � °• '��� C>> m 3 ,ic +' �o ' ^ N O m p . `fl Q �w � �'� � m r� r o � v - q ,o o� . oo � ? q � o � o � a oo .o co p ; . v � Z >> °c ? 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