HomeMy WebLinkAbout1372A � 1
WORY�:RS'COMPENSATION DECLARAT;ON '
I hereby oilirm Iha1 I have a cerrificate oF consem to self qpp�ICATION FOR BUILDING PERMIT ��
insure,o�a certllico�e of Workeri Compensaiion Insuronce,
vr a certified mpy�he�eof(Sec.7800,lab.C.) COUNTY Of LOS ANGELES BUILDING AND SAFETY
PolicyNo. Compony
� Cerrified copy is heieby furnished. FOR APPLICANT TO FILL IN sunoiN� 9�.7/O � G
A�DRESS •C.
� Certified capy is filed with tha counry building tnspeo- gUiLDiNG �� � � ��
lion deporiment. AD�RE55 �/in�r/(� �/�,1
Da1e Applicant CITY �/c2Mt»d [J�r ZIP �p�,q��Ty
CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF LOT��O��07,C3/�NOW ON�LOTS O NFqREST '
COMPENSATION INSURANCE c7 CROSS ST. Lt
�This�etfion need not 6e complated if fhe permil Is for one TRACf c77 7 D BLOCK t0T NO. ���� AUESSOR U
hundred dollars(y100)or le7s.) 3 MAP BOOK PAGE PAR�EL �
/. y TEL.
OWNER C'�lz ��.v�-� NO.H/Y X�61 U` USF�ZONE N✓aF �
I cenify�ho�tn�he performance of tha work(or which th's ��� ��.NO. /��—�5`/
permit is iss�ed,I shall not employ any person in any mann r qDDRE55 . Qp p�0, SPECIAL . �' '
so os lo become s�bject to tha Workers'C mpensotion lo � CONDITIONS Q
1� ' CIN �.. . _ . � ZIP ' U -
xDare �� APPlicant � .
NOTICE T�T: If, offer making�lhis Certificete oi ARCHITECTOR � / TEL. ' DiSTRICT GROUP NPE fIRE PROCESSEDBY O '
ENGINEER G �GY'liq^� NO. '— ��/
E�emplion, you shauld became su6�ec1 fo tha Workers' // � CONST. ZONE I— �
Campensotion provisions of�he Labor Coda,you musl foAh- qDDaE55 9 ��. L✓i�X$��i..itL ��val. /l'�/02 (,� • e �/'r' . �
wi�h comply with s�ch provisions or this permit sholl be .
deemed revoked. ,Q �� T��• STATISTICAI QASSIn ATIpN APT. CtlNDp, �
CON7NACTOR��'�+� �I'�• ' Z .
LICENSED CONiRACTORS DEQARATION � �� Qn55 NO. � DWELL.UNITS
I hereby a(firm that I am licensed under provislons of Chapter 9 ADDRESS p�p. ' .
(commencing with Settion 7000)ot Division 3 oF the Business and . . ��� SEWER 1rtAP -
Professions Code,ond my license is in full force and efiecl. CITY CLA55 BK. �. VAlIDA710N
5�.F7. / NO.OF q � NO.OF � CMECK
license Number Lit.Clas� SIZE !G 7 V STORIES .L FAMILIES ONE '
� VALUATION ��_ "., ��.�f1
DESCRIPTtON OF WORK
ControUor Dale � • NEW � f 2.y�3�6. '
/' _/ AD� � � �1 e • • a a � .
�I am aKempt under Sea �v��� jL'� qUER
� s � e � �+����i i
B.BP.C.for fh�s�eoson REPAIR �
Date: use oF . . � C�j,U n� ,
E7(ISTING BLDG. DEMOL
Si nafurp APRICANT TEI. FINAL ' I
9 oaiNt No. 0 9.0%—o II
OWNER-BUIIDER�ECIARATION DATE �
I hareb offirm�hat I om a:empt from tha Contracror's License '
Law I r ihe fol�owtng�eason(Seclion 7031.5,Business and nDORE55 FINAI �
Prof ssions CodA): 9y ,
BUILDING � .
I, as owner of the property, or my employees with qoDRESS � ,
wages as their sole tompensation,will da iha ork ond , - .
�the struc�ura is nol iniended or offered Iar sale(Section ����TY •
704G,Business and Professions Code�. MOVwG TEL. /
I,os owner of!ha property,am eztlusively con�raciing CONiRaROR NO.
with licensed centrecten to conslru;l the pro�eU(Seo- pDDRE55 �
tion 704d,9�siness and ProFessions Code). i '
REOUiRED iOTAL SE�BACk
CONSTRUCTION IENDING AGENCY Sei BnCK YARD HW1' PROP.LINF WiDiH
1 hereby affirm fha�there is a construUion lending ogenty ior FRONT
iha performonce o/�he work for which�his permit is issued p.�, .�
($et.3097,Civ.C.). 9DE � '
P.L.
lander's Nome_ �����.
/��� 1"}� I�MA Ref.N
m Lender's Address P.C.fee f Ge.mil Fee Jv ,
� I cerlify Ihat I hova read ihis ap Icolton ond slate ihot ihe Iss�ance Fea �'�`�' LDhW P/C N
' obove informolion is correct.I ogre to tomply with all County Inves�igatian Fea 7 �
'q ordinonces and$lofe lows relolin to building conslrucHon, To+al Fea / /r�Q
' and hereby �horize represemo�i as of this County�o enter IDMA Perm.M
� �ponp fhe ab e-me .' n d prope� for inspection pvrpose�.
v`-'� SEE REVERSf FOR E7(PUNATORY UNGUAGE
S�gna�ore of Applicam o.Agenr pore
. Z o
o �•
i
,
T ?
� � � C i
TC1 � �G O ? ^n
r C'�� 7 art, C � Tj C''' `� 'p � p
C � 7^ ��'+v. �O `� '� '� .
� � W
O � U U �. O
F � O � = ,. G <
r- � Q ' n 'ry � �L +� •O
-r U`n ' iC 7 7� n � . A
� C � � O O'O fl p ' �, ' �
� � f' '� G y �! �'^ = 7 ti . N
� a � 3 � c f� "'6° ? ` = .,
r„-.. !i� ° �p c t o - �° � v 2 O
7 7 � � J �JQ � � j M . 7 . � ..
-�.p C 'sj r" n-t 7 N O - 1 , , p =�
; " k G 4 � ° �
jn 4o c ca n O O 1 G' Y T� . C� (�
V � f �
� � ' � 1 i � G. Q N 4
� .n � 7 '� O p. a
� 4` � 0. n
� � � ,O
Q
��
(^/� O p �
(Y� �D V�
v� b O �
; n O
� t 4. 6
O , p �
� ' 6 O
O
N
• � ��
�p � 4
� • �{ t
� �
° ' C M
. � ��„. � .
. , �
� 4 . � N, �
� `� j t� - " �
3 � (�, i r�
� .r � ��o.
. c J �" , r' c� o
� � � C. � �
�C �� r
�
� �
b z� ,..
� � �
�.
�-
_ �. ...
' , . � � ,,
� .
m : r.= ' �r`z�w� " �•r;
,. �7 C r 3 ' `J N ^ �; ^ r� `
. ,� ,_.'y _z F t N� t. :.� � C � � c � C O I.
.. s = _ : _• » a ,r :.?n ` ;...'s: a^ c_ ` : 1.
.,�'�. �y G. ^ � C.:'G- e^-,� � O : '� K ""' _ e: �+ ,. '�' j ..
' .., 7"' O 7 J1 ' G-.� � ' 'rn =� v� � v' --•C, n »~ � � _ _ � G � r
n � b�o .� h � t _ � ; ° _ --�^ �' � _ �
o a .., m�•N� °�' 'c,'� �� �� � ^-= _ i„�' ? � »�."` G= `N , _ �c ±
� .�i� .,.1 + ;, ^ ` �' _ � "�..v. �^.. " `- ...'�' � : � �' ;;L ',� i � _ ..
. fJ O k n - Y O y .C'L"1 ? �' ^ � A " ...� y �% � : O V
3 t- ^ r.,� p O 5% �^ O
� � R � � C _ '7 a� � ''� l, ry O �� i� 3 C"i"y _ r.� : "'.
3 �.� c..H ' £ -^'- �=� _ � _ •:. „ � � �. a � ;.a. .; _ o` o T"
f" ^ C.:.Y � r: n ='.�,C� � 7' T- t`�.. ,c' �. C_ '% r .'�i
, „ �' N = G- ^� a e. .� .. N G� N �:.• = y ^ �. .. ^ � n r�,
' � ., f� O, � 'Ja .`^ 3 t- (D 1�5� .. L " y T'4 ' •� y ` i
� _ � c"o � c =?," ="r'= ro�� o �;. �.s'i ' _ o� �� �.
� + o � .`n ...�.3 _ �o c� :,".��"^ 't � i'
� �w�+ >�"'o� �L�" �:' t_ti :'• o �� �^ a . x �3 �*i~_ u ��.
N ^ . .. ^ _ �nL L..n � j �'�= �Q `� ^`'�, Y ' F ;,'�� � Cj
m � `, x. - ' ° N � ., � - .� C:�' �3 L-:__� t'4 a�-��s = - - �t� /-
� � L..� N n� � � ^ -..c-»:. � O C.� i"^a - '"� « n L �. L n O
- � _ � C`. � O ._...w`�' y' � � p '"�„'-". ^. � - "'v �y ?.
� � 3 ' � '��. ,�, � 3 �� ._..�•r.ti:_.� ' .,•i �c
� � 7� � �-F n C � �a � C� r. .- �� ^_�t ti C F � O r _
, u� � � � �-• �•. � � ia o � -._ "r - �o
` � �3�L C N y �.��6.. „ �l�/t O � �,/�f,. •JI' � ��� �a^ �• � V,
. N � � '7 ^,Tl � � 1 ^ `«' v'-� £ ,��„ _ 3. 3 ' •
.+ ' , 7 � � ^.;> 2� = ..- "�C F r� � 0.� . �..� '
1 n .'.. + ��"` i+
. b .�..��.`� ` / '..� �j ^ '' C"� '� .
.� '� � Y� _ : y
K'� ��� 1� ��
_ � � � � �p O .� •
p ' � F =+ n .
.. ? �. y �
' N