400%
200%
100%
75%
50%
25%
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1171A 1172A
- ,� .,.., ...•,,,,. .... :. .. .. .... ... .._ _. ----_._�..__.-----�- � pC,; . _G� __. _ _..... .__ ._ WORKERS'COMPENSATION DECLARATION �. � '• � ��� --•• • � - . -�` �" -"' "-""' "�" . ... • . .. .� ,., . ,..:. .. � � , . , ._ . .. . . .. ..----.. . _. _ . _ . .. ,. ,, � . ,. , .. . '� ._.. ! I hereby offirm.that I have o cer�ificoie of��o�,e��,o,a�f � qpp��CATIO.N�.���FOR�-BUILDING-�PERMIT� ���� insure,or a cerlificole of Worke�s'Compensotion Insuiance, or a certified cbpylherAoi(Set.3800,Lob�.C.) " ---� �"'-' � "" - - - - - ' � � P� y� �_Company � ' �� � �`' '�.'�OUNTY�OF LOS ANGELES.�:;. BUILDING AND SAFETY � - i`�'��i�0 7/17� "lc% t�:'_ �i;fliL��/:'� ,•,.;.=:,.;�_ , .- : , ._. ..�, ... _ • . . .i �••• Ce���f�ed'copy ii hereby fum�shed: � ... ' ;• . FOR APPLICANT TO FILL•IN}.}�'-�•` pppaE55� / (�/}�S' //l�1�^ � '. (� Cerlified copy is,filed�with ihe'county ilding�inspea � - ' BUILDiNG/' 4�'�Non deparlmenl.'. . . . . . �� .,. � 'ADORESS ' I- , \ •.. t�l��(�i'r�,'f.�:1,;�.�.. U G/:�� � Dare `'��APPlican��-s��� � � arv� j,!'y ✓--._ • . . , ZI77. 'f.`\. - �OCnim .. . �-,� ..-' " , ' ' �'��CERiIFICATE OF EXEMPTION PROM WORKERS' � -�� ' - - -� `� ---' ` -NO.OF BLDGS,-•' -•" ~i NEARESi.. • �•.., . ! SRE OF LOT ' ' -�.'_. � ��.__ '_ '__..._...._.. � � '• 'COMPENSATION INSURANCE"�--' � � NOW ON LOi � [ROSS ST. �y/ ,Li�f✓i/J � �, (This settion need nof be completed if�the'permit is for�one � -� - -�-�--- - �� � - �-�- -- ._ ._ q5SE550R � -�-�-- ----, ��.: , hundred dollars(5100)or less.) „ . „ , TRACT BtOCK � LOT NO. Mqp BppK � PAGE f PARCEL� � , , . ' TEL '� USE ZONE �P �. ..', ' -; 3 Z �. .. �.•.',.. � .., .'_ "_.. _ . ._...__.._ . _ ..I, ..� V .. . � r which rhis o�E�• N0.7/ . �1 r �. � !�!�� J , . , pe mi�is�ssued,tl shall nof em lo anheersorn n�'any manner � �1' �,_7 � SCECin�. ..... .-. �---- .- . . ...... i d Y. P P Y Y P AD�RESS I.S O(1�- /L-^�'�- /C7---'--- so�as to become'subject ro tha Woike�s'Compensation Laws. � �`�""-"� CONDiTiONS � ,, . � , � ---� � � -.. . . .� .. . CITY � _ . ._. ZIP >�__"' ' .' '• ' _' .. . ._. __ ......_.... _ . Date...,. ,.., ., � APPlicen� �.., , , - � � _ 'OG ARCHITECT R � TEL, '�""' •O NOTICE TO AFPLICANT: If,"ofter making'fhis Cerliflecte of ENGiNFER i�+�� /"��l p�p,�y _rj ( OiSTRKT, GROUP_ TYPE._._ .. � FIaE__. PROCESSEDBY. _ f. '.'.. Exemption,�you'should 6ecome�sub�en��to Ihe'Workers' �� CONST.;. � ZONE � ,� Compenso�ian provisions of the Labor Cod'e,you mas�fo�1h- qDDRE55 /'�� ' �._3 ��1,�� p, with comply�.witFi'such�provisions or this permit.sholl be - " " - --- �- - �� - _ � . _ . deemed revoked.;,}•„ � , .,,, � ., .. � ... S ._ TE�� STATISTICAI C1A55�FICATION ; � APT. CONDO. '1 Z CONTRAROR �?�RL r o✓Cr NO�I2�.rL O� i . LICENSED CONTRACTORS DECLARATION• • ��,� -�� � � � � . ...._ _ _ _ " ' " ' ' I- " -�-��� -- ---- -- -- ..UC.�- --- CL455 NO._�DWELI.UNITS I hereby offi�m thof I om licensed under provisions of Chopler 9 ADDRESSI.SOb A!M L y NO. (commencing with Section 7000)of D�v�sion 3 of the Business and . . .. SEWER Maa , � ,_ .._ _� _. - . �- -- - . Professions Code,and my license is in foll forre and effecf. CiTV�P. '✓I! L - ....-_. __ _ ti: CL45S --.. ... . . . .. .,� . .. . .... : .,.. . .. I BK. PG. � : . � � VALIDATION- '. , .. . . . . ; 5p.FT. NO.OF NO.OF CHECK . . ..� License Nombe � ��� - �Gid Cidss� � � � SiZE STORIES �- � FnMRtES � ONE -- � � . ..�. . � . . , . � �� ., • ' n ._.�, .�� ..� _, .. . . . VAWATION ....._ � .. ..-- '-. . _------- ' ControClOi� ' ••.�Dale !- ' ' DE IPTION OF WORK-- - N�- � '- . t .. � .c✓-�nr�� A� � 3r veo , ,.. , ❑I am exempt under See. ' - - - c� 11.�. - -- � --_ s , � -- -� --' '�' -- � . ,.�. . . , , � - n B.BP.C.for this reason � ` ' ,� / r AUER . �� I I � � � .. . !/JI J SJ /=� REPAIR_Q S . - . . .' ._ '. __ _ . __ . ._ _......... .- • • • �'7 Z '."_"''"' '"'._. __... ._ _ . ' " ... USE OF � � � �1 . . : �"-Dote:� � EXISTING BLDG. DEMO� ❑ � .._._._ __'_•___'. ,.. ., —-Sfgnolure � ..--- _ '..- - ... ..... .. naPUCANT Te�. �FINAL 'I!Z � ' •C 7.l;� � OWNER•BUILDER DECLARATION 7RIM) r.�p, ' - DATE- -I hereby affirm thot I am exempt from tha Comractoi s License �� � � � � '� - �� ' � a��j,���j�.--� Low for the following reoson(Section 7031.5,Business ond ADDRE55 FINAL - / � � ' ' ' ' ' �'' �"'' , "Prbiessions Coda):` -..- -, ._ . ..-'-.. -. ._ . - - N � �By � L�'J �� � � -� fi l� V r;-i,h BUIIDING 7 . � _� I,as owner of 1he property, or my employees with ADDRE55 i:•'��� .���_,. � wa�r.s ns their s�ln compensolion,�will do tha work and �,�,FCT �I/��� � n o the strocture is not imended or offered for wle(Setlion ����T�" � � ��'--'70d4,Business ond Professions Code). -� - -��� - MOVING-� �-- - - -� � - --- -� TEL -- - - - � • �•� � - -•-�__ �_ I,as owner ot tha property,am exdusively tontrocting COMRACfOR NO. , ��'��/ . ' -withifcensed comractorz to'canstruU tha project(Sec- . - . --� -- . ... ...._. . . - ---.-. ._. .-�--- ' .�. . - . - .Y - -- . -. -- •_J.�:L'_--.....! . ._ : � o .(� fi0n 7044,Business and Profe53ions Code). , ADDREu ' C•�i \;.;...�.- '+� � S�,,\.� �,�.....�.e _.„ - f .-..'"' '--- REUUIRED TOTAL SE7BACK fROM %I T.. --. -.. _ _"__'_' _: .._.. .. ...-^-'--°..��_'!./.O.0. : � CONSTRUCTION LENDING AGENCY � �� � SET BACK yARD HVJY p{tpp,�WE WIDTH I hereby offirm ihal there is a consimc�ion lending ogenty fo� FRONT ' ', r�!i'U::.a��� -�he periormance of�he work for which ihis petmit is issued = - p,�, --- �-��- �- �--- ._._. ... ..... _. ... .____�._ __ __.___.. ...� . _____-^_' . � (Sec.3097,Civ.C.�• SiDE ��� c• '�Rti t -��ti! � _._..._._..._.___' _ . . _'. _ ..._ .. . . . P.l. • ���.1. .. � lende(sName � ------ ' .`.��.. , .._._. �. ..1�:' m ..._...__"'. / /� LDMARef.N � _ ����� � ' .'_'. ____.._..__' ... .___. ._....._.. _. -' -.'- P.C.feeE�Z�i�G'�� __.. PermitFee �-.���5✓ �- � lender'sAddresz `-' � �- � _.Lcerfify lhof I have read ihis applimlion and sfata ihat 1he .._. .. .. _._. . ....... .- Issvonce Fee ��(�ftSO LOMA P/C k .. ..-- , � .. � �.. � .. � above info�ma�ion is corcect.I a ree ro mm I wi�h oil Coun ; -" � �"�"� �"��- '� , . 9 PY �Y Inves�igo��onFee �t�1 g _.ordinances and State laws relming fo bvilding constrottion, � . - iowl Fee��- �f 3�(�U - � '� '' ' G and hereby auth�represematives of Ihis Counly lo enter -i � -� -�- . .. . � .. .----'' ---...-'-..."-.-. . - � _, � upon t bove- entioned property for inspection puiposes. '� �� � �� ' , o -. . .._. .----� - .... . ..._ . . .. . . ." " - . .-- � �-y�� - �- - ----�-- � --. ..__ .. ' Perm.N� .. . a �/�� . a �/j�/</L. �J��(,f✓fj� ( SEE REVERSE FOR E7(�IANATORY LANGIIAGE �. � � ---''Signoture of ApplicoM n AgeM --�'� Dote �'- � ' "'- '.. ....__ . _. _ ._ � _� _.. . _. _ ._ . ... . . . _ ' , - _ __. . . ._._. O .. ... --- - --.. . _. _........ .i \. . � . .r. �_ ._ .. .. . . .. �; . . ' v v, �� _�_ _� �, _ � ---. t .- __ _ o �o.. �T o o � o � o o ° �o 0 0 0� c�.a o; o m o �o m'o ' c �- T m 3 � � �g i� p � ^ n '° o, a v ''° o � ^�o � � p � '� a o o D � � � '�'^ `a ,'n �' ? �f1 , i � Z x :•i — � �� b �. ...7 0. � o � �� D; �+ QO C N' a f � j Q° � o ' � O�: C'� � O - �i ocg � � p c . �n .� c m N �- �'•. . 3 �� �.� . v. ,. � ° m ° � ° a ° � = v ° " - ; � ,3 'O � � o ma i o a '" � vo' �� I , y im o � _ � � ��� :o � : _ � � ' _ . i • I - m _ . • � ` i � O � ' ' 1 , N rA{ ` . - i ; ••: ' Y , .,� \ � ' � , O O . .. , w., a 70 b I I C 1 � �f . . . , � . �� � .c' � � i � 2 d G� � D y. � . o ° y 2 � 7 O � ,. � � .. � �, � , � O v iI - �. . . , �� � M � , - . . . �. . _ � D . i . N Dm o� � � v � � p , . � . p q, � . � C O < � . �• ` . ' dA ' � . . � d . � ' ` � ' I '- - , ; � , ' � j � � \ � 1 � _ _ - � , � r � : i I ' � ' '- � � � , � ' ;;, ` ', : ,_ , � ; � _ , � � . ,. . ; . Z , � , ;.: �� - � � � � ' ' t . ' . � � � V1 � � �. - ' --1 ' � . ,� - O � � ' ' I' I ' , N . � ; ' ' , ' ; , . ; ; 1 � � ' ' ' • � ' � ; � ,� : � ;� �: � n � . , � � v i io', i n'� �'�p�=� C��m o4�L ti �.cls o �z ��c c'n �m � e`n — . o � Q � � p � n'a�p '° Z � F ��o .�•E .w �o m a �e o- �z n .. A ...� m T . ' ' � � o � ��'N:a�£.❑c `�, " �' fi `a'= N ��° ^�e L�,�n b ,, a' � m � ��b0.� � �s � .c• np � n,N iCie ' - .. ; . : , � ; ^ N � �u ��:- � �`.� � L�o F.„ �.o -��. � c'^��•^.Q�o c � - ' p o • _p C.n a �e n_c. o tiA�.�e _�.o":`� y � o�_Q 3 ,� � �•�s•n n� ° c M N•N F ° iD T a = .$.•.�„ o � '^,�,�„'�t n.0. f ° t � . � a-•. m �..o ; � 0.'•N:� o o �5 N Z =7 , i - _ � e"o �c c �a m � H�.�e R•fi `�°�*.�i o 0 o t��e ` �°t o':: O'�'n -�i 't .s"..-� 0 3 z 3 �- e w am c ^ � ,�*s`. c n � M'� [�-�� � A i ' ' :f � ��„ � � ^ �J- I C w .N � �� ti'C'y �. S G7 _ � � . � � C o .o.. � '�e �"c �: 3 � M � n -o.. �a b, ye o•� e � ti ° = S�'rC. ' - vZ+ � �' r.,; �^ �3s n � `�nc `o'� o sa-7 s� a�we": c ; m —'[-' _ • . 'O ' , a' C Y'�n C O fD C`� �if�.,,�"� C N.Q.� N t' .�.��OwC`Q4� M �^ 'O,�-C� � � . - ^ . ; , ! m `o o�N o� .. �A � �� F a �Q o� `,F�e o a � � �.� n 3,t^ - .a , i u+ �'<` o o � n.� c c � o � c'C.tib 3,i e ° rn x - � A . ' �� n. x N•�� �3 b A M�p���_� p Z7 ��O-�A �.�o,p w w �, f x I `C, O (0 .l ,t' `7 ip `t- �• �f9 v � aa ° m ° C` r.�' oo C'n �\ �o o .. ca�o3•t+' - � - �' � �, n�., a ti ` a o '+ ►7 ,.,� e � � C�-n a a� --o•C) '+ o c o ti o L'm.. a '�`�.c c � �� m ' _ i O '� , . M c o N a �`n � � ��n � £ �'o'�, 'a `^ °ti A M�'n o "? ,,., � 1 _ 50.- 3•. ;-' a �� o Kana . � m`^'c ��� o � ... o - � ^' ' . , m o � :°,� co -� �.� �,��^+ o c_ =3.ac•�'a M. .c M n „�_0 3 � : -- - v+ n - ��n ,� � A m �- �.o .� 'o c�M `•" a •� 9 ' . - i: ' . i �.1 �%/ ' �,:s C � y .�� C.� i::.�'.0 �. �O A'�,.n. c.o �.p�.�'b p . � J_ ' � �C {� .0 ..�,y�.. f0 O '.Z.:. �p L. 'S�� � � 7 , �'. � N y`n'ID N � 1 C C ��\{[ ti•O S� C fl � ,0 j�w'M IR � C O�N�-O " - ' l .W _ . A i � n . ' - - . ` � - , w , � ^e �Zi �`y� - �'��c,+ �'� .c, m'mo « s'��'�Coo.`a�� z ,no-Z . " ; ,,. �' -. - i .�fl "�`�� ��-o o ��.�,^1�° t,,,.,_.i�-� ��"c�w`n�F'e�m.�'p.��.pp a � a - oa "'owC- oE n '"�`� ,`� i" R �V+"' R � p 'e .,�� R_p O f �.�. �~ C'v'O m-y'�•L. �O � ' -J N'l_'�^'`�.^ � o L�..7`ti.p �:a 7 _' }��Q�A� .^ � iA An N j ' . ._ ._ _ .� . _. ..m C-o a� . � m eu .� M'�e�°'-d T . •�t m c� . .... L•....a � \ ' _ ... �c" ' . ' ' . __— �