Loading...
HomeMy WebLinkAbout1393A (216) �__..�_ _...__._.m._. ._.._____.._�.__.._...._....- ----_. ..___ i ' WORKERS'COMPENSATION bECLARATION � -- -� � I hereby affirm that I.have.a cer�ificme of�o�=e�f�0 SB�f ---� �� �APPLICATION� FOR�BUILDING PERMIT �� inwre,o�a certificate of Workera'Compenso�ion Insurance, ____..._. . _ .__...... .. _._._---._ .__.._ . . . ... . , or a certi ied copy�hereof(Sec.3800�,tta/b�.C:) COUNTY OF LOS ANGELES BUILDING M1D SAFETY Po{icyNo. Company.l".�7��5�.�� .. '. . - - � Cenified capy is here6y furnished. FOR APPLICANT TO Flll IN Bu�to�t�G +� � � , f�j� � ADDRESS J y Certified topy is tiled with the eovnry building inspet- BLIILOING fion deparfinenl. ' _ ADDRE55 � � � � Dote � �ll�w' •Applicont CI7Y N� ZIP LOCALITY ' � C�RTIFICATE OF EXEMPTIO FROM WORKERS' SRE OF LOT rIOW ON�LOTS CROSS ST. .�M!/��.... U�� I J ° ' COMPENSATION�I SURANCE � ►/S '1 (This section naad nW�campbtadl if the perr�it is fo�one ' TRACT i + BLOCK... LOT NO. f1�� /Nqp gppK' PAGE PARCEI � hundred dollws(t1.00)or less.) . f 1Et. E M1hM I cerlify thaf in Ihe�performance of the work fa which this � ownlER �" $'v"�'�'+ Np. � � � ' � permit is iuued,I shdll not emplay ony permn in any manner a�D SPEC�nL- � d so as to become subject ro rha Wwkers'Compensotion taws. - ADORe55 � � � - ------ �p�� , u . CITY ���!`i.� ZIP ... ._ ....: � Date ' Appli[unt ' � ARCHITECT OR TEL O NOTICE TO AP%.ICANL• if,�ofter makinfl this CertiNcate of DISTRiCT GROUP TVPF FIRE PRO('ESSED BY ENGINEER NO. �' Examptian, you should become sublecf-�to�the=Workers' � � CONST. ZONE V Compensalion provisians of�the tn6or Code,.you must forih- qDDRE55 with comply with aucfi provisions or this�permii sFwll be -- --. _ . . � �� ��L" v�i deemed revoked. �¢� u�y T� STATISTICAL CIASSIFKq.TioN qpr. cpnrpp. 2 - CON7RAROR � UCENSED CONTRACTORS DEQARATIQM . .__ r� A n i� �y (� �-�,y��Np oG0 DW[i�.urairs_ 1 hereby offirm ttwl 1 nm licensed under provisions of Chopier 9 ADORESS „7 d� �/r�QiF L� NO.�✓�i Q� (cammencing wi}h Section 7000)of Division 3 of the Business ond .__. Q� _ ��� ^ �R�v . Professions Code,au�my license is in full forca and effecc CiiV �i N�� aA55 C Or• �T/.� /�J ��1/� � SQ.F7. NO.OF NO.OF CHEIX BK.G LAG. N� VALWATfON License Num6ai�,�V�Lic.Class�� � SIZE _ STORIES FAMILIES ONE ' • /�(� j /�- vuu�noN Contrutlore�✓�4Kn•' . Dota ��I V� DESCRIPTIONOFWORK A� ❑ � �}Q`K/� ,S'6 a� �e1"� ❑ : 1u �-- � �I am exempt�ndec$ec. - � Al7ER B.SP.C.for Ihis reason W �pq� � S . � _.`1; _ _ ."Dale: uSEOF D ,.. � : , r E%ISTII�BLDG. �� a � ^ n e a e �Signafure � . ._._. . .. . . . APPIiCANT tEL FINpI OWNER$UIIDER DECIARATION PRIM NO. p�� �jJn� f _ _ 0�, i .: ., -t 1ep�eby aH'wm 7hW!am-exempt Erom ths Coa�raetw's lieense � `'' '� Law for the following teasan��Sectlon 7031.5,Business and ADORE55 p�Npr-� ���� -��---� �- - • �: .:;r.. ..,�:. . . ._..._. ..._._ _. . __. ... . .�. . .� . ,'.; Pro essions e):.. .. . .... 8y-=-� BUILDING �� n 1, as owner of the property, or my empioyees wi�h qppp�5 'wagea os�tFeir sofe compensation,will do�he work"6nd the str�cture is noi imended or offered for wte(Section ����n' � ., �� 791�,Business and Profeuions Codej.- ' nnqwr�� re�. � � - t»' � I -t'r', � n i,as owner of fhe properry,om ezdosively controcting CONTRACTOR NO. � � ; \ � � -with ficensect contractors ro consnuct the projett t5ac- - - ---- � tion 7044,Business ond Professions Code). AODRE55 REQUIRE� SOTAL - -- " CONSTRUGTION tENDING AGENGY ' Sei&4CK -YARD HWY pgpp,��NE WI�TH" I hereby affirm fhet thera is a constr'�ction lending agenty for pRpNT � �he parformante of the work fo�which-this permit is issued -- p.i. -- - - -- �- -� - , (Set.3097,Civ.C.�. SIDE . v.t. Lender's Name ' g h� LOMA Ref.N - Lend6r's Address� -�- -- ---- - - - - P.G Fee S RamH Fee oL . ._. _ . .. ._. ...._— � . i � I certify that I have read.this applimtion and stme�hat the . issuance Fee �� IDMA PiC N - � m above information is correct.I agrea to comply with all County Invesiiyauon Fee � g ordinances and State laws relaling to building construc(ion, , .,�b« .___/���_ � . . .... .. ' ......_.__ . .._.....__... . IDMA Perm.M u and hareby authorize representatives of ihis County to enter m u the ove entione property for impection p�/rposes. . . .. . a _ ..__ _Y��( '�iG SEE REYfRSE fOR EXRANATOQY LANGUAGE �- --5iglwMe of Appliwrt�or.hqem . ... Dc�e - - .-_ .- O� � .._ :'�:�y„e i�m. y lp,�syf o^4-O..�1 '� C c 7l� a �'�t .�R,'� O N��''L'� .-Q. � . . .,,F �M ;,�+a"x �V"r•� ��n C o 3 °o Y ��'�r � y �v� °, 3 y � o ' c� r' di �� �oz`^ 3� uo �"� oE a �� � � � a�i � 4`�.. �j �`' . .� O ` T ."+�l' M � i:` T'—C � !.. Z U N O � a� c e G'�.o� o ► .n d d � �'� d"��.. � > aU a� � °a � a� v. a mR' r-L'es.a, �,v.�. E�o � �o� �•� � .N � � ��<.� m c. E"L • �' �. V.wC.4 t �'� v y� O w�y o~i .3 m N C �L„p`� 4•- . 'a � � ° �x n.: °' S^'b o�i �� �-v � 0. '!! � � 1 ts � �n ° e s. , 3 o o ;;g � � � F d.x� e �—.° o o"� m o,��� y ` �v'tc,•� O . N , a� ° �d� _ 4` � �~Y� o �m�y�°��� ac �.�$ �+ O �. �; ..� o-- o r 3-v d E �v- �e V e m�ood W E �+Q v� Y Na�`�y �� �'o�[-. `m'et r"c a � � ^ o V_n �.�. 2 _ QX ; ei � � '. om� o�,��o'� aN � °' � o �m � �ZF � ° c� �y � � . W � o � �� � e `yc`'a "`� aa�i m�U ° � �,d•� ° � ° o �^�' �o� " � Qoo M �wo�,,,�q>,.• � ma� „ n'tf R � • o,"� nu,�iY � � 3 m W . �— a � 4 a V � � « E c X � A•.. o'w v o °w n o, c Q "o `r+ m .� � °ii+ i'�'� �,� � om.a � ° � ec ° � Mw�.l c � f; t�Lsr y �t� y �J-:i � xa� � °1 '� 0�.?��.O1e�.cet.�°. ° �� � d � � a Z � � o�� 4 d .?:� c 1F a�o `o��� � � .: e v v v � � a c � Lti E.� i. � H .Gn\ W'y " � C C d Ol 0 � ����' �^ C y � O Ct w G7 Z� 0. ��-«`�� C "Q �,�.. 3 � �,�Y � es'+� C o 3 c H tt q y►a x 3 � p k �����ti'�1� d 11 � �L �� r. d� Y w �O �N N V,F �q �lMZ'` E O T� Q tl'^V.w ►�o k.�+� � v� « d .'1 �,' 4�O �— "�',.7•1.a� w O ,p N y:':� '`� y C`� d y - O U y m y� 0� i: C _F O �i b — d d y d tl A.m i C'�'�b 'a� H.: 01 � � �+c� ��x � �'G y w o � ,.�• a� c .x ��C a� c h� m a.. y �T! C� a y c, � 3 e " c�a .�', o � - L ?; � a` Gc �$':�•�• ?'.C ❑ om�� � •��� 'c8 `nro � � dv��"^� ❑ o � — J 1�.e.a N..� K d ` n �.,-e • c m a y c � � � o m �' c +. .. „�n �s a 3 �.: c�.. c,�4 �;-c r,r�-+rw:^.U o . •4! �'• � �; - 9 .J .�...�� a „ �s 1 . � � . � .n .. .r , ,� . •� �i. . W � � � f4 0 ' �• •-� T. !,' .,7 e/ . � _ ^�"^ � .,, .:4 � G - ` . \ ,r. . W �� .i/ N � '� Z � �� �. F'� � I .. ,j ?'� ~� r i .. 'S . y� i ' � •.� �'� �. / . 1 �R � • � O - > 0 ; a :'S � . .,..,. ao � o . - .AC 6 . t..-� p1 �n, Yd� . � � � ,o � �, � 0 .. � � .� � F� A , L• w a � c - � z° : f, C � � � � � � , 'o a `� e « - O e ..• ' °L i v4 z � � � � � a ��- . � � ° � � , d , � � � � °_ o o . � C° ,,� . o c E 'c m a ° `c N .c `o_ I v ' �^�� a � �� ° � . d � y > Y ° — o �p c -� n »_ 6 E a aa o � o — Ea Q l"� a d � d V o u �-� ° d � Y ° � r� ,c Z"ti � U W C� Oi . " p Qi �' p � 0 T p� W y O = o o n� ° � = a ° v °' �, � � � � v � a � d o ��1� -°oy ao � ;= °d � o a � �— � oo �v } Z . .. . .. . � = LL C7 V d�LL... V1 V � 1 J.�... IL VJ lL W J J� S V LL.W