HomeMy WebLinkAbout1396A , . .. _._.:_-_----= ------- -- ------
' WORKERS'COMPENSATION DECL4RATION - . . -� .
I hereby affirm that I have a certificote of�o���,�0 5e�f � � � APPLICATiON FQR BUILDING PERNtIT �
insure,or a certifica�e of Workeri Compensation Insuronce, �
w o certified copy thereof(Sec 3800,lab.Cj•.. .. - . _.. .. ... ...... ... .. ...___._ _-_._-_..__.__._. ._ .-_..._.._
COUNTY OF lOS ANGELES 8 DI AND SAFETY
P❑ol�ityNo. Company r`/g�el s �i,
Certified.copy rs hereby furnished. FOR APPLICANT TO FILL IN Bl11LDING , `` O /�u�
� . , AOORESS � U/ L7
Certified copy is tiled with ihe count bu Idin9 inspec- Buit ING f•,� 'Q� � �`
fion�depnrl M.•.. ADDRE55 W 3S Wi vw
ppte'. � � V AppliCaM �"� CITV N / 21P IOCAIITV �/y L .
��CERTIFIeA7E OF EXEMPTIO WORKERS' - 5¢E OF LOT O ON8 l0 CRo�ss Si.,��N A,0 �', CQ{.��M/9 �
. ..COMPENSATION RANCE-.
(7his sec�ion need not be completed if.the permit ia for one � �� - 3 �1� S I /+��R� �' � � �
hundred dollars(S1oD�or less,� «�T `� BLOCK ior No. �,y�,p epq� P�¢ PAR�L
' TEI. U 2 E M�P / �iY
I certify Ihat in the perfarmonce of the work for which this OwNER ��e� LC NO. � NO. y
rmit Is fssued,I shalt nm em la on rson in an manner �,j, - SFEO,aI� - - � 0.
so ns to m�e}/ bject to ihe W Y ker PCp nyp On dws. ' AWRESS - ( (�C��L�� �U��� CONDITIONS 0
Dme ` ''' 8 � . .. ; . . .. . w . � V
QiY . !;'.. 1 I'y'e ...ZIP__ p�
I
�P�i��t � ARCHITEQ OR TEL. O
NOTICE FO.�.PPLI If,-after ing this Cerfificrna o ENGINEER � DISTRICT GROUP TYPE .FIRE PROCESSEpBY
Exemption, you should become ubject�to the Workers' ^ CONS/T.� ZONE �j
Eompensation provisionc of the i Cade,yoV must forrh- ADDRESS (% � 4y/y LV �
with comply with such-pravisions w-tbis-.permil sk�all be . . .._._. _ ., w
�/ � / �}p 4� STATISTIG4L C IFlCATION APT. CONDO. Z
deemad revoked. � . . - . CONTRACfOR /y NO. G �/ r � .
LI(�NSED CONTRACTORS DECIARATION�--. . . .. � t rt .�� as.SS NO. �� DWELL.UNITS
i here6y affir�F{pt I am Ikensed under provisiorn of Cfiapbr 9 AD�RESSQ/a� ��V�L� ,,�.33 Q
(wmmencing with Section 7000)of Division 3 04 the Business ond _ � E�Q Q ��C _ �� /
Rofeuiom Code,and my license is in fuli force and eifecf. cm Ctnss C"/� ��� ,�,3 VAL�ATION
/� SGI.Ff. y� NO.OF Np,pF CHECK
License Number�� �" ' lic Class ��� � SiZE STORIES FAMILIES ONE .
�/ljV�.G6�/fl. . .. .. � VALUATlOH _
Confracbr �Date DESCRIP,IONOFW�2K � ��' s aaBD D/,
�+ �l ❑ t V �
�I am exempf under Sac. J� �� • ` '�r��`��R qDER Q �
B.BP.C.for this leason qFpp,�R-0 i �
..-... .. . ,.� __,.-Doter._..., -- U5¢oF a . .
E%IS71NG&DG. �
_ Signalure ...._ ._... . ... .. . -. APPIICANi 7EL FINA� , I
OWNER-BUIWER DECIARATION .. . . ..atIN7 . . . No. � � i�I :i .�!;!;
�^^'^' _ DATF
.�..Ahetabyof£irm�hWlcupeaac+ptfrom.lk+a. �o+:slicanse • e e •�
ADORESS .` . ^a
Law for fhe following redson�SecFioo 7031.5, Busineu and FINAI
�PrOfBsslOnf Code): _. . .............. _, . .. ..,... . PRE _ . . . __ _ . __._.. _ . . .:'g�,_ ' -`'�+� /� ' ' � 4'-. __
/ a p ,
Bunouv� -'`�"
Q _I, us ownar of the properfy, or my employees with ADDRE55 _
_ _ _- ___---.__ .. ... . _......_._.._.._.._. .._.._.. .
wages os their sole compensation,wilf do ihe woiTc and ---- � � -- �� � + � � ', , � � T
�he struclure is not intended or offered 4or wle(Seaion ����TY � i � �� . �- �
. . ..7044.�Business and Professians tode).--.. . _.. ... MOViNG.._. .. . . iK. - � G..H i i —n�'�
.
i,as owner of the property,am exdusively controcting cOrviRaCTOR NO. ��,_ � �-�., .•
..�._. . . :".:-, �. .
� wifh iicensed contructors to mnstruct the project�Sec- '- - �--�-- -. ...� . ... �...... . _ . - �
tion 7044,Business and Profesaions Code). AOORESS
- �� - �CONSTKUCTION IENOING AGENCY�� �-�-- - � ��7ngq�K YARD� MWY TOT pTpBA`WE WIDTH
I hereby affirm rhat there is a construction lending agency for iRONi
��he-parformonce of�thewpk for�which thia�permit is issued - ..-- .-p.L ...... . .. ...._ . .. ._. ._.._._ . . ..
(Sec.3097,Civ.C.�. SIDE
m .... . P.L.
_... _ .__ . . _ __ .
� Lender's Name
�"- J�j � IDMA Ref.A �
. .... .. .. . . ... ._... . P.0 Fea S ". .. . ._. . Permk fee..-..._c?O�'. .._ ' _
- lender'a Address �f , .
� .i certify thot 1 have read this npplicatinn ond state.lhai_iha _._ _ .hsuonce Fee �L' IDMA P/C M
_...- --�--' ---- -'
¢ above informoiion is correct.I ogree to comply wilh all County invasii arion Fas ��Q U
� ordinpnces ond State laws.rela�ing�o building construction, �
._. . _.... ... ...' '-__.__ ....._.__... - 7ablfae'_ ' -/- '..._. LOMA Perm.M
� ond hereby authwize representafives of this County to enler
� u n f abpre-man one perty for inspection purposes.
�.\ y.,�,$
a 1/G SEE NEVERSf FOR EXPLANATORY IANGUAGE I
� �� Signnn,mvFAppficam,o.�.Age�F. _ .. ......_.p� . . .pi
�
, r
< -'; ,
. ,'
d 's
�-.
J� 'C x " � �.'
� � o O:�� .� M � . 'l.. ,'t
�o E:c�`^ `d �o V'+. .�,'
t'�� �Y.�r m � °' o `�' �t C."S� °� : G - .
� �.�:: p p �y m•� ;�y �6 � T'O D * �. f9 � 3 . N
N W''^ '�"A � �i 1� i� 'x^ `� •�� � p•v p•Y'�� Q � yf .
O �nr'a�n�L'�j� O * � ' � d w+.�' „ r , �
�--.i'.S w x �y�w� 4 �S� �� O N L'�.'i' p `n s..II O : 0
'" `^. " "1� �� s ^°.<n ,�,,� i��i`�Y'"'e.�ye�-'o r� ° '. .u 4..,,-i u.-� Z
`o ��o o+;;.�i'''���c " ° d d w ..d M 4� X ` �hs ,� ,
u`'' $ 3 �.. �" � � "a�— `3 �•.93 w.'2 v. '� .1�,. ec
o � �.` 3 � o c � � r.�^d,�..'�-0 E c� '� � �
0 r' �� M o�Cs.'� sQ := � o �;�.ys�+�a,..,K... o` �,j •�s;.,
O V ? v E w ��=i Y�-L G.� T�.�. a �''N.p � v ,�p p �� �a'� Vp1 y1
U O ? �p'� �� m�'CS E . '4 V � O 4 �j 4 C 'O �^,4, ��� V1 O� �i
ii� o o,���'� �x'i°o'=� � c.°Y'EA- d-°�c'o :�� o� •¢. O �3 � � '.
Y,d � o y�`� d �o �o � '^ � r °o,dKrm� i�� � °'o°gd�-� � ''.
dp v �,`,o,,�'^.°`aYo.e'�'? � o °.° °o 0 3 M�':s s �w oY a� fl- ;,�
So o, Y.�:o^ M gcvv ti � o. �� o t �', '+ m � "'
,� d �'�y r t.�� p 7t;,^ �,d N eS� C''_ m[ ' O v� p �w N �
CJ E �d .E� °. ;; „�« �« e d E�o�'�d�:o�' � er,°; d-c n y 4 "'..� m
� u' °' � '' n° c.r. � s om• �.. ��• � � c � �-er..�✓= E
a u o'`� �.°��d.a a. � ��,. u c '�..a. � w �;: ' „-, ; c d g �"" � o
+c,.�y,.0�ar d" w � d »-,�- 4'.c a�� b� �4�'C�� o d
�/� p.a�- �p v.Q � �.C.v.�•:.Oi y` O C N � G � �,�",� � d �G' m 'n 'r �/+1 �' � N
M^ V 4 Y Q.�:i�_w b L' � � �. J��.� v,�j p ia`r-.b i'�W m d G � 0
:�o� � �n d���o.�o o � m� �e o'� �„ �,,,_,° � . .3 ��3.c,K m �
�� o��.�.*,a.,���Z,��, �y�., o� ' ��`�}aw d �� �G.co'4':s 'a.V -
� E� 4 i N d M O � O j N"'�� `1 9 `.�. '9 �'L1 '~(l 1 1
Q-��.t.`�.�.o. ��, r �, e � � c o d,� .. �
y O� 4 ?.
Ri � j `sN_.. c,� N �'dtt� K��6L'X+'^� � �5 .
�
O � � N 1�.�'�f.w C� �"�O� �Q. ; . l^'° 1 � . �
� C !��M. M�� M� 4 . .
.F
j V � Ol � 1 t ' ' ,
i J � k� �• �. .
• � . 1
. �'.` ;
�! �♦
..,-: � ,z . -1� ''�f.~t'• �;.
�^� ? '` ` �` .
:i/' -�, '(+ .��, :(' �'� v "'
�' .r=, t ' . � ..:i .
y�' ~ �1': .*' � .
�� '%,/ .
;'y "� .�' .C'
O ".:'. ` '
Z - ��i
C � �• � �
o �� _. .
¢ . , : , .
w . :� i -�
Z . . �,
� � �„� �n X'
� '
� Y�� O
..`..+` � �' . r
,l �
, . • C
�...c. O�
. M
.� M'
�^ •tO
i .O , . t.:. a
4 O 0 � �G,
O o p -
�F:
� �a �r .
" i
` ��' . h'�y p ' " .
i; IO � �
. � � �
� 0 �
.��_ � Z , � c
� � � � ° Q
�- ,� o, 4 1 o E o- �i
� O c
4 � _ � q N ° o u �°a o
V J ' � T 6� � m >O �i 4�d 1 d
O� � �-" ' G � > pp p a, �C L O U �y w
6 �O � � O T 6 G v � � V t J 2
� O
0 � Z .r.. U j. ' � O� O 'O � 8 G J
1� ��• d Cy, �N � � . $ � p � u�
0 0.
s � m � o,o �� c o, j� � �n
� } n � E m cU_, ° �
o. �,, o o E o o � c � p o
p `p * N J
61 ••• 6 � � p, � �p N G Q,J � O,
G ..�.: Q v � p 'a °u� �°'� N
m o � o-
� � ` �
o = �-
7i
O
O Z
�