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HomeMy WebLinkAbout1315A , .. _ ... _ __ .. _ ----.__. _. - -- ._ _ _... . � WORKERS'COMPENSATIONDECIARATION . � �� � I hereby affirm �haf I have a certifiwte of consent ro 5e�f � APPLICATIQN FQR BUILDING PERMIT � insura,or a certifica�e of Wakers'Compenaolion�nsurance, -- --- - - - - -- -- - - - - or o certified copy rhereof(Sea 3eoo,�ab.C:) � - COUNTY OF LOS ANGELES BUILDING_AND SAEFTY Poliry No. Compony � ��� � } ❑. Cerlified copy i:hereby furni:hed.- � . FOR APPLICANT TQ PILL IN J a 9 0� � Certified wpy is filed with the counry buifding inspec- BUILDiNG //� tion depariment. � ' ADDRESS � G� ��`" �V� � � �/��'`� . ,. .... _._........... .. ........ _ . .. ,.... . _ . .. ..... . ... ._. . Dote Applicant CrtY ��V V 1 ZIP LOCALITY � .CERTfFKATE OF EXFMPTtOM'FROM WORKERS . . . ... nio.oFeiuGS. ....----.... ._ nFakESt ' • ...C�MPENSATION�NSURANCE -- � S12E OF LOT NOW ON LO7 CRO55 5T. � (This section need not be`comploted if the permie is for ona � -- - - -- - - -- .^} �R - � � �' i h�ndred dollors($70�)oc less.). TRAQ � � BLOCK LOT NO. ��/- µpp gppK- - p,qgE PARCEL I TEL USE Z�NE N�O O �� } I I certify that in the performance of the work for which�his �'�'�'�ER p-�77 �^N NO' ormil ia issued,I shall no1 em lo an rson in an manner C ,/ {� �r �� SPECIAI - � � oc to beFome subject to the Worker Compensat/,o�/Jni9'ws. �DRESS ��,vt Lld7 'V� ��� '} /J�� COhWRiONS V Date j'v- �6 Applicun s�-�"��+`�`��� - CITY (/V �F1'}�✓� ZIP O NOTICE TO APPLICANT:�If, aflCr making Ihis Certi4imle ofi ARCHItECi OR 7EL. DISTRICf GROUP TYPE . FIRE SSED BY. F ENGINEER NO. �pry$T,, Zpp�E `j I Exemplion, you shauld bewme subjad to�Ihe Workers' . . --y �� ? �y I Compensation provisians of the La6or Code.You.must forth- ADDREu / 7 �. _�`..._.._ ' .... - �.,,7 y.-• y wi/h comply wilh 5uch provisiona or Ihis pBrmit sFwil 6e - - �--��- �// TEL.[�p 7� STATISTIGIL CIA5S4FICATION APr. CONDO. Z � (ICeR16d.revOk6tl. . . - � CONTRACIOR ��%��' NO..J/6��6�J .�l � � UCENSED CONTRACTORS DECLARATION ' � '/ �K,� �� -Q.455 Ai(S.�*+ DWEtt:UNFtS I t Aareby affirm tFwt 1 am licensed under provisions oE Ctwpter 4 - ADDRESS �.3� ��.'* 1• �. S�yyER AMP �f (cor�mencing wit6 5ection 70W}oi Pivision 3 of"the 8usiness m�d __ . .. . . . p�, . - { Professions Code,and my license is in full force and effect. �iTV � C/ ��---i-� /�` UASS Z-' � � ' VALfDATWN i _ .� ��y $p.FT:.._ . NO.� NO.OF CHECK I.kense Num6�r ic,Class" -� � SIZE 570RIES FAMILIES ONE • � - viuu�rron � . ��� �6 ---- o�scRiv�ior+oewoeK - - rJ � _ _ — _- - � S � Contmctor 9 te� S U � �3a`7 �"y� noo � I om ezempt under Sec � /?��7 � ALTER 8.8P.C.for this reason � �-- REPAIR � s . . _ ._.. - -Date:-- �/�/���,,�/J I -- USE OF //!/�7�-+f..s/IG�" �+O . � E%ISTING&�f'i. I i _. _ .Signotwe ••��. �� �ct�a—� APPIPRIMT NO. FINAL +�/�y NER-BUILDER DKlARATION , - - _--DAiF���i--/--�-- - .J harobyaffi.mahatlamsxemptfsamt}w Coahaclor'slicense . Law for the fdlow'vg-reasoa(Secfion 7037.5,Busineu and ADDREu RNp� � Prafeuions Code):.... .. .. ..".. . . .. -- � BUIIDiNG --- � BY f --. t'i �.:1 � I� az owner of ihe propeny, or my employees with ADDRFSS . wages as their sole mmpensation,will do ihe work and � �. , . . o • � the siructure is no�intended or offered for sole(Section ����TM � - - ' '704�,Busln¢ss and ROfeaiorrs Code):"�. . MOVING � - i�. - n •" - .�. I,a5 owner of Ihe property,am exclusively contmcting CON7RACTOR NO. ,_, � " � J witb tiCenseC tontractors fo construcYlMe pra�ecf�fSeo- qDDRESS ' " � � � � tion 7W4.Business and Professions Code}. " .._ . . . CONSTRUCTION LEN6ING AGENCY ' . _RSET�BACK YARD HWY T07AL�LME WIDTH . . .. .. - -_ G�u,i..;_�s G'._ 1 hereby affirm thaf�here is a construction lending agency for F�7 � I fhe perfumonce of the wo for which�his permie-"r�isaued P.L. - - � i (Sec.3097,Civ.C.). / /` SIDE i � � . � � P.L. � Lendar's Name � �� _ � LDMA Ref.N . . _ .. . -' - P.C.Fee S � Permn Fee - - lender's Addreaa - . � � I ceAify.thof ihave read�his application and siate ThN the iss�nMa Fee 1 . J� - LDwv+P/C M � � Q obove informotion is correcf.I ogree 10 tomply with oll County Inves�igo�ion Fee ordinq.nces and 5tate laws relming to,6uilding construdion, . . To�ol Fee �. ��tOnM1A ie.m.M� � u and hereby aut orize representatives of tAis Count ntar � upon The o - emion property f pe ' paip es. � c !�� /.• SEE REVFFSE FOi E%PLANATORY LANGUAGE �.�..�.�..�Signahrta o4 Apptimnrw Agen� Dote - �� � 1 N n `� L �n C v-a J 4'� .9«'' � . . m ti' D d .O, '3.� .6, y, 07 �' .t/�i v �:,1' " V � ,i• � O �^ �~ p O v .�+ y_v, C adL m . L'4 4 �. r Cl �'r' � `� v%X Q.� N � � � d r. � y ��.a�;' � a o �� �M w'�s � �¢,cV 0.� � ". ' O � � � o y�o F v. a� y'�`o �i M.°n.e �„„��,,,� � ��s�°�c'' i . �-s s � o, o v ✓�'. 3� a `3'r 3 a E-� 4 -�s '/� �fl M V ,a �'y•�s f„ a�a.W,�,. T Tl �y b� O� .�y �jt� � C ht N `U� � p ��u r•� 4.6 bt�� a L � y.�O �'e1 W�w'�� �G N 0.�� U ��! 6`�"' a,Ti� .0 „'G�'�S ct Q ��C � � F os�t d p v,ya 0 OV.,�'�_' u V � G j � '�RSy �^'u �.Cr. y�p`tiS 7��w C,�P.^� �'C' � � � St�O`�� tt� 6� � d�� ° ��„.� � m �"� w� E:;� �oo�„�� o�.,� `°'�,�,+�7,�c� m 2 � t � �.� ?. 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