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HomeMy WebLinkAbout0656A 2146A 2147A WORKERS'COMPENSATION�ECLARATION � � .. � :� � �� 1 ^■■■� ` . � I hereEp.c��fi�tn�hot I hove a certificote af mnsent to seH �PPLICATI4N� ���/ �.`.-\' ■ � � � insure,br a�ce�hficcte of Workers'Compensation Insurante, o�a cert�fied cor .�eo�SaS'3800,�c�6.C,��N� �, COUNTY OF LOS ANGELE AFETY ' . � PolicyNo QPa^Y � BUR� G � Cenitied copy is hereby furnished. FOR APPUCANT TO FILL IN • t,poaEu FA�c�v 'ew , Certified copy is f�led with the counry huitd' g inepec Buaow� �� � � � � � -- , lion department. ADDRE55 ���� /��� u�h r//�\� , Date Applitanr UTY I�Rf'� � ZIC //�/ LpCALI7Y 1� �/� ' - CERTIFICATE OF EXEMPT�ON FROM W KERS � � NO.OF BLDGS. - NE4REST C�C , , � COMPENSATION INSURANCE- 512E OF LOT NOw ON LOT CaOSS 5T. ' (ThiS beCfiO�need nof be campleted if fhe permit i3 fOr On¢ TRACT •/ BLOCK l0T NO. �'V '�ESSOR � hundred dollors(5100)or less.) . �P BOOK oAGE ' PARCEL iFl. USE ZONE NOP U U -� �- OWNER � � C� �� ' NO. I certity that in tha performance of the work for which fhis ^� �+� /y0 aeCin� � permit is Issued,I shail nof employ ony person in any mvnner pDDRE55/�- �'iFC GOh v CONDITIONS so as to 6ecome eu6jec�to the Workers'Compensarion Laws. � , , , V Dafe Applimnt . � . CITV LP � � NOT�CE TO APPUCAM: IF,�tlitBr TOking�lhil Cerlifimfe of ARCHITEGTOR TEI. DISTRICi GROUP TYPF FIRE ME ESSEDBY O ENGINEER N�� CONST. ZONE C �"' Evemption, you should betame subject to��he Wo�kers' - . O Compensation provisions of fhe Lobor Code,.you must/orth- ADDRE55 16 � W Wl�h Comp�y with Suth ploVi5ionl Of Ihiz permit thall be . TEI. $TATISTICAI CLPSSIFICATION APi. CONDO. � (n � deemed revoked. . COMRAC70R (/ NO. �� � �� Z LICENSED CONTRACTORS DECLARATION� UC. CLA55 NO. DWEIL UNRS I hereby affirm that I am licensed under pravisions af Chaprer 9 nDDRESS � /(/.G�✓�- NO ��R�P (commencinq with Sec�ion 7000)of Division 3 of the 8usiness and __ /� ���, Professions Code,ond my license is In full force and effe�. CIiY ` N/NrL M55 '�� � BK � � VALIDATION - $Q.FT, NO.OF NO.OF ' CHECK LiCenSeNumberS,tb33Y UC.CIass� $IZE . . .570RIE5 - - FAMIlIES ONE � � , - VAWATION ' ` P� �0�� � �'3�� DESCRIP110N OF WORK NEW -- ` Contrac�or Dare �D S .. . � '❑I pm exampt onder Sec. ��r~ �'��'U'-S � , ?0 6 5 6 A ALTER Q' ��1 B.BP.C.Tor thie reoson ,. . . . � REPAIp s !Q/ Q v� . �� �i� s • •�3 � , � -D016: ' USE OF y0p - o�r,�o� I • •�7,6 3 - EXISTING BLDG. Si naturo � . . �- APttICAM ' TEt. FINAL ... _ . g OWNER•BUILDER OECLARATION � vRWT NO. DATE ' • �Z Z 6 3� . � I hereby affirm tha�I am axempt from the Contractor's license � qoDaE55 �/� 17 C��✓/tt� FINAL �&�9—�Pi - Law(or the following reason(Secrion 7031.5, Business and ' Proiessions Code): , - � � - - � �Y � � eunowc I, as owner of�the�property, or my employBas with ADDRE55 �Z��Q 6 Fl wages os their sole tompansation,will do Ihe wark and - . Ihe slrucfure is not infended or oftered for sale(Saction ����T� , � � �t • • •2�j � �� 7044,Bosiness a�d Professions Cade). - MOVING . - TEL. � � . � I,as owner of fhe properfy,om ezclusively cpntracting CONTRACfOR NO� � ,•9 7 g,6� with licensed mmraaors to constroc��ha project(Sec• - � � � � - ��on�Oaa,Bvsiness ond Profess�ons Coda). AooREss� ' ��a�p��x CONSTRUGTION IENDING AGENCY ��g�q�K �YARD HWY TOiq�OP UNE � WIDTM � - 1 hereby affirm thm the�e is a consrroUion lending agency for fRONT � 0 0�—&3 � . � � Ihe performonta of tha work for which tbis permil is Iswed � �.L. � � � (Sec.3097,Civ.C.�. SIDE � ', �2� �.` 7 A - P.L. � � � — , . � . � tendar's Name �` � ' ' ` � IDMA Ref.M � � m Lender's Address�� P.C.Fee S Permn Fee � . � � � � J,(�7 5 � I tertify that I have read ihis opplimtion and stale Ihat the I � i,suance�e� � S� t01M c/c M � - • o I �U�:� � = abova informotion is correct.I ogree fo comply wlth oll Couniy Invev�goron F e 7/� � $ ordinontes ond Stata Iaws�eloting to building wnstruction, To�ol Fee J�%� � IDMP.perm.M - -� � R and har au�harize repr sentarives of fhis CovMy to enter . �1 Q�J—�� - upon e v •m nt' n proparry for impection purposey�y�y�s. - , �� ' w � � ,-J �� ' SEE REYERSE FOR E%RANATORY LANGUAGE.' .. . � ' . Siprw are o A i�com ar Aqent . . .po�e . . . . � , � � _.� � . �____.__._ __-_�_ _ , . PIANS TO APP A IhSPECTOR'S NOTES ' ,�OR'NIiR-I{UlLU1fR UGCLARA'170Y, � �' , ' . (here6y or6rm ihol t om r1e�*+pl fror ihe Co���acter's � To: � . .. �. RifBr e . . . ' _ � .. . ... . ' � � license la.✓.�1or�thc�followmg reaso �.�So^.'''703�.5)� ' L'�: v¢ Burrneasn+rdYrn/e.cciousCndo:Anl'crtl'�oF:nunive•4icG No. Dafe No: � . ' • . '. ' . �-.reyeires n.r rmit 7r^,cnnslrucf.°v!!M;inifrqrr.dern7�lisl, � — ilrr purJnl�irrueen•:Priurliiiisisci ke� hi�rryairrr � �.i��!•; \ ;�.'- �yi .\���.. 1�y � � - _ __ _ - . .__ . . . . . . 1b afpL a �J sur!f�rrn�it to filr a sr� �J slatrrnenr '� -'�d.. . .., ' . . • .• ..... . . . ��- �, . . ,tfiat Ae�a ln�as�d furauant tn thr frn�n� s (�! G'pn- � :+�.:\�� .��.��`;..1``�'.�� ,. 1 ��i'-t�� � � era.fnr�l.i<'rntrl.�to(C1�apIFr'11(cvn�mrncin,cu�r�hJc2� .. � . _. ... .__ . _ .. . ._..._. _ . .. . . . . . • . �. . . ,�, i 00 � �Fv 1 r liutin s and Pr� rrnc �• i �'`l 1�'�..5. ��,�- ..,_� '��`�.1'� `_� .._. .�-'�.•'..� .f`�.l�.�_� � . .. .4nJeJoc�l�Sfb�''iae�k�fttlterrfrunranddchnsifor�6e ..-.. - .� _. .. .. � , _— ���Ro9uirod •..'.. -,,i.1 � �� _ _. . _... . . � .�d .:.:t . �. . �„,.���i��t/nraf rnrifsuFjecls7 r�a��i,<a���i��.r rl A rovals � Date Recaivad � ` . PP � �-Yoc No orApproved •� �1.,�, � ,�' . � . pnnult�n/nntmnre�thun�irr/randrrddnllurs(5500).J.� ._ .. _ .. � � .. .. ._._. . _. . . . _ _. . � � f , . . ,��..� , „..�� - ' � � � � .,::.�� ��� . • C� ,as owner o Ihe propnrty,o�my employees with — Wo��r CrrFf�co�e `-Y� � ._. � - � . '� .; ...,. .�. � ,. -• " �.:..- .�..-' . '. -- •. � . x .. .,wages as their sole compensatmn,wlll do the work,and � � � � ,-� � � . 1he strucWre is not intended or offered(or sa�e(Se<.7044;- . . .. ,.�,.� ,- . .. ,..:.�. � .� . �i ., •. ". .; � . . .. � � Heahh�Depanmenr—- -.�- . . ' � . . ' � .-. .... .• - - -• .. . .... .. .. • ...-.-. -�. 13usr�ieas und Prn/essim:�Code:71+e Cnuhd�lnr's l.iqen.ce ._ . '._. . . _ _ _. _ , � l.c�r dna<nnl opflp 1n att numer n//�rnferty�r/�u FuilJ� F,re De ArtmPnt .. . . . � � or frnerx thrrenn,and u�/ndues.v�!u�uri-Gimsef(�or p .. ... ... . �.. . . ,� . . .oun.rrn Iu�rcr. ,ruriJcd 1hai.sucL,i�x- ' .' .� :�. .. .�- . . . 1Grav,qG:Gis P 1 1 G•od y,�, ' � � � � . . ,-.hmreinen�s arr.nnt inlenJed or�f/rreJ�Jur sale. If, � � - �''Gnieei�rr,ebe burlding orineJ�m�rement i:suld eritbin nne � . Geoloyicol �' - � .' . + , � , � ��t � - �, - �. ... ���prur ri(rnmf7rtion, tbe uumer.lr��ildrr u if!!>are tbe , �. �.. � � �,�� 1 v�>>� _..._. ._._ ' •:.}_ ,-.1 .' ...... burAen n/Prm�iqG tl nf Le J�d nn(buill nr�impm�•e fnr . _ , .., . ' •: :,,� .nG.� __.L�ri- : , 5. �\'C: thipurhnscn/�al.�l. . . . ._ . � � Pedestrion Proternon � �• �� � . � ♦ � ` (Fen<e)IConopy) . � - � - � � � �� � - � � L� 1.osownerof ihe p oVerry,am e.:lvsrvrly cnnno�c= _ �� ��� .ting w�th Gccnsed contractors 16 construct ihe project{Sec. .:� � .._. , . . - ... _ __ . � Speclal Inspecf�on ... .- .. . - - � ,. . .. ..�� 7�04d)I1��sinrsr and PrnJrx,sinna�LnJe:71 e Cantrur�nrs (Conc.)(MasonrY)1\4eldingl . �.,� . � .� -_.'- . ..:.. ._...- - . - . '...._. �� . l:irensk�f.au•dnes nnt uj`�'p'ly��� y u nrF�f prnferp'u•Ga � . ��-hui(Js or imfrnres ibrrai�n,and u jrn"onlructi jur sr«!r . ; y�.. ..:, .. , � _... ._ .. .,_ _. . �_ 1prejr�s�uithp ]S��u Lcl Dromoge . . 1 . . . - . . . . .. . . 'nn�ractr r{1/icpaFeJ i 4 ant tn d�c � . . � . �..__ . ._. , . ....._... . .. . , � ._lr l_•J ••�i�,.,.:. , -'f.ontrmlors I ensc L�re,J __ . a . Porkin� .. .; , ,.,., ��:' , ,. . . _ , .. .,, r , �,` . .. . �am exempt under Sec .B.BP.C.1o.��h�s � [� . . -! .. . � ,. �..... ' " . _' . . . . � . . ._ ____.. .._ ._ . .. .. .. . . . . , .. . � .,.. > ,. :.,.,..... � ..�. reaso� ' : . . : � ., . . ___._ ._ __ . .__ _. _ . t . . . `. .\ . _ . , . , . � � . _ . . . . . ,.�a ole O �ner .�. .. . .d..� ,�1 .. .::.��.�.;_� �-,.,, t .._.__. . . . i �'APprovals•"� Dato ',I : InspeNar's Signafure '.��"i��.1� ,�,t.:-`V} ��i`. n�\�-.i , . . . . � INSPECTOR'S NOTES � . . �. locai�on— 1 ?( • `^L_-. .. ' __' i (Seiback&Yards) �' �..., �, �- . " � . . .. , � � � PoundoYons ' .. . �. . . .� . .. .. . ' Slab ' . � , ,.. . . . . . Frame .. .. .. . . . . . . � . . . . . ,. . � . Energy Insuloiion �. ' . .- �.. .. � .... . . ' . _ .'. . . . . . � � . Loih<�rywo11-. � �V ! Y ,'nt �-,., . _ . .. .. . . ___ ._._. ...__ �._ _ . .. _ _. _ .. . . InterVor J 9 1 V��— .... ..._ . � - r � . . l6ih�—Eaterlor � ; . � � �... . . . . ..-- . , . .� . . ;_ , . . _ _ .._. _.____ .. ...... _ ._. , .. . .. _.. -, , ; ' .- �, . � Flousc Number-:. ` .. -_.�. .".. ___' . ._ �` ..� �., . . . Carrec�8 Posrod . ..,J �.i�. ' , _. .. '_.__. _... . . . . -. -- . . Finql-. � - - . . � . . .. . . . - . � Enrr.on Fron� j.\� �.'t� � ' � - . . � . . ,. . . . . . . - _ '- � . . . . . - . .. . � . . ` . � :: ` . ... , _ ':.�_ ;._ .{ . �\:-�.n�7.��.��,� '\