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HomeMy WebLinkAbout1135 CHISOLM TRAIL (2) i WORKERS'COMPENSATION DECLARATION � � � - ' . .-� � � I;hereby affirm tha�I have a certifitote of consent ta,e�, � qpp��CATIQN FOR BUIL'DING PERMIT insure,or a cenificote of Workers'Compensarion Insurance, or a certified copy�hereof(Sec.3800,Lob.C.) � . policyNo. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnished. FOR APPLIC NT TO FILL IN BUIIDING , A�DRESS �❑ Certified copy is filed with the county building inspe[- BUIIDING _ tion deportmem. ADDqE55 �'� . �Date Appliwnt CITY ZIP LOCAl11Y 1� (Ai� CERTIFICATE OF EXEMPTION FROM WORKERS' � . NO.OF B�DGS. nleave5i COMPENSATION INSURANCE Srze OF l07 NOw ON toi CROSS ST. �This section nead no1 be tompiated if the parmit is for one TRACt BLOCK LO7 NO, � �SSOR hundred dollars(E1D0)or less.) s / NAF BOOK PAGF PARCEI OWNER � � /i / L NO� ^6 Z�3� USE ZONE MAP - I certify that in the performonce of the work for which this I r1 —I NO. " 3 permit is issued,I shall not employany person in manner qpoRE55 ,�� -f C7�in ./ ` j` SPECIAL � � . so as to betome subject to the Work Compe ion taws. - CONo�nONS 0 Dal 7 j'��j�_APPlimnt�, CITY , h+�� ZIP I/�' � . . � ARCHITECT OR TEL. NOTICE TO APPLICANT: 11, after makin i Ccrti ca of DISTRICT GROUP TYPE FI2E PROCESSED 8Y 0 Exemplion, you should become su6jecl to Ihe orkeri ENGiNEER NO. � NS�T.�����;q 20NE /� �( � U Compensation provisions of the Labor Code,yo�musf forlh- ADDRESS • � " `" ""` lil wilh cOmply with such provisions or this permit shall be TEI. � STATISTIG4L C1A551FICATION APT. CONDO. N deemed revoked. COMRACTOR N Z IICENSED CONiRACTORS DECIARATION i�. CtA55 NO.�OWELL.UNITS 1 hereby affirm thot I om Ilcensed under provisions of Chopfer 9 AD�RESS NO. (commencing wilh Section 7000)of Oivision 3 of the Qusiness ond ��� SEWER MAP Professions Code,and my license is in full force and effect. CiTv CLnSS BK. �, . VALIDATION 50.F1. NO.OF , NO.OF CHECK License Number lic.Class SIZE ' STORIES FAMILIES ONE � � � VALUATION /� Canfroctor Date � ' � DESCRI7TION OF WORK NEW ❑ s ��✓ , - � /� /� s� ADO ❑I am e■empf under Sea �� i��N ) ri.i ALTER � 0.8P.C.for fhis reoson REPAIR s � � �7 8 Q 9 A pa�e: USE OF E%IS7ING BLDG. OEMOL #• • • •`�� Signature APPIICA TE�. FINAL�Q OWNER-BUILDER�ECLARATION vRiM t' � NO. '� DATE'/j`�� � • •��1 O O .1 hereby affirm�hai I am exempt from the Contractor's L(cense ��L ��r � � law(or 1he fol�owing reason(Section 7031.5, Business and AD�REu J 7� FINA � / • • •2 rj.O O c=a Prof ssions Code): � � - E By 6UILDING O�' 8�8� 1, as owner of tha property, or my employees with ADDRESS � wagesastheirsolecompensation,willdotheworkand ' • � - . the sfruclure is not intend�d or offered for sale(Saclion LOCALItY ' _.. '. 7044,Business ond Professions Code). n�ovwG TeL. . . 1,an owner of the propeny,am ezclosively contracting �ONTRAGTOR NO. �-- �- . ' � wirh licensed cantractors io construct lhe pioject(Sec- - aD�aE55 �� ' � ' tion 704d,Businass and Proiessions Code). . � REOUIRED TOTAL SETBA K -- --- ' CONSTRUCTION LENDING AGENCY� Sei BnCK YARD HWY pROP.LWE wiorii - � � - I heraby affirm that there is o construction lending ogency{or FRONT �$0 Q 4 A Ihe performenca of tha work{or which this permit is ivued . P.t. (Sec.3697,Civ.C.). StDE - lr��� v.�. �. . . . . � Lender's Name - � - ' (^� LDMA Ref.M � • •3 Q 5 0 � Lender'a Address P.C.Fee f �J Permn Fee Qi _ , ¢ r, • • •3Q50� g I certi4y 1ha�I hova reod lhis opplimtion and slote fhat the issuance Fee �V •� LDMA P/C M , pbova Informafion Is mrr . ogree to tomply wilh oll Counly in.esnganon Fee n O 5'2(1—H S $ ordinanc s ond Sto�e ws elating to building consirvction, Toiol Fee b � �V tph�q pe,m.M R and 6y authoriz rep sen�atives of Ihis County�a enter- a u e obov�m ad property for Inspection purposas. ^ �;a,�� SEE REVERSE FOR EX�LAHATORY UNGUAGF � Siqnar e pplica rA enl pe�e - . . , � PIANS TO APPLICANT INSPECTOR'S NOTES � OWNI:It-ISU71,UIiR UIi('I,AHA'I'1O\ I Fe.eby p16rm tF(�r I am ezempt 1r�m ihc Conr.a:�o-'s To: '- . � , . � Returned. � ' � .. � . . , , . , . , � � ,� license la�.+ for �he (oliow�ng reo;on (Sec. 70�� SI � ,APProred .. . Druinr.cannJPr�frssinnsCudr�AnYrih'��r:.iunlverl�i:! No. Date No. � 'Dote . .... .. . .. . rryuires o(�ernii�10 a�onsfnrr[.rltrr,inrfrurr.deniulkh, , _ , -,�..�p�.,.un,•..�.u�t�,��;�r��„�•n�,a«s„u��:�•,�c,��.,�,,,�.��. :. , . _ , :,� .,,, :-, . � _. i � ; � .�. . �p1� �r/�. 7�p��. �/�& ,�,¢R� . .__.�.- .- . ._ ... . .. .--...'_' .' - - -- 5c r� �sur nr t/ .. d e�t�nenr . . , .`. .\ . ,. . t J I � (�ur t. �f � .n.e t t f f f fuJnf f�1 7�+ t•Itti�ni nf r�I( _ , . . . . .:,. . \ ����,�� trmtr�r's�l.irencr f.n�•(CbJ ter 9J(�,��m�nun,4'u rtL 1eo �._ .. :.. ... ... .. _ . . _.___ _ .' . .. , , — � _. P : . . __ . i\ . , tiun i000J u/Uiriaiun 3.+lthr pusinrss�nd 1 ru/rssi ms ____" __ _' r__. . _ � ' . . ,-, .. �- . ._ , _ ..,., ... ' _CuJcJor.tL�ll�eisetrrmpttbarrjrnnrundlbehnrrs/urtl,v I� . _ ullr,CrJ esemptiun.Anv ri,�latrort r f Jeitinn '(13L5 b� . -. -- - Required- - .... � . . _ . _ an�•�ppfi:emt(�,.upcm,rtsuhjr�ts7Lrapplic��nfluu�iril A rovals � Dato Raceivod � PP Yes No ar Approved � -� .. , , . �, ,��,����. . ..� pennitY oJ rtnt nenrr lfian fie�a hundrrd d„Rq.s lg9oo/.): _. _--• . ...:', . � l�'. � .. . . L I.�s owner of the p�oPe.lyi o�My rmploycec w,lh N:ole�.Cernhcme .._ __. . � __. ' � , � - - _. ... wpqes os rhe�r sole compenspi�on,wAI de the wo�4,and � � i ,�� '- � 1he sxuctu�e is no�intendod or o}fe�ed for sole(Sec 704.7? � , . r, � Heolrti Deparrmen�--- �--'-- -�—- - �'� � ': - . . - �, '.• . -�� . --. t. �..' ' .�. - - [)usineis anJ Prn/essiorrt G+Jr:Thr Conds�Yar's(.i:cnse ' . � � � l.u«�Jnrs,noi oppf�`m an nu•nrr o/proper�e�e�b,�hui(Je .� ... ;. ., . , _ . ���.,. .. . � � , . . . .." , .. � .�` . ' or inr r i•es tl erenit;un�!u�Gn Jucs surf�u�urA;l�in:tvl nr . F.e Depanmen! . .___ . . . __.' ..;. . . _ .. . _ P�� . / , � . . . ffr�nu�b bis nfrn eniplqyre�.prnrideJ tloe such r.n- Grnd�ng' ' . � . . prnrernrnfs�are nnt infearleJ ur .r/���rrd Jur aalr. !/. . . . :.Im�rre�er,t1�e buildin,q ur ineprnr.�>nrn(issufJu�ilLin o , , , . , . _. . __. __ - . • ' _ _ _ Geoloqrcol � '�,, � ,l�eor oJ�cnmpletinn,�fhe ou�nrr•M�ilJer utilf I nrn tlre _ _.._ i�.-:1,� 1 ._. . .__ ... hurJen nl frarin,�lbat I�r did not 6uilJ nr inrprnrr/nr :i,•��,r�„«��.�a,,•�. (FenceJ�ConoPYl '�� � � � �� �� y � .� . ....��_�-�� '� �� _ �r " ��,Iinqwqhi�:.ensedcofnlracorstotansler:Ivslveiq�en!rnc. 7edesrnan Fro�r.ction�- ruct Ihe pro�ect(Sec. - - -. ... . . � . . -- -- 704t)(lusinvsr anJ PrnJcssin�rc CnJr:Tbc Cnntrua�enr's SPeuo�Inspec�ion . . ..- . . ..-. '� � . �Conc.IlMosonrY)IWeldm9) , . . _.__ . __ ._. _ ._. - _..Lrcrnsrl.arodnesnn��ppl�'rounnu•ner�Jprupert��u•La , _ . ... . ._.. - . hu;IJs or i�nprore:lbereon.wrsJ mLn rnnlrocll Jur sucL l01 Dramagc _ � ' �- '.. ...___ . . .. _ .. . nr jccts udfh a rontractnr/cl fi<�cusrd pursuant to fhr .. . .'� ..�...,, ' - Cuntraa�br's l.irrnsr Lou�)• .. . . Fo,k�nq . _ _ _ . . ._ � . ' . ,,�;�; - , ❑ I am eaempl u�de�Sec. .B.BG.C.fo��h��s f C. ,.. ' � _ �eoson _ ._ . __. _ __ _ . _ r �- c .. � '___. _ _' __ ....'_ ;l i � .. � ` . r - : : .'•: . , '. . _ _. �i., '', t - . .7 . � '_ - ._ . w�, Oa�c O er �.Approvola o Ootc Inspetlor's�5iqnatvre _. . � .i:� , . � 1..:",i`.`� . );. . � . . � � ' � � � � � �INSPECTOH'S NOTES Loco�ian.-. r �.�.- . . ... _._ _ ..... _. � � (Setba:k 8 Yords) � _ . . - - • . .- . . .. , . Foundo��ons - . �.�� � . .. . � � Slab � 2' ��� -. - --- -- - -.. _ _. _ ... _.._..: �. _'. - . ..��,�, . .;.,�, _ .,_. , . , Frame � �Q{� � �� .. . . . � i.. � . . .. ' . . . , Ener9Y.Insuiolioo ._.. '�.__ . . ___. . . . . . � . . _ u ___ .. . . . . , .. .. lathrDrywall-- _.. .._._._. ._..__ ..'_' - . - - � . � � �Inlr�ioi � t � . , latFi�-l.xicno. • i � , , ..., .. . ' .-. ' . _._. . - -� - -- � ' -. . .._. . . .. . . , ' __-___' __"._. ... . . ... . . , � � ,-, ' '�,- � . _� .. i - House N�m6e�a.o ___- -- _'- ._._ __.. .. . . , ., �.._.. .. . Corrca 8 Pos�ed - ' , - ____ ._ .___ _ . _ __........ _ �� : Finai.�..tlti�xt'� - . . . . .- . , , . . - , Emer on From � , � � ' ,�. , ., . � � - _. .._ �. . _. ..__ __ ._ . ' �., .