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HomeMy WebLinkAbout1354A :'� WORKERS'COMPENSATION DECLARATION . �- � I hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT insure,or a certifitote of Workeri Compensation Insurance, or ay�g�rtified topy ihereof(Sec.3800,t i nC.) o �J( COUNTY OF LOS ANGELES BUILDING AND SAFETY 'Polic"yNo�$ `i 3�Cat�rpany "__ BUIIDING � Certifiad copy is hereby furnished. FOR APPCICANT TO FILL IN ADDRESS � A'L-�� � r�F—Lartified copy is filad with the couny buil ing Insp BUILDING 1C3 tion parf ent ADDRE55 A �L LOCALITY � �n NEAREST �Date � 'APPlicant att � �'�l�tP CRoss st. I NO.OF BLDCS. F+SSESSOR � ' ; CERTIFI TE OF EXEMPTION PROM WORKER SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL �. COMPENSATION INSURANCE - (This aection need no�be completed if the permit is for one ���� USEl�N E Mna U� ,^ � .,_ bundred dollars(E1o0)or less.� TRACT s�ocK LO7 NO. /�_� No. TEL. (:(�yv SPECIAL }� � 1 certify that in the performante of tha wo�k for which ihis OWNER NO. CONOITIONS � Q DISTRICT .GROUP TYPE FIRE PROCESSED BY O permit is issued,I shall nat employ any penon in any manner /� y� CONSi. ZONE V so as ta 6acome subject�o the Workera'Compensation laws. ADDRE55 f� � ��\ � Oate Applican� - ��TY Zlv STATISTICALClA531FICATION APi. NDO. UF ARCHITECT OR TEL. �/ , V NOTICE TO APPLICANT: If, afler making Ihis Certificate af ENGINEER NO. CLA55 NO.�DWEII.UNITS � �Exemption, you ahould become subject to the Workers' y � Compensation provisions of the Labor Code,you must forfh- qpDRE55 SEWER M4P ' , with comply with�such provisions or this parmit shall be � deemed revoked. - . CONTRACTOR O. BK. PG, YALIDATION ' LICENSED CONTRACTORS DECLARATION ¢ LIC. ry�'7 ' I hereby affirm fhat I am licensed undar provisions of Chapfer 9 ADORE55 � J NO. �`J�6 VALUATION � (commencing with Section 7000)of Oivision 3 of the Business and � p, /�� /�__ LIC. . Professions Code,and my license is in full force and effect. CRY W 'r" ClASS s � �� ► �� � � �T��W S ORIOES FAMR ES CO EK � License Number Lic.Clasc SIZE N� � S � Conirocior Dafe OESCRIPTION OF WORK - � G�_ ADD ❑ �1 3 5 4 A - ❑I om exempt under Sac. . AITER � FINAL J-r'�,p G �f. . . . . � ' 8.&P.C.for this reoson REPAIR � pATE M� USE OF FINAL I • � �U,L J -� _ �/�(7�e' _ EXISTING BIDG. DEMOI ❑ B '� Slanafure ��Y"��� I APPUCAN7 TEL. Y e o j ��t;..C.:>u � a OWNER-BUILDER D RATION PRINT NO. _ I hereby affirm that I am exempl from the Commcror':License � . , �1,� 5�8 c Law for the following reason(Section 7031.5,Business ond ADDRESS . Professions Code): � . ae nl � � QBUILDING � � I, as owner of the property,�or my employeas wilh ADDRE55 � wages as their sole compensation,will do the work ond � � the slructure is not intended or offercd for sale(Section ioCauTY � . - 7044,Business and Professions Code).. MOVING TEL. . �r - � I,Cs awnar of the property,om exdvsively cantratting C NTRAC70R NO. , � . - with�licensad contracfors to conslruct tha projact(Sec- qoDRE55 ' . tion 7044,Business and Profiessians Code). � . � � ; � REqUIRED TOTAL SETBACK FROM E%IST. . CONSTRUCTION IENDWG AGENCY � SET BACK YARD MN'V PROP.lIN WIDTH � . � I hereby affirm that ihere is o consir�ction lending agency for FRON7 - � � � � "' � the performonce of ihe work for which}his permit is issued . p.l. , � �Sec.3097,Civ.C.). - � . SiDE . . - � - . ��... P.L. Lender's Name / � _ +"` � � � lender'a Addresa P.C.Fae E Fe.mil Fee /�' sr � �� �� � - �� �� � � I certify thot I have read this applimtion and�tate that the iemooce Fee 0•V� � . � above informafion is mrrect.1 agrae to comply with a11 County Investigmlon Pee y . ordinances and State laws relating to 6uilding consiruction, Toral Fee � i a"" � ond hereby authori representotives of this Coun �o enter � upon iha a va-m ioned properfy for fnspaciion urpos s � . � � n � . ��/ � SEE REYERSE POIC EXPLANATORY lAN6UAGE � Siynofure pplicon�ar Agent pat � � � \ ,�..�. r�_...._ _.�._. �.._.__ a __. . �. _ __��.�.._._._ , � ^ tzr r rt> >�ic�t �� -s.. a k � � -� +i�.- �s•W.� `i '�.s:r�-...�..+..�.._, __.._...__.,. - I h �.- 7 y�:r f;�� the Cor•trac!er's ._..,._�.,.-�� . . . Ta: .BstsrsFd� � .. . Lic L - I c ��;�a n 7 recs . ($�c.�,7E337.3) ._,....._. i , .____.____.". ___ _' . .__.Y____—.___�___, !%s. �-��..-'.. . �..f .!'.n.•c.vnrcnxxtyw ' Nw.. Da:: C�.I G , . . � . . � ' .... _. . . . : , -, :P o�.�,dcnxol� . ._:.:_-�.�...w..�.�_.�- � :— . ,.-� ..._:. ---�-- �--. .. ---.—. ._�__ ._._. n• � a . or¢quiraa ' ., � .v .. s.,.� .m,b!s � ' _-1_ - . ' .. � t]' ChM1� " f f C� :n t. jf .6 5}��II��PfeFN1n1lY! � _._.. __. ._._____ __.. _T__ _—. ._ __—._ ! .. _t __. _.-_.._ ' � " f�. �. Q[ISAII��T 616E r.(HA _I .. — I.. � .. . � .._ . . t•. 1 .r /�c>�rs�cHee uvtnSoe- � i . ._— _ .._ ._ ..._ . � ____ .—�.— r! )��i�( � fpf� f�4T iYM56K(d dIORS aK(Pr9�4 I I .___y—. ,� I , ,=r/ r -". t w✓r rx r.»d tlle 8leisjar ths �—- ��' z ,,y r- .. -ti�r ._.�.:.rrf Seerrnn 7031.5 by __— _.._. ____. ,....�..._.,_.,�__....._.�._....J,................:... .�.. .... _ _._. ._ ., _ . . . I . � � . � . •I•...;J ... ' �� , . �rc.iM tb ae%b!1 �-.. k -�.,_,, _,_ -- - _. _- –- ---_ __ ----- r �.,..��s�nen/,�, ..., � �/f. � . I h' .�,-.. - — ... . .� . � - _ - � . � i I � ' .,, . �. , i� fy, ry am�ass with . . . I I . . - � .---__. .... _--�- ----- ._-- --— w c i .V o . �I`s ths�werlx,amd Wa1er C t f� :. I . �. _ . ` � �.;h ,-i� .'r c .ed(cr aeFe(�ec.704k — — ____�.—_... . —_._ ___ —__--._— f.. • . C ....C .tar's Licenae Hualth D:.,�e,r.,..rt I , �I . -'--- -�--, . .. . _ .. - , � .. . crly wL•o Grik�� � � . — �' �'� � r r Fire Dc ..cr-.r:t ' �' .______.. ___._.. __._..__._... _____ � ;.�� .. .� ; . . ._. ��rer-b Adn�ie��or ....____ __._____.__—�.'_'_ � � . . . t?,vc Y ! s a .c /n•rr.- � that sur$ inr ' .`�. - � .—_.�. _;----�-------- " .� n��c� trr soN� . Gradinn � �— . J'r r r a 1 rr.' f If "_.___ _...______,. ._I.—�._ .__...___ . � . . 1• .. . . rrsn! u El�rx one � I _ I �.—__.__` ___.—_. _._ .___... ,..u.__.___ � ._..._____._—_� .;. r r .__ . ;_: .. � a�xl!l�cue tGe Gecicy c-v' . " . �� - � , , . _ _—_—'_—___--_. . . ' . . . � .���Mmue fr�r --__� � . .. .. .. . :. . . : __ Fedeslr an Protection - Y —�.�_ � �� .��" �' . . (Fen<n;(Can�oy) � , - . ' �� _-.a� -c c � -:n . I�,ivelycoMroc- _.___ .. _. _.._�� _— ____— __ �: �,,-.s�,��rihupro�ect(Sec. ___'. ._,��..._—. ___.__—___ _� -. Specialln..pcction , . � . �`.':� 7C z�.: � �� G...' .4i�a�C�wwMr's (Conc.J(�AasonrY)( is:Id��.nnJ � ._..__ ____._ __.__ _.__:_— . — - L. ,t �._�r . t ��. - aff�roperW who I . l �, i orts Je��ack - _------;---'---- -__ - _ - 1 • • �+�':._...__. . _..__. ._.. .. _. _._. .-� --�-----.—'�--- .';. '' . . .,:7t to fAt Lot G�r.�i� '; . ' . . - . � � I ,�. . � . C . . . .. .. . . . . ��.__._—, . . _.. . , . , .: Parking . � � . - � . . � 1--µ— � � I �r:: .:... � ----,G.4P.C.forthis I _—' �ITi --. __. . . . � . . .—.._._�.___ . __.— '--_ . . . .. I �—I ......_— .....___—_ -.___ ._—__—.__.----- _ D� . ._____.�. ._ ._w_ _._ Owner a -. . -._-_-_--._ . r . ,. ._ �, e . a-- � - --. _ . ..,_ _.__ .,_� _..�_..__..... Lomlion . .�.:. I _.__ .. .__ ..�.. ... ._. ..._ .____. .__._--,-----'-- � _.- . . (Se16�c £ �crc'_) � " - " � - - p - � -- —�-_-- __ �--- � — .- � Foondat or.. '1 0�✓�_ ,. ____ i __ --- _.____.._._—___ . � — __._ siab p < , _ �� �x m.�-�`–`�-�'��-�.1�-------- --- -- — — -- -- Frame �' � � '�f� � �� � ��-�7 - ---- _ ,�1-._Sez�o k.�--����^�"�"�" — - -__-- -- - Energy Ins la'�en � �/'A,q + ' � . .—.,.._ __ . .-. _ . .. _—__ � �.. �/^-•^/.1V�•��_4'� .____ __._.._ - _.—. __— __—.. . .. Lath/Dywull— ( _._'-�J/?l�,Iy � n`��- . � . � �:! . Int-..io � � _ . . . . .� '."____. 1_ ____-_.�ti ------�.— .__. . __ _-- C Lath-Exterior � . . . .. � � . House Nur�,b.:r�. i — _-_ .. _ _-. __-�_— __-.—_ ----, .. Correct&Pcs•ad � . . .. . . .. . . .. � ._____-'__.____.�.._______' -___.__'__-.__-__-_--__ Fnal- . . . --.--__-__-_._ Entw an Frcrrt � . � • . . � . . . .. -' ___- '_______-_._.____ .._..:. ..._ .. ... ' I ...__ �__.__.-�-__.-- _--_.______.__ ._ . (