HomeMy WebLinkAbout0854A ; ..
-WbRk�:RS'COMPENSATION DECLARATION
... --. � .__ ' _
� ' 1 hereby�affirm'tho� I have a�a�„�.�a,e of�o�.en;-;o se�,�- �. qpp�,�CATIQN FOR BUILDINC3 PE�tM�'�� �
insure,or a cerlificafe of Warkers'Compensation Insurance, ��
or a cer�lEle{d'�copy��Iphereof SSec.3�'b�.C.�� �����,� COUNTY QF LOS ANGELES BUILDING AND SAFETY
PolicyNo. dd`����
1C'4 . C�"Compony
� Ce.trf�ed copy�s hereby 4urnished. FOR APPUCANT TO FILL IN BWLDING(1n
ADDRE55 d� 1
� Certified topy Is flled with the county bui�ding iaspeo- BULLDiNG/A 11 1 � M�p {Gy S�
tio1n depQ tmenL ADDRE55 67 i F_ �-�
Date�1 ZJ�I Applicon� CITv ry Q [�F� ZIP Q�!�f LpCAU7Y
CEFtTIFICATE OF EKEMPTION ROM WORKERS' ' NO.OF B�DGS. NEAREST
COMPENSATtON I SURANCE � S12E OF LOT � S NOW ON l01 CRO55 ST. �
(This section need not be comp�e�¢d if the permit is for pne TRA�T ���/p� g�aK l0T NO. l MAPSSBOpK -PAGE PARCEL '
hu�dred dollars(5100)or less.)
��h � G�pA iEL USE ZONE �P
I certify tha�in the per4ormonce of the work for which this a`�'NER K-. ��'-'f!'�NO. � �,�p,
permil is issued,1 shqll npt employ any persan in any manner qD�RESS Z 34� F-' •1�'�"'�TJCi1�`��C-� � �CtAI �
so os lo become sobject to the Workars'Compensation taws. � (� CONDI710N5
Dota Appiicant CITY D/d�.�ND S�F� 21P 'IIZ�S O
NOTICE TO APPLICANT: if, after mokin this Ceriificate of ARCHI7ECi OR TEL. DtSTRICT GROUP TYPE FIRE FROCESSED BY �
9 ENGWEER N�� (prysT, ZpNE
Exemptio�, you should become subjetf 10 Ihe Workeri �^�7"�T� W
Compensafion provisions of the Labor Code,you musl forlh- qDDRE55 O ,oSls-. �� N
with comply with such provisions or ihis permif shall be , TEL STATISiICAL CIASSIFICATION APT. CON00. Z
deemed revoked. GONiRACtOR T ..� . NO.
LICENSED CONTRACTORS DECLARATION ���, 5-"�p, MSS NO.�DwELL.UNI75
I hereby affirm that�am licensed under provisions of Chopter 9 ADDRE55 r ���1�Q NO. 4'v
(commencing with Secrion 7000)of Division 3 of the Business ond � � `�1 ���, ��R�P
Professions Code,and my license i m 4ull force and effetl. CITY 1w��N��� cwss� BK � VAtIDATION
� SQ.FT./� NO.OF NO.OF CHECK
Litense Number S, �� Lic Class � SIiE �Y � STORIE$ FAMILIES ONE �
V ,Yr/-JI VA UATION
Coniroctor � �i� Da�e ��"3 a~`� ' DESCRIPTION OF WORK NEW
� �o FiD �!a �{- 5a4 °D s Q� ,
1 am exempt under Sec.
ALTER
B.BP.C.far�his reason L� REPAIR ❑ f
Da�e: USE OF �EMOI
ExISTING BLDG.
$i nafufe APPtIG4NT TE�. F(NA�
9 PRINT LV V� N TW' �'�' �� ��`✓�
pWNER-BUILDER DECLARATION `f ` DATE �
I 6ereby affirnt Iha�1 am exempt from the CoMroctor's License � qDORESS V 1� G�� b�F�Y k�' FINAI
low for ihe following reoson(Setlion 7031.5,Business and i
Pmfessions Code): e dY �-�&���F'
BUILDING
� I,�os owner of Ihe property, or my�employees with ADDRE55 �.;• . . � s �
wages as their sole compensaiion,will do the work and -
tfie structure is not intended or offered for sale�Section tOCatrtv , � • m 6�O�
7044.Bus�ness and Professipns Code). MOVING 7E1. � �
� I,as owner of the ro ert am ezclusivel coniroctin CONTaAROa NO. � . c.
P P Y, V 9 ° f%��(1Qu
wirh 6censed con�roctors�o conatruct the projec�(Sec- qppgEs '
Non�044,Business and Professions Code�. ��� 2—&a
CONSTRUCTION IENDING AGENCY SEa6ACK YARD HWV TOTAP�P`NE WIDTH
I heraby affirm that there is a constru[lion lending agency 4ar FRONT
the performance of tha work for which�his permit is issued P.L.
(Sec.3W7,Civ.C.). SIDE
P.L.
Lender's Name I�MA Re�.M
� Lender's Address P.C.Fee S Permii Fee
� 1 certify that 1 have read this epplication and stale thal the Issuance Fee •.J LDMA P/C M , �
above information is corretl.I agree to comply with all Counry � in�esrgauan Fee y'�
ordinonces ond State laws relating io building conatruc�ion, to�ol Fne CS 4 1DMA Perm.M
and hereby authorize reproseMatives of ihis Counly 10 en1e� . � ,
� upon a6ove-mention property 4or inspeclion purposes. � . ..
fEF REYERSE FOR E%►LANATORY UNGUAGE
~ Signmurea f Applicaat or Agan� Dme ,
� PLANS TO APPIMCAN7 IhSPECiOR'S NOTES 011'Nh:R-Fi[!!I-UI•:K DL:C'LAPr.q�1'IQ!V -.
,_„ I he�eby o!hrm ihot I am e._ir�p+from ihe Cnntra;rcr's -
c
To: � R�eurnsd Lic�nse i�w tor ihc (ollow�nq rc ,,n l,Sec 703L51
ApProved Busin��sc unJ Prn(i•.rsiuns Cnde:Anp Jtc nr.nuatr ie-!i�i
�ho i... .. Oata No. Dote .. �y� royu .� /•rnrit t �.�iru�t h � � rp� d tish
-�'---=----�=-. -...-_�=�_.---. --.- urr��puerunystrudu e p inrt t.cessuan���, ho«qeurce
� ._ , . . . . . � � rb��appr �r/ � �pr, � 1� � ��
' r Jueh nref 1 � titP �l t f� 'r�f
.� �.__._. -_—. — U��t b i-f nscd purou�nt t i!e p u�s . ��!hr(,or-
�_-���. . _ ' i'l- .
,. � , .
��1�_i . . _.- i -- 1,',' . ', � ��y� CnJc)�Otl�et he es uxe3npt�1�/��m�nd t1�b�u�/.�ry�cc-
_.___...__._.__ ,�_�� nnc
� .�. r[,�
... .- o7legeJ ex�:nap[idn.Auf��d..latrnn nf Sndrnn�7U�1f.5 bti.
..._. �' � - � ��w°�r�� DnteRaceiv�d - . � � , .. anNu/�(�[icantJnraperpeittnbjoeislhrafiJ,lyeanllnuririT
' AFp ovals '-`-`. or Approva�! - j�nncltq nf nrzt morc tHu�i Jro bundred do/!mr/850Q1./:
� _ � ` _ Ycs tdo � � - i._i �
�_--��„ � as owner oF rhe pra�,ry.or my . ploy_.s wirh
..�e-Cc-[I�tate� . -� ..� � "� � �woges s their sole ccmp5nsat on w II de Ih. wnr ,onJ
. , the st � ture is noi inlendad or affered 4ar s � tSe .7044J
�* Bresinesx und Prnfcssruns Cod JGc�Gbut t s 1 ronse
{�H,_:..�JePa�rmenr . . �.
- , � .��� . . I.nu�J�r�n�.t upf�/y!> �n ��ine J(rr�p r)�f buifds
I P�e Deparimen+ - - --'--- or m p �eu tber�. n und u.!'in dons tu�b k� sel(�r -
( . e!rouRb Lrs ou n rp(o�Nr,, pr��4J�•d eboe rh ��
��,�id,��q � . prnvemett[r r�re n t inlendeJ or aJJer�r1 l ralr. If,
{�-�. . . �. ._ bnu�erer,�tbc bra�ldmg nr i.npm ent nt sv snld u ith�x one
fC,e•o�ogica� � . _ . -- yeur n/rampletinn, tbe nunerbreildvr tti1!bare thc
j •�� V_' ' - ' ' . hurdcn nJ prnuin,y t/�ae gr drd nnt buit;f nr rmprnnr/�ir
�edes cm orotecri�n 4 � . , . the pu p.se n/.mle/.. .
�e.;«��r.a„aEyi - 1 � �� L� I asawneroftheproperiy,amexcl s�ve*fycamro<-
ti . , un wrth licensed cpnhacrors to cnnsrrucr tha
g prc�ecf ISec.
� -m� oocton � 7044)8uarnest snd Po/as:enn La1: 'Ibc Cnneraclnr's�
� �c,:r yi+Josnrvy�fWe�ding) � � � -Lirensel.au�doetnifapp'yt an�ownerof�/ropere�uhn
� builda or irnproe rt!1 a.rer x,und u f�i rontraces fnr aiecb
� :i�«�.�,npe � . projects�u�iti u mr�trwctnr{sJ Jxensed pursuant ta tbe
�": � � � , .� Cnntrncrnr'a I,i.-enso I.Qu.�l. . .
r-.._._.V..�-�- . _ .
i P�;�k�n<; .
- . . � _ [..1 I am e�empr under Se<. ,8.8G.C.tor ihis
r�__
� . . - _ �. . .. . . reoson .
!-.
I Dote Owner
1
Approvoix Dctn laspactor's SigrtaWro � - � ' '
�� v � INSiECTOR'S N07ES
i t �or� .. � . . . . . .
��rbrad d Yards; � .
ro��nz) ians ��� . , .
Slob � � � �
fra•*+e -
i Fnergv Insulatlon � � - � .
i.n;n:prywo4l-- _ �. .
Imerior
Loih�_Exrerio�
House Num6er.__ , � �
Carrecr&Pos+ed � - - �
F�nol- �
Enter on FroN � � � � �
0 �i'i � f