HomeMy WebLinkAbout1421A � WORKERS'GOMPENSATION DECLARATION , �
� insure,�or afccrtif ca��e of�Workenr'Compensat on Insurantef AP P L I CAT 1 O N F O R B U I L D I N G P E RMI T
•or a certitied copy thereof(Sdc.3800,Lab.C.) �
J� ���.+ COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo.�2_lS.�Company �^laT'� FLaN�
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 (��
{� Certitied copy ia filed wilh the counly 6uilding inapec- gNtDING
; l�d' lio rpar�e,�nt. � AD�RE55 O 3a `
Y
Dale Applicant CITY LP LOCAIITY /
� CERTIFICATE OF EXEMPTI FRO ORkERS' NO.OF BLDGS. � NEAREST
COMPENSATI INSURANCE SIZE Of lOT NOW ON kOT CROSS ST.
� (This section need not be completad if tha peimit Is for one ASSESSOR
�. hundred dollars(S��)or less.) TRAR BLOCK LOT NO. qnqp gpC�l( PAGE PARCEL
TE�. USE ZONE P
� I tertify lhat in Ihe perfarmance of tha work for which fhis OWNER 1�( N .� NQ
permif is issued,I shall not emp�oy any parson in ony mannar SPECIAL � ��
� w as lo bewme subject to Ihe Workers'Compensation Lawa. ADDRE55 ODNDITIONS U
� Date ApplimnT CITV 21P
ARCHI7ECT OR ��� OISTRICT GROUP NPE FIRE PROCESSED BV O
NOT�CE TO APPLICANT: If, after making�lhis CeHificafe of ENGINEER NO.
' �- Exempiion, you should become subjen io the Workers' t CON 20NE V
'� Compeowtion provisions o4 ihe Labo�Code,you must forfh- qppRE55 1 O d
� wifh comply wilh such provisions or Ihis permit ahall 6e tEL. STATISTICAL CLASSIFICATION APT. CONDO. tn
_ deemed revoked. CONTRACiOR N � r'� � Z
' � LICENSED CONTRACTORS DECLARATION ���,� CLA55 NO.�DWELL.UNITS
' I hereby affirm fhat I om licensed under provieions of Chqpfer 9 ADDRESSz9� /�1"J� NO. �fS`� ��R�P
(commencing with Section 7000)of Division 3 of the Businaes and UC.
Prafessions Code,and my license is in full force and effact. CiTv � /V� ClASS ��� BK � VALIDATION
Sp.iT NO.OF NO.OF � CHECK
LicenseNomber J7a8a3 Lic.Clos�/ ! SIZE S70RIE5 FAMILIES ONE
�a vnwnnoN
Gon�rocto�N���`��� Dote � 1/V' DESCRIPTION OF WORK �D A D ❑ _ ` /�A O'�r
p�,,���,� \...7��
❑I am exempt under Sec �°i�'Z'
ALTER
8.8P.C.for this reason REPAIc � s -
USE OF /'
E%ISTING BLDG. �� �
Signature APPLPRINT7 �EO. � FINAL �� � �
ER-BU ER D CLARATION DATE
I hereby affir a�I am ezempt from ihe Contractor's License qpDRE55 2��09
Law for the following reason(Sec�ion 7031.5, Busineu and !• E pINAL �,
Profeuions Code): � By �1 4 2 1 A
� I, as owner of the properly, or my employees with ADDRESS ' , ��• . . o o �
wages os their sole compensat�on,will do rhe work and `
�he strucrore is not intanded or offered for aole(SeRion LOCALiTY ' � ' � ,� 3���
70d4,Business and Professions Coda). MOViNG TE�. .
� I,as owner of the propeny,am exclusively comracting 7enCTOR NO. - � 6 1 z�,�,_�`
with licensed canrractors to consnuct the projecr(Sec- � qpoRE55
� lion 7044,Business ond Professions Code). fl 9 O 7_S�
CONSTRUCTION LENDING AGENCY SFT�BACK YARD HWY TaTApROV.LINE WIDTIi
1 hereby affirm thot thera is a construttion lending agency for FRONT
the performance af�be work for which ihis pe�mit is issued P.L.
(Sec.3097,Civ.C.). � SIDE
P.L.
LendePs Nama ` IDMA Ref.M �
� P.C.fee S 7ermit Fee {, Q �
Lender's Address
� I cerlify that I have rood Ihis cpplication and sfate that ihe � lasuonce Fee LDMA P/C N
abova information is mrrxt.I agroe ro mmply wifh all Covnty Invsatipatlon F�e
$ ordinonces and State laws relatinq eo buildinq conatruction, Toiol fee Q Q LDAAH Perm.M
R and hereby outhorize sentotives of thia County to enter
� upon�he o �ve nri�e eny f r inapectlon��g � „ . _ . .
� 9 C•CJ f!�REVERSE FOR EXPLANATORY UN6UA6! �
SiqnaNn of PPIi<anr or A nt Doro
\
PLANS TO APPLICANT � � INSPECtOR'S NOTES OW'VF;K-HUILUF.B DfiCl.r\RA�PfON �
. I hereby nEf�rm I�iaf I am exernpi from iho Cor.imcror's
To: RaPurned � � . Gcc:�nse Low for rhe follqw�ny remon. fSec 703L5)
Approved �—�- Braiinacr and F'rnfe.ceior,s(;r�de:AnY citY nr roxnty�rbic6•.
No. Doie Na Daf¢ � _ � reyurrEr _p@rm�£ro�nrrs�rs�t�rtr e sr��r �l�rnnlivb,
.— -..,..�-_.. _� ' - --- �/ --nr J+,ranv.i'ru�tarc.p .. a u! r.y>a,res
--��:� rUJ-f�� f(: .f '.-•�'r. t�" / s �G�.�L !/y� �YfI�� eb� uffrloan[/rarsr�ch��ermtt�/ileus{ dstut e»t
� ihut 1 e u Geen�ed/ursuant tu!6v pn aiscnns nf tl��;an-
� ..... .... � ._._ :
_ ���r _.`e ''d���; ernclor's d.rrem t_/au�(C,.`bapter 91(rnrr m�n-ing u etf 1;ec�,
" � ` "' � �� fi�n,7(�T 0 t U�i�lrnn j n !Ge Busmcss an�l'P��(�ss'nns•
'__..,-,.- �_—.. - ... j w� .
r• , _._.r J f
J '�,1_I �, j�/. . � . . ,. .. . , , ....Cnd%�n✓tl��nt-f ��s.exc»i/>t tbere�runi and EI�c�fiasiYfur th¢ .
•� alle,qrd exenspAion.Any..inlulinn o/SerNon 7U31.5 ht .
Required Dafe Roceivrd . . .�>�l ahplicant Inr n Jrernri!sa hjads Ihr apph�un�tn�rir il
Apgrorab � � � panul�y n/nnt nror« tbun/�i c l+nndmJ dnllurs/d50pJ J.
Yes No or Approvad .
�_ .....-_..-�- '_�.. .'_—_ . ,. ,� �� ` � .1 �... ' �.i 1 ns omner af Ihe p o�e fy or m �:•mployeas w 1h
Y
i�hc ier C 1 core ` - - � � , �- �. . woges as their snle c.ompensoron,will do+he work,�nr. .
the strvcture is r.ot�nrended o ofiered for sale(Ser.704A)
Hcal'h Depanmem � _ .. pusinnss and Prn(¢s.eior�s Gbde:'Pbe Cnretru.��lnr's/.icensr
I,uu�Jne.c nrt ap/�lv tn un oumrr n�proper(y�rhn huilrh �
�'�� � � or irnj>rni�cs the�renu.and irhn Aor.r su��h v�nrk bnr:,eu!/or
Fire Depnnment � � . �
� , I!ruu,�G kris nirn-mnplqyees, prnrided tl�uF surh i�n• ,
Crad.ny �� f��-�J s r� � Qmeernents�are not intenJed <rr ii/�csed Jor sale. 7f,
",..;. .� ' '
_ _�, �_�_ !'� .J� bou nx�rr,tEra ba!ldtn,q nr impro-ue+nent is suld u�itl�iro nne
,:..�__. � . ' .
G ologitel -. . Vear q(cnmple4nn, tYe nwnervba�lder xcill ho-ee the
�� r�, .. .. ... _ . .. �. . n. _� , hurden nf prov:p,��Irrtf ba diJ nnt Guild or imprnrc,/r�r .
..— _ � ...� ' � .. �. � � .
Pedestrion Prolection ,.. , - , , ; tfic�urpase rf caleJ.
�Fc ce)�Ccinopy) - - L.1 I,as ow � of Ihe p aperty,am rxd�sbe�y controc�
Jing w ih licensed coi tracrors ia cunstrucl Ihe pro�et�(Sec.
Soe:lal I.speuion � � � 70441 73u.rlxesa und Prukssmns Cade: 'lGe (;antractnr's
.p,...
i�C�onc.)�Mosonry)(Welding) � a•__, h�cart.vfou�drsanta/rf+,(�arr�eunae�nerif�rnpert�yu�hu .
J . . .. , � � utldc. r i nhr<� s fGereon un!u.hr nlrrrcts Jn suib
lor�rainoge __.? � ( � � . .�r ri.c;a.pitfi u nntr¢rt,nr/sf l�u,n.aed�riasuant [0 1�e
Contru.tnr's lacewse 1,m<J.
Pnrkina
� , [..,.� �amexemptunder5ec ,B.&P,C.foriF�s
� ,._._: .... ..... reason
. .: . . ,-, . .._i � . .
, ....: � � �,_. Dnte"..._,.... ...:.,. .... Owner
Approvalz� Dote ��+spesfor's Signa4ure ��-- � . �-�� . � � ��� ' - �
INSPECTOR'S NOTES
—..�— — � '_ �
local;an-- .
jSeYoaek&Yards) � - �
F'oundations�� . . . � . .
SIOF] � , - . . . . '
Frnme� . . � . � . .
Ensrgy Ins�{at�on � � . _
LO��l%�YYWp��-- .
Inie•IUs
Larh-Exterlor -
. -_., �,.,�`.
HCUSP NUrtlk>Br... �-�� - . . +�-_
Correcl&Pcsted
F�noi_ � _ . . .
Ente�on Fron! '� ; .
..� .�� � _ • . .. _-__