HomeMy WebLinkAbout1035A 1036A WORKERS'COMPENSATION�ECLARATION -
,�s�;e orofcartifca'teofWokenr'Compenaa�ion�lnsurana" APPLICATION FOR BUILDING PERMIT �
or o certif�ie�d�co(�py�ih(e(r�eof( 3600,�ob.c.� �OUNTY OF LCS ANGEtES BUILDING AND SAPETY
PolicyNo.[1l=1-Co��any ��o�i. �-C//1�
❑ av' v FOR APPLICANT TO FILL IN BUILDING n� � �
Certified co is heieb furnished.
ADDRE55 � I �i M � �
� Cer�if�ed copy ia filed with�he county building inspe[- BUILDING r- �C
tion deparfinent. ADDRESS Z � 7 US L M�L/S p! �� .��
Dafe ��APPlica�.x--�� �� CiTV +i— .a.� QFv� ZiP LOCALITY
CERTIFICATE OF FXEMPTION FROM WORKERS' NO.Of BLOGS. NEAREST
COMPENSATION INSURANCE SIZE OF lOi .,,,/ NOw ON LOi / CROSS Si.
(This section nesd not be completed if ihe permit is for one 7RACT J�°"�1 g�p�K LOT NO. ! �ESSOR
h�ndred dollan(E100)or IBss.) MAP BOOK PAGE PARCEL
I cenify�har�in the performcnce of rhe work for whlch thia
OWNER � .S�n �p.�jp, USE ZONE NO. ".3 3
permi�is iss�ed,I shall not employ a�y pano�in pny manner q0�RE55 � �. ONORIONS �
so as to become subject to ihe Workars'Compenwtion Laws. Q
U
Oote Applitont � CITY ZIP � �
NOTICE TO APPLICANT: If, after moking�thia Certifimte of ARCHITECTOR ?E�. DISTRICT GROUP 7YPE FIRF PROCESSEDBY O
Exemption, you should beCome aubjecf to fhe Workera' ENGINEER NO. ONST. ZONE U
Compensatio�provisions of the labor Code,yo�must forth• qDDRE55 � W
with comply wilh such provisions or this permit shail be ' n-'
deemed revoked. G✓� �.GaS 5-�-�.-�TEL. STATISTICAL CIASSIFI TION APT. CONDO. Z
CONTRAGTOR �U NO. �p�
LICENSED CONTRACTORS DECLARATION � ���,(� �7 CLA55 NO.—L�WELL.UNiTS ^�
I hareby offirm fhat I om licensed under provisions of Cbapter 9 ADDRE55 /it c�� NO.T ! � � �yER MAP
(commencing with Section 7000)of Division 3 of the 8usine55 ond ` !���. IIC.
Professions Code,and my license is in foll force and effett CITV �✓�` CV+SS BK � VALIDATION
� � SIZE� 5 ORI�ES FAMILC,IES CONEK
Licanse N�mber '-}� � �lic.Class� .
/ ❑ VALUATION
Cantroctar��Gs� (�1rL_g Date DESCRIPTIONOFWORK � ADD ❑ s 1 .6a ,
�I om exempt under Sec. v ❑
� �1035A
ALTER
8.8F.C.for rhis reason I� G� v r) ra� REPAIR ; # • • • •2 3
� Oate:.,r.#..�rl ,� / USE OF `i !2 G � •z EMOt I • •Z�O O
E%ISTING BtDG. J
g;���}„�� � APPIICANT TEL. `�
� O R-BUIIDER DECIARATION PR�N7 NO. DA E`i G � �' •2'S'O O c=i
I hereby affirm fhat I am exempt from the Contradw's license qppRE55 fl 8,�G-�u 8
�pw for ihe following reason(Section 7031.5, Business and FINAL � �
1k Professions Code): � oy �
❑ B111L01NG I
1, as awner of the property, or my employees with ADDRE55
wages os their sole compenwtion,will do the work and- � �
the structure is not intended or offered for sale(SeUion ���iTY
T0a4,Business and Professions Code). MOVING TE�. � �1 0 3.6 A
� I,os owner of rhe property,am exclusively coMracting CONiRACTOR NO. ���Q
ru
with licensed commctors ro consfruct the projed(Sec- �'•+ • • • �
tion 7044,Business and�rofessions Cade. ADoeE55
REqUIRED TOTAL SETBA
CONSTRUCTION LENDING AGENCY �T gq�K YARO Hwv pppp,�INE WiDiVi ��2 � � �'J b'7�
I hereby affirm that there is o cons�ruction lendinq age�cy for FRON7 r x
the performante of ihe work far which Ihis permif is iuued P.L, �' �'3�� ��'�%
(Sec.3097,Civ.C.). SIOE
v.i. D8.22-88
Lender's Name �
a`•=S IDMA Ref.8
Lender's Address F.C.Pee f �''� Parmii fee
� I Certify thof I have read this application and slate thaf the Isauonce Fee ,Q�� LDMA P/C M ' �
o6ove information Is correc�.I agree�o comply with all County Invesnganon Fee y �j c
$ ordi�antes and State laws relating to building construction, To�al Fee d� •/ v IOMA Perm.M
and here6y authorize representatives of Ihia Co�nty to enter
n upon iha o -�ned propany for i�spection purposas.
. ��"�� ��_�ZZ_ J� SEF R@VERSE FOR EXPLANATORY LANGUAGE
!J
�-�—'��3igrrfure of Applicon�or Agem �ota
PLANS TU APPtICANT IN3PECTOR'S NOTE5 U�'��`�'•K-6LqI.DFK UE'CLARA'1�101
I hereby c�ft��m rf�ol I mm �xem�t�rom the Conlronor's
To: Wetwned � - . '.k�nse Loe'v Eor nc� foliow ng +ca�on. (Sei. 703�-_:��
_ APprovad — � lTusrnecsr+nJ!'rnJi�-cdonsG�dv:.9rsvcity'i�rwurctv�ohich
No. Dote Ne. Dat¢ � Teyuirer u.rern+it[n cori.clruvt,uker,irnJ�rere,darrrralial.
, . "" —� i.._ ' - ur rapairam�,srructurc,pnnr du�tc u.n� �u.a�str rey�eares
__..�-------_ �_.---�-��---
. , � , � � �l P u(�ylicunt fur rerh perniia to(ilr u srKrted sFate�nen�
.�. _ __._..._ —_._ _.__T....— - _ . . =. — tbui be�s hcenxed purxu�n!tr the proe ni n. �(the Can-
. . ., . . ' � - ._ .� � .. . tr¢�fnr'�7�rettse Laii/Cl�aphr))/��.mmcncing n�i7L ScC
.---.--- . - �--_ ----- � tiun 7O0!!J nf Ui��lsinn 3 uj'tbi�Hasin,c:rs qnd/'rnfessi��ns
_ . , . . - • . .-. .� . ; -C��i�eJ nr tbut be!c exene/rt 1Lerefrun�r nd 1/c brrsis fur thr
aReged exenipti�n.Anv nin[ufimm�J.Scr[Inm?(1if.5 bs
HeRuir¢d bafe Raedvad � � �nv applicpnt/ora pvnrit u hj«4ts the appkc¢��ro u�.i�r!
Approrals Yst No or Approvod , ... penulty o�nnt mnrc thun/�a c hundred dultars/CSppf,J•
'_,�_...--.-- _�.�...--�.,_=:__.'_- . �� �,J ..�,�5 owner oF the properfy,or my nmployees w�l+h
vVat=r(�erriflcnre - � � .. _ � � .. � wages as their sole compensolion,wlll do ih�work,an<i
� � � - ihr:arrucWre is rn�mtended o offered for iolp�Sec.7Q44'�
'Ne.olth Denarvnent . . ' � . . (lariness unJ Psnfc�ssin�n(r��:'!%>e Con[r�c tor:s Lr�ensc
_. . Lam ilnes nat upplv tn mi m�ner o/pmperty ir/rn huihts
Fi�e Deportment . . - or irnprove,e therena,und u�bo Aoes siicb u�orb hin�.celf or
_ � � tbrnu,qG bis nu�n ernhloyces, prnrideJ tbat surfi i�m
Groding . � � . prnt�emuats nre nut intended br ujferad/or s¢fa /f,
� � hnu�aner,tbe SuilJin�y or empronemanF issold�vit5inbne
GeoloyVmi � - . . .. � . .. . , . . . vear n/cmnfrletinn, the uwner-buildvr xri7!hai�e the
� 5ur�len nf prnoin,�t!>nt fie dirl rta1 bu�ild or irnpmr�e fnr
Pedestrian Pro�ecflon ,. . Lhc purhose nf su1eJ.
IFence)(Conopy} - � � � � - � � � I,asowner o4 the property,am e�cltrsively coniroo-
, fing wrth licensed contracrors+o construct the projeat(Sec.
Sp�.c��oi Inspecrlon - - . . - 704aj B�esinau und Prn/essions Cudr+: 7`bc Conlra�tnrS�
(Co�c.1(MasonrYi(Welding} � Lreers.�e Lau��lnes no!�Wpp17'to un�hw�ner of pruper(v a�ln
hurldc nr irmpro�,e.s f7ereurc,und�u�f.�o n+ntructs fnr sr�ch
Loi Dromace , proje�cts u�itb a rnntructar(sf/i��rnseJ p��rsuunt tu tGc
" . . Contrntfor's I.itenae l,au�J. � .
Porkin3 � .. I,� I am�xempr under Sec. ,B.&P.C.�ur Ihis
� _ � � raason
� � � - ' �� � �ote Owner ..
Ap�*ovals � Dofe Inspacior'�Signafuro � INSPECT4R'S NOTES -
tomilon-
�Seibuck&Yards) �
Fo�rdo!ions -
Slab
Frome ' � � , � �
Fne�rgy�nsulation ��� . �
La1h;Urywall- '�—'�—... . . . . �. T` �
In!
la!h-Exterie>r �� ^'{. . �—�^ !^. .
.,__..—.. _._._..�.__ . .
4-Invse NumF.e.._. . � .. --
Cc�a�i 8 Posted -=,=� . . .
F �I-
C.te�� F .nt _ - � _ �_
—._
�--____����.��_ -_�l: ___� -, � �