HomeMy WebLinkAbout1761A 1762A WORKERS'COMPENSATION DECLARATION "� '�
I hereby affirm that I have a certificale o,�o�se��,o se�t � APPLICATIOIV FQR BUILDING PERMIT �
-inwre,ar a certificafe of Workers'Compensafion Inwronce,
or a cc�rifled m y thereo4 Sec.3eoo,�ab.C.� COUNTY OF LOS ANGELHS BUILDING AND SAFETY
7�Wr�005-2�19-001� Nationwide 2 C
Po icy o. ompany
� Cer+ified copy is hareby furnished. FOR APPLICANT TO FILL IN BUILDING
ADORESS
� Certified capy is filed with�he couniy building inspec- BUit�iNG
tion deportment. ADDRE55 598 Armi.tos Piace
Dato . 7-30-87 APPlicant T� �IN GROUP CITV D1aIf10I1� �dr ZIV 91765 IOCAIIN
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. NEAREST
COMPENSATION INSURANCE 5¢e OF t07 Now ON�07 CeOSS Si. D1dI[IOrid BdT' B1Vd & GOLC�211 Spring
(This seUion�eed not be mmplerod if the parmit is for one TpqCT 42579 BiOCK LOT NO. 19 �ESSOR �
hundred dollars($100)or(ass.) NWP 900K PAGE PARCEL
TEL. USE ZONE MAP �
I certify�hai�in the performonce of the work for which this OWNER NO. — NO. � '7- 3y9
permil is iasued,I aholl not employ ony person in any manner ADDRESS P•�• �X 3329 � � �ECIAL �
w as to become su6jecf 10 the Workers'Compensailon Lows. Q�� CANDITIONS �
GTY �.'OVlI13 ZIP 91�]22 - U
l���e Applimnt ARCHITECTOR TEL. �
JTICE TO A�PLICANT: If, after moking�this Cerfificofe of EN INEER DaV2 .SZdIl AIA r,o.445-40�3 DISTRICT GROUP TYPE FIRE PROCESSED BY 0
Exemplion, you should become subject to �he Workeri (� CONST. ZONE y� F-
Compensation provisions of�he Labor Cade,you must forth• AODRE55 314 N. F1x'S't� Areadia 91006 �Q 1'�3 �N � '1 '1q�0(�� W
with comply with such prwisions or this permit shall be p.,�
daemed revoked. � TE�� S7ATISTICP.I CIASSIFICATION � APT. CONDO. fn
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION � ���, CtA55 rv0. �d DwELI,UNrtS} Z�
I hereby offirm�twt I am licensed under provisions of Chopler 9 AO�RE55 � abOVL' r.,o 510560
(commancfng wlth Section 7000J ot Divislon 3 of the Business and ��� ��R�P
hofessions Code,and my license is in ful�force and effact. CITV CIASS B VALIDATION
510560 B 5° `� 1314 NO.OF 1 NO.OF 1 CHECK BK. PG.
LicenaeNumber Lic.Closs SIZE STORIES FAMILIES ONE
VALUATION
CoMraclor T� �DIN GROUPpate �-30-87 DESCRIPTIONOFWORK Sl le famil - N�" s 68�z�Q ��' 7�' A
ADD
❑I om exempt onder Sea A 44S SF A�R � , �• • • •2�
B.BP.C.for this reason REPAIR ❑ s � °��3,8 4
DOta: USE OF
EXISiING BL�G. DEMOI ❑ • m�u�,U j�_�
Signature APPLICANT TEL. PINAL
OWNER-BUIIDER DECLARATION PR�NT n�o. ppTE � �..�"/�SS 0 9.1 6-�7
1 hereby affirm Iha�I am exempt from�he Contractor a license j�S d2�OV2
�ow for the following reoson(Section 7031.5, Businass and /oDRE55 FINAL
� afessions Code): 6y
JBUILDING
I, os owner of fhe proper�y, or my employees wifh A�DRESS
wages as their sole campensation,will do ihe work and :�� '�Q 2 A
Ihe siructure is nat inlended or offered for sale(Section ����T� �
7044,Business and Prafeasions Code). MOVING - � TEL , *}• . ,e e • �
� I,as owne�of the properly,am axclusively caniracting CONTRACTOit NO.
with licensed tontrattors to consir�tt the projatt(Sea qDDRESS � '�7 C,0�
tian 7044,Business and Mofessians Code�.
CONSTRUCTION LENDING AGENCY SETaBACK YARD Hwv i07ApROP lWE WIDTH " "'�� �����
I hereby affirm�hat there is a mnatruction lending agency for cRONT
�he performanca of the work for whith fhis permif ia issued v.l. ��',� �J��7
(Sec.3097,Civ.C.). SIDE
Lendar's Name
Cltl.barik v.l.
444 S. F1�P.T' L.A. 90071 v.c.feea 233..84 permitFae 36�-.SO - ��`Ref.k
Lender'a Address � , '
� I certify ihat I have read this application ond alate thot fhe lasuance Fee 1 Q+50 IDMA p/C M
obove information" corroct.I agree ro wmply with all Couny in�estigarion Fee �
q ordinonces an te lows relating to building construction, To�al Pse 3 Z�L�.OO � LON,q Perm.N
r and hereby �'e representativee of�hio Counry�o enror
� upon ihe d property for inspecl� rposas. .
� �I,/ fFE REVERSE FOR EX►LANAiORY MMGUAGE
Siqnatu.e of Applimnt or Agent� po�e '
PLANS TO APPLICANT IHSVECTOk'S N0T4s"' -- - OW'Nl;R-}3UILUF?R I)1!CI.ARA770�'
I h by cff - . I . � .pi t c Cr,r+�t..
To: � ReRurrMd � . � � . � l.c�i L� f �d.c fnll r a .� ;S c. 7'1�1 ;J
APProved /3r si� a rnd!r 1 . n ( d An�c�l r aunr}i i G
No. Oate Na. Dnt¢ � . .. � reyu�rrs u frrnr>t.t���unaf A�ltrr,, n( ..r��.d t L�.
...—.....—._'-_�=�-- m r�, ditru<turr, !�,rts�c �
.__.—__.--.--,- _.---- rairun . p .��i.e,uls� I .
— ----- �-- - � n•r r.�rev
. . . �l c applicent!nr sacb permit tn fLr�-rz si,ened stnEemew�
. _ . ._— . - thai Ge is liconser_!pursuan t i��1l�e pr.�ri.��inrts nJ 1he Cni�-
� _ .. � � . � trnifnr'al.rn•nse•l.uie•/Ch.�pin�r+JJkmnm�mcin,q�e�i16�5r�=
-- tir�n?00{I/n(Uirivioa 3 n(tbr�13vsirir.cv ar+J 1'rn/rcairms
_... .... . � � . . . . - . .. - �_ CndcJ nr that h cv escm/rt thesa/runi�nd tbc Aa.ci.c/ur(br
rrllvKed exempfion.Ani'rL�latinu u/Se<tinu ,.'f131.5 b�.
�� 'Requlred � ... . � ' urtV�h/+Iicdntl�raJ�crmits��hjei6�llrenppliu�nrin,�.i�.�il
A ovals Da4e Reteived
PP� � or Approved � penalFv�i/�nn!m��rc Chun/rrc_Gundred dullurs(SSf1UJ.).•
Yac No
� . � � � ,... I,os owner o(rhe proCirrry,or my emplaye=s wnh
WnrAr Cc+nlP�a�te .- � ! . .._ . - , � wcrges as lhelr ynle rompensahon,wJl do ihe work,nnd
- ' . the skucture is nnr imandr.d u�offe��r.d 4or sole(Scac 7U411
Health Departmenr .. _ . . � � -. . . . . . _ U�ainess unrt Prn�e.ceinns Cudr:TI>e Cnntr�rrnri l.i�s;nse
�___ . � l.uu�dne�s not uppfv tn un oirncr nJ psnprr(v�rba huilds
Fires DePoriinent _ .. . ��r irnprnr�es t6cre��n,ond u�brr rines s�ocb u�nrk:Aimsell�'"'
. . . 1Grriu,qL� h�i' nu�n ern/il�il'�'�'.+'. pruriJad tbut sucb.�
" Groding �� , . . . prni�rmen�s are nnt in1 nded ��r �ryr J/nr eale ./)
Lnne e��rr,tba bvildin,�nr nnJ r nevunnt�s�uld u•it/irt one
Geolo9lml . . .. _ year nf mnrplstion, t.Ge nu�wer-b�eilder ari!!I�are tfre
_._ � . � heardvrc n/frnvrn,��brr1!•e did nu�Goeild or inrprore Ir�r
. . � tl c purpusn nl.�alcl. .
f;eclwercian Pro+act�en . . . . . . . . �
(Fr_nce��Conopyl , � � � � .., I,bsownerofthe�rqpertp,ameK::lus�ve�ycnsxroc�
_ — ling with lieensed cantrvcrors io<ansGuu�he pro�nci(Sec.
Sv�clol irspection . . � . � - . .. 7044J�r�sinn.aa�and Prn(e��.�rnr:.e C��dr: 77�r Cnnfrn�tnr's
�Cr.nc.)(Masonry}(Welding) � - - . - , l,ice�s�.ce I,nm dnes nni applyln un birner uf f�rnpertl���/n
.. ." . - . h�uilrls or imprux�ns IGur'enn,auAu•bi�rnrztructs Jora�r�el
Loi�rolnogen . . . . . _ . .. .. prnjectr aitJr u n��ntructnr(sJ 7itereseA pnrrnant to �8e
� Cnnlrartnr'.r I.icon.ee f,auy. . . -
Parkinn - � - � f-1 � '
,. I am caempt under Sec .B.&P.C.fo�tbis
reosan
—� Date �Owner
Approvals Dote �nspec}or's Signature � . � •
� IPifiFEGTOR"S NQTfS
--- _�...�=- —_...�.�- l-
Lo<n�ian.._ � :1,p+ �
(Seiback&Yardsl � � � �d� '.w'µ�� '"� � ' �
ao:,�,dm��o„5 I .. // 3 �"J� j3'l�$ � ---
_-----4-- -
si�h - I � � �
F,��,e �� � �+— ��
Er�ergy Insulol��on ,6�a G.J - � � - . . .
LA _� __
l.arh;U.ywall-� /��2 7'7 -��V`�y �. � . ._ . `
In�crlor � �
�.�ri E .,��� q a3�fr'y � . _
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H �,«�N��.,nP,_ _ --_-_
c�„�:�,s P�si,-d �;
����n�� �
�Enter Qn Annf - -
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