HomeMy WebLinkAbout1737A 1738A � WORKERS'COMPENSATION DECLARATION . ` � �.
I hereby affirm that I have a ceriifica�a of�o�Sg��,a��f AF�PLICATION FQR BUILDING PERMIT �
,�insu�e,or a ceriificote of Workeri Compensation Insurance,
or a certified co thereof(Sec 3800,Lob.G) �
'�3Wc005-2'��-0016 Natiornvide COUNTY OF LOS ANGELES BUIIDING AND SAFETY
❑olicyNo. Compony
Cor7ified copy is heraby furnished. FOR APPIICANT TO Flll IN BUILDING
ADDRE55
(1 Cerlified copy is filed with the county building inspec- eUIIDING
��J fi0n d0pariment. ADDRE55 626 A7CmltOs P1dCE
�1e 7-30-87 APPlicanr T�' ANDIN Gfa.7UP arr Dlamond B3r ziP 91765
wcuirv
CERTIPICATE OF EXEMPTION FROM WORKERY � NO.OF B�DGS. NE,4RE5T
COMPENSATION INSURANCE SIZE Of LOT NOW ON LOT CR0.55 ST.D1clIllOT1C,� BdY' BZVCI S� GOLCIP_Tl S rin S
(ihis section need not 6e completed if�he permit Is for one TR,qR 42579 B�OCK LOi NO.28 AUE55OR
hundred dollors(5700)or less.)
MAP 800K PAGE PARCEL
TEL. USE ZONE ' Nu4F
I[ertify thot in ihe performance of fhe work for whith ihis ��ER N — I1`1 No. i 17-3'-/9
permit is issuad,I shall not employ any person in any manner R � SPECIAL
so as to become su6ject b the Workeri Compansation Laws. P.DDRESS P•�. BOX 3329 Q O(� CpNDITIONS O
/'lte Applimni QTY V� ZIP a
9TICE TO APPLICANT: If, ofler makiog�this Carfifimtc of ARCHITECTO �E�� DISTRICT GROUP Q7E�T ��E PROCE@SEDBV O
Exemption, you sho�ld bacome sub�ect to ihe Workeri ENGINEER `�ave SZdri AIA n,o445-4073 +�
Compensation provisiona of the Labor Code,you must fonh- qpDgEg 314 N. F'1TSt.� Arcadia 91006 l0 � R-3 IV �•� 1 a � W
with comply with auch provisions or this permi� ahall be d�
deemed revoked. TE�� STATISTICAI CU155iFICATION AFL CONDO. (n
CONTRACTOR NO.
LICENSED CONTRACTORS DECLARATION ���, C1A55 NO. � DWELL.UNITS� Z
I hareby affirm thot I am licensed under provisions of Chapter 9 ADORESS AS auOV2 No510560
(commencing with Section 7000)of Diviaion 3 of the Busineu and , ��� SEWER MAP
Professions Code,and my license is in full force and effect. CiTV C1n55 S BK � VAtIDATION
510560 B S° FT1535 NO OF n,o.oF CHECK
License Number Lic.Class SIZE STORIES 2 FAMILIES �- ONE
YALUAT ON
Comroctor� �DIN ��UP Da�e�-30—$� DESCRIPTION OF WORK S1T1 le famil N� s 7�,090
❑ ADD ❑ ►
I am eaempt under Sec. �
AL7ER
B.BP.C.for lhis roason REvnIR = 7iJ,��1 , �1 7 a 7 A
Date: USE oF DEMOL �y . .
EXISTING BLDG. ft• '2�
Signature APPUCANT T��� FINAL
OWNER-BUILDER DECLARATION PRINT NO. . DATE I ���� � '2 6�,6�
I hereby affirm thot I am exempt from tha Commctor's License qDDRESS r+S �70Ve /�7'"'"" - • 4 2 6 Q 6 1 c=i
Law for the following reason(Sectlon 7031.5,Business and FINA�
��ofeuions Code): � � 6y
JeuaoiNc 0 9,1 6—8 7
I, as owner of tha propeny, or my employees with ADORESS
wages as Iheir sole compensation,will do the work and �OCALIiY ,
the siructure is not intended or offe�ed for sale�Section
7044,Business and Professions Code). enOVinlG TE�.
� I,as owner of the property,am excl�sively conhacting CON7RAROR NO.
with Iiccnsed mntractors to construct the project(Sec- qDORE55
tion 7044,Business and Professions Code). }^- � 7 3,�p
CONSTRUCTION LENDING AGENCY �gq�K VARD HWY T�TAp�p��NE WIDTii
I hareby offirm that there is a construction lending agency for FRONT �� � � � � �
Ihe performance of the work for which this permit ia issued P.L. I •�,� �5 O
(Set.3097,Civ.C.). SIDE
V.L.
lender's Name C1�1ba17�C • "y.� �.5��
LDMA Ref.M
m Lender's Addres`�44 S. F10W2Y'� L.A. 90071 P.0 Fee E 260.61� pe.mo Fs� 402..0�r ' 0 9,1 6—�7
� I certify that I huva read this applico�ion and state that the �ssuonce Fee �.�.S O . LDMA P/C N
a6ove intormatio ' orrecf.I agree to Comply wifh oll County In�estiga�ion Fee
ordinances an f laws reloting fo building co�sfruc�ion, _ 7mal Fee �{].Q�.50. . �onsn rm�m.r � -
ond hereby t ize representatives of this County to enisr
$ upon tha d property for inspection pu oses. LDMA �—
$75:00 $35.00
SEF REVERSE FOR E7(PLANATORY LANGUAGE
� Signature ot pplicont ar Agent o�e � � �
PIANS d0 APPLICANT INSPECTQR'i�1QTfS�- 01VNf'H-RUII.UI N UF:CI.IKA I tUti
I � �by n9�- ,ha!I a �F�.,t t� I�r'„�, . _
To: Radurrn6 � . I�< :e Law toe thf (ol,,w i q r tSec �'7�1�5
�PProrad --- — Bus -.�anrl!'r.�/��sciuns Cndu:An�r:�ciry nr���uaty�ohecH -
No. Date ko. Dotx . .. r�,yun u prn�rit tn�.n.�fn�ct.�Itr��..impr� �,d�•in.,li.sh.
�� r �rr
...__'—_--" ._._�.... __' _' .
. _.---. .:�__.. — �---- - —_—_ <�r .�,�ir�nv.���ruc[ur��.pnnrt��rtsc�ei�,�m.�.�Ltr.r�yu�ro<
. � . r)e u�J(ic�r�!Jor ucb perroit[o frle a fi,q��ed st�denrrr�l
' - --- Lha:br k licensrd pursuunt tn ibe prorLcinn.c,�{d�<,C.'un-
. � . ' � . - trartnr's l.i��una�r l,u�<�(CG��pfrr JI(cr�mnaersrin,c u�itL.Suc-
— ' . linn i0001 of Uiris6+n i n%thr liusiness und Prnfv,vainns
.. �- . . . . . .' . Cndef nr xh�t he is c.rcm/�t tlrermJrnm and�Gr,ha.��ie�/or Ibe
allr,qcd c mpGion.AnV vi��latinn n/Sai-�inn iV�37.5 hM1�
ReGulrad bcTe R�eeivod . anyup/�Li�un!fnra jrernril snhjei7sJheapplrr:a�l fn,��iril
Approvolz or Approved- - . pettullv nI aa(nrnrc tAun fire lrnndre,�d dn!lars/SSpp/.1:
Y�c No
�.___ .�.. . . . . . �, ' I,�s owner of rhe p�o�xarfy,or mv employee+wilb.
Woter Cernfit.nie � . , . � � . , woqes as�he�r sole compansarion,will de th5 work.ond
- _ , the srruclure Is not iniendad o�offerr^d for sale(Smc 7044j
Healih 6eFarrment. . . . . . . . . 4ui�rners and Pru/a:ssions Cadr:%7m Cnntraa��or'sl.icense
. . _ I.uxt�dnes not�epply m a niancr qJ prr�pertt uG:i huilds
Pire DePanmam . - - . . . or imprn re:s tJ erenn,und�ohn dae.c sati�u�ork��irre.ce(���+�-,
� . - , . . . , 1Gruukb�/Is u�vn erxpl�{1'aes, pi�n+�ideJ tfiut s�il <
Grod�.ny ..� . � .....p�mmmenn rvv ant intended u� ��JJ< �d 1or sule. 11,
.. , . . . . . � hnu ever,the 6reildin,�or imprnncrorent es r�utd rrilbin nne
Geo�oyical , Tear n/cnmpleeiutt, the nwner•baildrr aoilJ fiov�<� tk�e
� . . . . hur1len n/'prn�dnX thu!L�Jid nu�hr�:ld nr irnprore/nr
. . tl e purpusv�iJsaln/. � -
Pede;irion Protection . �
(Fence)(Cano�y) � � - � . ���� ) I,�us owner of rhn pro�aerry,am e d,,islvely con'rnc�
� liny w�A��Iir,ense��3 contrauws to consfr��cr 1h[�P�ol�cf(Sec.
SP�clnl�n�spcction .. - � - ... 7044�O�avno.c��and Prn('ssieras Curle: 7'1 c Cunlra<'1nr's
_ (Conc.)(Mason�y)(Weldingl � � � l.i�ense I,a«�dnaa nnt unply tn qn nu�nrr if prnpertv u•l,ro
� . . . . . hui/Js nr rrnprnres I!>eseun,an<1 u�Ln ronlr���L�Jnr.s�<.! �
lr,r Droina9e ' . . . prnjects.wiab a cnnlruttnr(.aJ lerernsrd partsaan[ tn tbn
� Cnntra'tnri I,ieen.or•l.a�t)• .
Parkicg � � _ . . - . . .
. [,,,.�'�, I arn exempt undr.r Sec. ,B.&P.C.fo.this
reasan
Dnte - � � � Owner
Approvals � Dato Inspecfor's Signofure .. �
. . �INSPECTOR'S NOTES
.ro!ior��. ,'�
ISe�buck R Yards) �� �� �d f�i. �� � �_�
FOU;1(�C]I�O�iS � _ .
5��,.5� �._... _� ,._. . _...
' .•�--`......__,e°.} —_..^.._ . . . . . _-- - .
Frame �I�i.7ti �£'� /!�j!,-,,.. . . .
/ V'
T�
Fnergy�nsulo+ion �/30 � , �
La!si;Drywali_. I �� 6`I� . . . . ... . . � � —
�a�er�cr � � � - '
lnrh--.E.rer�nr �Z�7 ... /?/�i. . .
_'__f�'
Hoa:e Nurnber_. . . . . . , . , . ..
Cnrrect R Fos•ed ��
i�ir.ni� . � . . �
Em n Fro
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