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HomeMy WebLinkAbout1578A 1579A (9) ... WORKERS'COMPENSATION DECLARATION ._. . . ._ "_. _.... . . ,. _._.., _..._... .... _ . _.. . .. _ .... ._ ....... . :._.. .. ... '- - _... .. .. or,a certified co thereo4 Sec.3B 0�t 6 C)� �� NTY OF LOS ANGELES BUILDING ANO SAFETY � �� ..��� I here6 affirm ihaf I have a certificate of tonsent fo self APP_LICATION��FOR .BUILDING PER_ MIT_ � �_ � insure,or-o certificate of Worke � on Insurance, . PY ( . COU WCP6255241 ' Great American Plan 3AR PolicyNo. Company - -�� /� . , � Certified mpy is hereby fumished. ' ' FOR APPLICANT TO FILL IN AD�RESS �.l �' .Ud��C" � .Certified topy is filed'with ihe counly 66ildinq inspec 6UILDING ' 'tion deporlment. ADDRE55 t� The.Wm..L on Co. Walnut 91789 Date �� lZ-ZZ-86 APPIicoM .. Y cm zir ' iocnircr : � '� � CERTIFICATE OF EXEMPTION FROM WORKERS' ' '-� -- -NO.OF B�DGS.� � - -��� -� nrEnee57 �- � � � � --- -- ,.,. . . . , . ___ .. .. ... _. . .. ,� �� -� -� �''�COMPENSATION INSURANCE � 5¢e OF�OT 3 800 SF Min.Now oN�or 0 � cROSS Si. ... hundred doll�eed not be completed if fhe�permit is for one �--� �� -- -� AUES50R. �-� � " " This section TRACT BIOCK LOT NO. N,qp gppK �" VAGE PARCEL ars(5100)or less.) .. .. . . . �P ` . TEL. �$E ZONE � �� � ���� '-�� � _--- - OWNER THE�WILLIAM LYON C0. -Na833-3600 I certify�hat in the performance of ihe work for�which this N�� a Dme A� IimM• ,, manner - � SPECIAL -- - � O P PP Y Y n laws. ADDRESSI9 COt OTdC@ P1828� ' '" ' '�"' CON�ITIONS . V OTICESTO APPLIICANTnIfeaP�rYmokneflhs'Cetifi ��TY Newport BeaGh� CA Zip 92fifi0 ---- - � �• - � - - , � ---- - - �K s6 as to become subject lo the Workers'Com ensatio ,m ensalion rovisions of tha Labor Code, ou mu � ARCHITECT OR TEI. �y ` mfe of ENGMEER t�ales-Langston r,o. 547-0862 DISTRICL. GROUP NPE- �_ FIRE _P O SSED BY. � { '�mption, ou should bemme svbject'to�ihe Workers' ----�� CONSi. ZON � p p � y Stfollft- ADDRESS]7] S. Main St. Ste. 105 Oran e � � - � °' p y - p �his�permit 5holl be -- �� TEL STATISTICAL CUISSIFICATION ' APf. CO 2 de med�riICENSEDCONTRACTORSDEC, S8[OE AS Owner � � � �� . CONTRACfOR NO. . __.._� �/ ' . __ .._ .. . .. . � - - ��� CLASS NO. � O DWELI.UNITS=L[_ LARATION�. ..,.. -.. . . _.__ . ._... ._. .. . _ _. . _.uC. - .. I here6y aifirm Ihal I am litensed under provisions of Chapter 9 ADDRE55 NO. (commenting wiih Section 7000)of Division 3 of the Business and _. LiC. ' ��R�P ' � _ ... . ...... . . .... . . ._. .. . _. Professions Code,and my license is in full force and effect. Citt Cit+55 " �BK: �� �� �` � - - '- -� -VAUOATION ' . . .� . . . . � .�. . _.__._. 5�.FT. /:-' �.OF _' __ NO.OF. .CHECK_.; licen5e Numbe/ 2�6801� �� -���,Class B-1 � SIZ . STORIES FAMILIES ONE � - - � . . .. . .. �.. �.:..:- ` •.�i � VALU TION'. � . . . - - The .Wm. Lyon Co. . 12-22-86 -- oescaiPrioNLrWoaK . _ _ _ .. - NEW � . ' CoMracfar Date ADD s O , _ . _ . . ❑I am e,cempt under Sea in 1 fami 1 home construction A�rER B.&P.C.for this reason � . . � � -� _ . REPAiR -S - -_ ..__._. .� . _ . . ... - - ___. . __ _ . . -.-. .Dafe: __ _ E%ST�iNG BLDG. DEMOL _ . . .. _�� .S�I.S F .. . . -' """ APPLICANT TEL ' . .' ___'_ _. '__... - $ignalure PRINT ' NO. _ FINAL ' #• • : •'z� OWNER.BUILDER DECLARATION ._. . . . . ._ . _ -'DATE - ��'. . .-_....-_... .. ._ .. _ . ' -I hereby affirm�hat 1 am exemp�from the Contractor's Licanse • . ..... � .p 7 6 6 8 law for�he followirig reason�(Section 7031.5,Business ond ADDRE55 FINAL � "Professions Code): .. ..�_.._ ..._ ._._..._._. ._....._ .._ R � . -� - ' . . . �,L-1 BU4�ING . BY � • •2 7 G 6 8 c=.o�. r��' I, os owner of fhe praperfy, or my employees with ADORE55 , � .' . . -_ .- - - , � ' �wages as their sole compensa�ion,will do ihe work and ��-� ' � ' � 2 3� -�f7 . �� ' Ihe sfructure is nol inlended or offered for sala(Section _ ��!��7Y '� --��7044,Business and Pratessions Code). ...' . .-- MOVING. . .. - . ..- ". . . hL. - --- '. '' �� . , . .. . ... . , ...��1 5�.Q{� ... �_ I,as owner of Ihe property,am exdu5ively tonlractin9 . COMRACTOR - . . NO. ... . -.._ _ ..' .. � ' � •-• • " wi�h�licensed coniractors ro tonstroct the pro�ec�(Sec- qooRess � ' ��� � � � fion7044,BusinessondProfessionsCade). � �-%� - =��1,����� � ' REWIRED YARO HWV � TOTAlSETBACK . .." -' -'.- -�..' 'I-�LI'7 J�.�O -�-�� --- CONSTRUCTIONLENDINGAGENCY - " ' �" sersqcK 7ROP.UNE wiorH` - � �� _ I ,. � 1 hereby affirm�hat there is o construc�ion lending ogency for FRONT � - " - ' -Ihe performance af ihe work for which thie permit is issued - - -- �P.L. .. _.. --. - . ._ ..'. -. - .. . . . .. . . .. �. '�". . � •"�4-7�.��'0 v - (Sec.3097,Civ.C.). 9DE i I 2 3 1 -fi b ' g . ..,. . . .__ . . . . _ . P.L. _. .. . . . .. !. .�'.:.. . . . . -'_ __._..._._ . . __ .._ ... _ : Lender"s Name r�.,r;,,ent�� T1 7 inni c R�nk �//` lOM4 R f M � s 7(O�•Q� e� -- - - � ' ' _" __. . _. .. ... .__' '' P.0 Fee 3 .' Pe�mit Fee '" - LenderiAddress ��� c.. r.. c�11e Cr �1�;C8g0 ��n , , - � I cenify.thaf I have.read this applimtion and state that Ihe . ._. .. - -_. ..-..-- .__.. Issuonce Fee � - �• IDMA O/C M- o� - � �� � : � � above informa�ion is torre ee to comply wifh all County invevigarion Fea �(� �, g d'n fe ws relai to b�ildin construction, .. . � - i g _ - _.. .- _.__ . To�al Fee ��7� IDMA Perm.N���`3-- u ereby aoth n representa' s of this County to enter • � � on th ov -m tioned pro ert for inspetlion purposes. f.h L, /Tll _ ;�.�V+,Q b . - _ _ __ ,a .' ... . . _.... __ ' . .. ... _ . /✓ VC/ ... . .___. ,_ _ "_ _ . _ . . a . ZZ SEE IIEVERSE FOR EXPIANATORY LANGUAGE � .� " ._ . _SignororcofAppl ent -. . Dor - . . . . � . . .. - � . -._ . . . _�.. .. - ..____.- ... . ._. . . OO i ' PLANS TO APPLICANT INSPECTOR'S NOTES� .OR'NF.R-AUILDER DGCLARATION I hereby aifirm that I am e:empi from the Conrractor's To:. � Roturri�d � " - • . � � �� ' .. � � ' �Ucenre law'-for the�followinq reason:�(Sea`7031.5) ' � ' ' � ' � ' ' ��Approved ' DusinessandProfessinnrCode:Anycityorcoun�yu�hicG No. Da1e '� No. ' - DaN �� � �-- � � � ��-� • � • � �- . �.,, -[equrres aQermif ta conslruct,alter,imrrove.Jemolisb, . , . , , .orrc/�airnayitructum,friortnitsi.csuanic,alsorequirei ����- . -v,;\-; . , ... . � i'.: . . . tbe applirant for sucG fcrmil to fife n srgned rlatcrnent � ,tbal be is(icenteJ f�ursuanl 10 tGe pmnisinns of 11 e Cnn= ! � � � Jrortor's Lirenlc Lau(Cl�apter�9J(conrnicncing u�itG Sco , ,.,.. i _.,,..�.�_!ll. "'," . �,.. . . . _. ._ ._ .. _ .._..' . :...' . . . . � ' hon 7000J oJD�i�is�on 3 of tbe Butrners and Profesrions �, �•," .�,.,��� .�\�`, �_ � '� '� ' _ ����� � •'��� CnJeJorfbathcisexemptfbcrejsomandt5ebasrsforfhe ... .____-___. ._ .... _ .. _ -,.. . .. . . . __._. _ _ . _ _ _ ._. . . . _. alfeged exempliun.Any vinlption of Sertion 7031.5 by . '. . ,'_.'' ; R�quind � �.��Do}eRaeotwd --� -...--' � �-- - � '- � � -- - ...- _. �nyaJ�QfiranfforaJ�erneitsubjeetslheafQ(icantlaaoieif .r.., . .. ;�.; ._ .' � .. ', - Approvals�� � � . or Approvad -- . ,, . . „ �,..- • J+enalty of nnt mnre tban Jine bundred do!lars(f500JJ:� ' .� , Yoe ,No � - � _.__._......._ . . .....� .._.. . .....�--'-__ . . . � ❑ I,as owner oi the property,or my employees with -�, Water Cer��ficote �;.- '- �',�:'` � - � - � � ._._. '_�_ _. .�. '.- ::.. . - �_. . �+ages as iheir soie compensotion,will do the work,and - - - � - - - � � �the structure is noi intended or o(tered for sale(Sec.7044) •� Heahh Depanmem____ . _ ��� ' �' � � --- --'•- - � � . . Qusiness and Pr%ssions CoJe:Tbc Corttraotor's Lrcersse � � � �� � � Law docs not ar(�Jy to an owner of/+roperty w/�o buifds . :�'� ,��. . _��':, :: ,.,.,��. �- Fire DeparlmeN . .. -._ ._.. _ . __ _. -.-. --- ---— . . . . . . . -_ __. . _ . _ _ or imprones lLercon,and u•lio does suab u�ork Grm.relf or � - , ' _ � ,. IJ�rougG�bis..ou�n.em/�loyees, frovuteJ lGat,rucb im= Grading � � � , ' �� � - . 1 prooements,are not.inlended or of�ered fo>,sale. � - . ' � , ���� _ , bou�ener,tbe brsildirsg orimQroeement is sofJ u�itGin o. Geofogical .' ... - �.. .._ - ' - � : ' ,Ycar o/mmJrletion. 1!c nwner•builJer�u�ill.havc lle � � ' � �•� - • � burdem nf frnvin�t!nt Gc drd not build or imprncr for Pedestrian Protecron . _��. ���. •:� �� � . . .�. . �- -------_' .. . ._ .. ..... ..... ._... .. _:`. .. e purpose oJsafcJ.� � , ... ,- . � . (Fence)(ConoPY) � ' . ,. . �.�.� ' � -----� �- ---� -� - -'- ---- -- -��------ -�� th❑�'I,asownerofihe,proPeny,amexdusivelymnirac- � ling with licensed conlracfors lo conslruct�lhe projeci(Sec. $pecial Inspection-- - _..-.._._.,-.. ... __'_:__ .___.. .__._ _._ .- . - ...... . � ' . _.:_. _.. ... i _.. . .' '- . �. .. . " '' __builds��Im/�roi�s��ercnn,`as CoJe•7I c�Contractor's (Cont.)(Masonry)(Welding) � � ' � � -�� .i� _.� hP y an owrscro/J�m�rrty¢•Gn - � nJ u�bo conlratlt for sutb Lof Droinage .' (�_�`\� �. '.�: . .; . . ..__ __'__. ._ ._._... . . _. ..... _ .. . /n jccls u�itL u rnntracior(sJ�lircirseL purtu6nl to tl e �.� . ' � --Cnntractnr's Lirensr I,ou+J. � � , ... Parking . . . . . . . . . . .. .__ '. .' r._. �� ' - '-' -... - ..... �.. ._� . .. .--- ❑ I-amexem �underSec. B.BP.C.fo � ' � P r��rhis M� . . � -: .. ' .. .reason -_- _. ___._ . ��. -. .. ..._ 4 ; . . .( . ,. � � --- . ---- ' . _ -—.... - -, .- Date Owner �� 1.7.� `.� . . � - . ApProvals �� Date Inspoctor t Signnfurv, : ' . . � . � INSPECTOR'S NOTES, Location— -� , � �Setback 8 Yards)� / � �� � - � -. . :i'� � e` � . . . _ . � . ., . .. . . . . . . , . . , Founda�ions � ' �� � � , _ .____ '_.__.__ _.___.._. __ _ . . . . . , . . s�ab � �3� _ Frame. . . . . ��1, ��J • . . . . .. - � - - ' , . . � . . . .. - t � , Energylnsulalion ��� A ' ._ __'•_.__...__ . ___.____ _.-_ :_ . .. .__ . .�_.. . ._. .� ,... _ , . ,. „ . ��, Lath/Drywoll— , ...- -�--- ----.. _.- �--, - -- �. � . --- -----_. . Interior. � : � .._.... _ _...._. __ _-_ _ j � ', � " .'. .''� . .. lmh—Ezterior ,. . �� . ^ _ .� _`}..� ; ��-ti( .._.. . �_i._.._.i .__.... .... _.... .. ..... . . . .. . �. __ l� r House Number— _. � � ....` _.�_'..__ _ _._'__ .�..�- „ r.-�• .,. '.__. .. ....� -. :.r� . . � , . � Correct 8 Posled ' - i':'��). _ . . .• . . . • ._,.• • � ... . � . ,� � Final— ._.. ._ _' __ ._ .- .. _ .. . ... ., , . . . _. _ _ .__. - _.____._ __ . .. ____._.- �� . Enter on Fronl _.. . - - ,t,�. ; . � ' .. . �' , _ . - • , ;\ 'i: .. , .\ �' �- -" _I_. ! J. �