HomeMy WebLinkAbout1570A 1571A (9) i , , . . _ _._ - __ _ _ --. . - _ -._ - - _ . _._._.. . _: __ .. .. ...___ . _ __ __ � WORKERS COMPENSAT�ON DECLARATION . . . .. -, ..,. . .. , . . . ,.. . � � ..._ . � . . � , � . . . .. ___ • I he�e6y affirm,lhot I hove a terlificole of consent fo self APPLiCATION FOR�-BUIL�DING�--PERMIT� �-� �:� ' insure,o�a cerfificate of Workers'Compensation Insuroncc, orotertifiedc y'lher oi`(Sec'3800,�Lob.C.) ' ":� �" --"�" ' - - - - - � ' -. . � - WCP6g552�+1 Great American Plan 1CR COUNTY OF LOS ANGELES ' BUILDING AND SAFETY � POolicy No. � .-. ' Company � . .. . .. , v FOR APPLICANT TO FILL IN • swi�iNc ry C � �/ Certified copy is�here6 fumished:-� ADDRE55 Q 3S G. I�dZL(=� ' f'Y�,Certified ropy is filed with'Ihe county boilding inspeo- -'�� BUILDING , L� --fioddeponment.��'�" � ADDRESS 20835 East Boulder Lane • : 6 �' '� The Wrti. Lyon Co. Walnut._ _ 91789 �L- Date S2-ZZ-H Applicant aiY Zia 1OU41TY L ,.. , '' �CERTIFICATE OF EXEMPTION FROM WORKERS' �'•��` -- - "- �-�"- -�"" - rt0 OF etoGs.� -� -- �� -� Ne.aeESr SIZE OF(OT 3,800 SF Min � �0 �� - —"'� � "-��-�-"-���-" -�� � � �� COMPENSATION INSURANCE �� 'NOW ON�Oi � CRO55 ST. . ' (This seclion need not be�completed if Ihe permit i3 for one --�-- TRAct �4J 760 BtOCK 2OSOO t0T NO. S�+ �ESSOR : � --� � � �� hundred dollors($100)or less.� . � . . . ' � MAP BOOK � • VAGE i PARCEL I cerri( thm farmance of rhe work for owries-THE-WILLIAM-LYON CO..Na 833-3600. us�zor,e /�wo so as fo bemmersubP cf which this � � No. � �Q'Z"�33 " ��Y permit is Issued,I Sholl not employ any person in any manner � -- SCECIAt - -�� � � , - -- - -� - - � - -� ADDRE55-19 COI'POI'dC2-PI.822 �- � --� � � -�--I � CON�ITIONS V � �to the Workers'Compensafion Lows. �- ` , . PP ' an Newport Ileach, CA nv 92660 , — .. __ _ __ � --- --- -- ' Dat P fion,'�Yo��shou d bec�.. .,... ,, . . _'_. . . _. _' _ . _ _.__.. . .._ , . '.., .. � . . ' . ��� ARCHITECT OR 1EL. O '� �710E TO APPLICANT. If, after making ihis�Certificate of ENGWEER Fiales-Langston Np S4�-O8G .DISTRICf_. GROUP_ �P�t ,fZIRE . _M2. O�f95ED BY... _ � p ome su6jec�-io rhe Workers' � r� ' //EE �-l�' . �W , .m ensaf�on rovis ons of the Lobor COda,y0u musf forlh- qDDRE55��� S. Main $L.� Ste. 105, Oran .o�L .J � • % �d wifh comply with•such p�ovisions oi this permit shall be - SBm� AS Own�x' TE�� ' 4ATISTICAL CLASSIFICATION APT. CO .��- 2 � deemed revoked., � ,., �,-. .. - � ,,.,,.�. . ,,..�..., coMRnCTOe NO. ' ' ' _'__ . _ �-.�-- - -.. .... . LICENSED CONTRACTORS DECLARATION�� �^� -- - -� --� -- - �� - —� �- �iC. - � �--- Ctn55 NO. -dd DwEtL UNiTS ' I hereby affirm that I am licensed under provisions af Chapter 9 ADORE55 � NO. , , ' (commen<ing wirh Section 7000)of Division 3 af the Bus�ness and . .__ . ___ . .... LiC._ ... ��R�P . ' ' � � ... . � � _.__. ._____.. . , . ' P�ofessions Code,and my I�cense is,in full force and effect. aiv Cv+55 ' "'� BK,'—�-�-� - ' � � -' �"'�VpLIDATION �� �� . . Z�GHOS . . � �. $-]. �.�. _, SO.FT. NO.OF NO.OF _ _CHECK � � - license Number � '' '" L�[.Class ' � SIZE !+ STORIES � FAMILIES ONE -' � . . . ' The Wm. L on Co. ' 12-22-86 --. - -- --- - r,ew--. v�tunTioN: ._. _ . _ , -' . Y DES�RIFTION OF WORK J � Contracror � � � � Dafe App ❑ S � QQ �� .. _ .. . .. . � . i❑Iamexemptunder5ec. -- -- S1R le_famil home constructio -. --� , ,-- ' . ALTER .� . � .:° .__. __ -❑ s .. • . . B.BP.C.for this reason REPAiR - ... ._ ._ . ...... ... _ _. .. .__ .. _ . . . _ ._. . _.._._ . ... . . . . USEOF � , ..Date: Eff15TING BLDG. DEMOL . .. . _ .. . ... .._. 1�� Signature - . ... . . .". .. .��... APPLICANT TEL FINAL � , '� OWNER-BURDERDECLARATION DRINT The William L on Co.rao. 833-3600� _.pATE 7 6 - -- . - . . — - !$ ..--� _ _. _._.__.s 1 {7.O A .. I hereby affirm that I am axempt from the Cont ocror's ltcense . � law for the following reason[Seclion 703t 5, Bvsiness ond ADORE55 p�N �� ' �j �.?�� � Professions Code): . .... -.. . -__ ._ ..____... .-- R EN By.' _ . : � . � BUIL�ING � I, as owner of the property, or my emplayees with ADDRE55 " .._.. `•_ . � _ ._ .. �. _�_.�_�2 2��i�. . I wbges os�heirsole compensmion,will do the wark and � � � �' �� E the sfructure Is not imended or offered for sale(Section ��A�RY � � : ' • •2 C�a� u � � '- -7044,-BusinessondProfessionsCode). �-���---- �---- MOViNG �-- �� � � - - � �"TEL:-�- -�� �-- ' � � -�� �-- �' , ' --�� '- � � � I,as owner of 1he properry,am exdusively conhoUing CONT2ACTOR �NO. � �. �.�.. � _ �� . ;-; 1231 86 wiih licensed mmmcfors lo construct 1he project(Sec- ..._. . ... .. ...._. .. . . _. . . ._ - . . . .'_�..__ �.- . tion 7044,Business ond Professions Code). ADOReSS __ - -__._, , _ �� J�7� F� . � REQUIRED YARD� HWY. . .fOTAlSETBACK . .__.. .- J ,.. '. ...'��_ ._..• •....: - .. " --�- - CONSTRUCTION 1EN01NG AGENCY �- -� � - " SET eACK PROP.LWE WIDTH r _ �. 1 � . ereby affirm Ihof there is o construUion lending agency(or FRONT - 1 r performance of the work for whicb this permil is issved .-.... P.L.. - .. _ . -. '. -._.. _.. . ... . _.____. ��.�: . �.. . c.3ov�,civ.c.). sioe I •3 9 Q 0 0 � P.L . _.". •' . ... � der'sNome Continental Illinois Bank � � • `39G 00 �� lDM4 Ref.M � � � � � � � �� � --� �� � P.C.fee E + Permir Fee �'-"-� - deriAddress 231 So. La Salle St..�Chicago� - ' � ' � 1231=H6 � � � � tify thaf I have read-Ihiz aPPlication ond stafe fhat-ihe _.. ._ _...- . .. ... _. --yeuanm Fer - . mrnn Vic M � . - ... ' . ." .� �. � .. � ' � - e informoiion is c ., grea to comply wi�h all CouMy in�asr9aron Fea � � a Sf laws rel �ng to building consfrutlion, ..__. __. . ._ _ _ .__ . . . . 7mol Fee- � LDMA verm.N-�� -�-� --�� - - - - � - � iereby aui ze represe t es af this County ro enler ; � � bo �ioned p. fy for inspeUion purposes. � � , . . . . . . ._ __ __. . _ _ _ ...._ .. . .___. . . ..... _... ._. . _.___ . . ... _ ._ . . _ , .. ... _... ._ _.. _.. � -. ` �� SBE REVERSE fOR EXPLANATORY IANGUAGE � :. ' � ISignature o p lican or Agent. __.._ ._. Dor - ._ . . . . . .. . . ... .. . .. . . . . .... . ..'.._......_ . _ _: ... .. '.: ' ' _._ _.."_Q•� t I � PLANS TO APFtICANT INSPECTOR'S NOtES .�OIYNfiR-DUILDIiR DCCLARATIO;V • i f hereLiy offirm�that I�am e:empl fromlhe�CoMracfor's �To: � ' �� RNum�d � �.���� - - �� License law�for��,the�followfng reaidn.'(Se�.�7031.5) , " '� " '� �Approved ' OusinessandProfessionsCode:Anj�tilyorrountyu�hicb No. Date � No:� � �+ �Date�• ��- �1�� �---�- � �•• �- •�- � �� ��-� . �,;I �� , . n[requiretaperorittomnstruc4allrr,�rnrQrvue,denrolisb, , , . , _-_-orref�airanyatrutlurc,Qriortoitsissuancc,alsoreguirei � � � - - � , , , , ,, ,,. , - . �. . t/�c aQflicant for sutb pern�it to/ife a aigned atntemen[ � ..tGaa bc is liccnsedpursuont to tbeyronisinns of tbe Can- � :,.I,.� .. lradois l.icerise lnu.�(CGaptrr 9f(wmmencing mi�h Sec= . .\ 'i.i�.- . , .V O+nn 7000J af Uiuisinn 3 of 1Le IIusrness and Professions � �'. _.- _ ___'___ _ ' ..._. _ _ __ . _ . ._. .._,_.. � CodeJortlatGeise.rem/+ltJerefrom�andtlebasrsfortbe �. . . ._..____ _.__ _]�:�+..> ,:._. __ ..._ �.�: . . _... . . .-_ . . .. _ -� � � � -- � uUrged exem inn Arsy erolalion o Section 703[S 6 . . �. ,� ,.,..�...._Required`:.. �•��DataRe[�ivsd . . .....�..-' � "--� '���� �•i�.l .-.. .� .� - �--- - 6tl.YaPJ'licantJnrapern�iesubjeteseh arrlicunetoaeivi! I , Approvals � or Approvad ° : �fenalty oJ not mnre�tban Jine 1 undred Jn!lars{SSOOJ.y.�. '� , � �:Yes No . ... . _ - �, �. �. ,�. .,_ . � , _. , . . , - _ -� - . ❑ I,as owner of the property;br my employees wilh �, � ��;- ..� �„ . :�: Wo�er CertiFicote �. ��' - ' -� - '�� - �� �_ .waqes os their soie compensa�ion,will do the work,ond . . . :.� _____ . ..__..._ . . . . ..____._ ..._ .___:. . . . . . ��-�--��- �--- -- �- � � -� �� �� the strvcWre is no�in�ended or offered foi sale(Sec.70a4J ' Health Depanmem _ ._-- - . ,._. ., . . . �. . - . . .. "._ ... ....,II� . , ,__ . . , , __ _. ,_.. usiness nnd Prnfessiuxs�CoJc�TGc Contractor's Licente ... �� ---�-' � � �--�� i,:..�� , :� �. �,. -� -. .,.- •;. : Lau�doesnota ! toanou�nero t u�GobuiJJs � ra v JP•�r�•y l�-;� FireDepanment_. _ . _._..__ ...__. .__. . ....,.. ' -..,. ..�_.: - .. . . .. .. ... . - ,- � . , --11 upb�bisr/ow•n�cmno e`es,d�roe�duthat t'ncE imr -� sJ-:.• ;, r x P Y P . � Groding � `� _ , � ,-prnvemen�s orc�not " tended or,�.offereJ for tale.�'� �. , � _ , �t ���.,, , �, \�\" . bnuerer,tfie b«ildixg or rmprovemcnt is sofd u�itLin u. � Geological.:.' � � �.. � - - - , .�_. . ., , ,... . . . -�)'e¢r nJ rompletion, lbr.ownerbuifder will:bave�tlo - burJen f pmcing tl at l e did nnt bni�d or improve for .. Pedestrian Protect on . � � -. ..� .-�.'.- `:.... ����-��- � � �� � � � � ���� � t!a urposc of sa(eff� �: .�. .... . . �__._ . . .... . . . _ .. .. . _.��... .�- � , (Fence)(CanoPY) �; , . . ... _ .=. . _-�-` .-...-.. . -"� � `- ,...�. . �.as awner o the properlY,am exclusively wnfrac- � � -�� � '�in9 wiih licensed contracwrs to�construc�'the projea(Sec: • - '� '�' •.��� ���— '� -� -� � 7044)Busrness and Profetsiont Codc:.TLe Contrattnr's . SPecioi Inspecfion-- � .. . _..._ �... .....-�'� "_� �' � � ' �• ' � , 7.icenie I.au•dnes not applY tn'an oumer ofOrnperty u�l o (Conc.){MasonrY)(Welding) '.�.. ..�..: . . . .� , . . ��_.;. . . . � � �� �� "--'""'i' ' -� . .-.. `.-"...-.. �`\� .� `.--�� ----burlds or improi,es[bereon,hnd u�lo mntracls'f rsacG (�n lot Droinoge �- '1 '� � �' , ' .. � . .. . r rojecls"witb a tonitattor(sJ licensed pursuant tn thc • _ __ _ _..__.__ _ P . . ..�� .' �` >'�-.1 - - -Cnnereceor's I,irense I,au�J..- . .. •.„ ��_ , „__ � . :... . . _. .._ ..� c , � i , � Parkin � . . . .__. _.. _._.__. . . . ..._.._. . . ..... .. _. .P.. . .. . . . . � � - ., 9 � ❑ 1 om exem i under Sec. ,B.BP.C.for�his ... . .. _ . _ .__. __._._. .. .._ . .� . .. .... . reason . . � . .., , . . .. ._. _ ._ . . _ ._ .__..__._._._ __.__ . � � , Dote Owner ' .� ., � =�� � ;nr-2���;. . �� ,., . ,1 . . . � � ___ _.. ..._.. __ .. . - _ . � �. " , . . -; '.'; .- :- y' �"': , . . " . .. .,.." ._�:. � . .. . _. , . ._._ A roval .___ ....�._ '_�. . .. ..... . pp S DaTe Inspecfor's Signafura � . � . , � � . . � INSPECTOR'S NOTES � location- , ..:. � .,. _.... � . ., ,:;._ . .. . ,.. (Set6ack 8 Yards) ', - '- �: � ., . . - ,i. 1 . � ,� '�� Fovndatiom � `�f r � . . . . . . . ,. � . � . . . .. � . Slob� - ; -` - 1 %C� ��_ . � .,-._ , ,. . . . . - � " .� Frame � . . , r.�"1 � .. . .. ., . . . . . . ... . . � . . r . Energy Indulation '�� � Y` l ; .__.:... .__ . _�_ . .. ___ . __�_ � . ... ..� ,. . . . . . . . ,. . . i LmhiDrywall-. � / -..._.... . _-_.__ _. ._ . _.. _ ., _. _, , . ._ . .. Interior ,�O�- ____.__. _.__. __ . � , , . . . , � �, . . . .� , . . La�h-Exter�or .. .. . .. . �. . . . ,�.� .' '.' . . . ; . ._ . _ � . . . , , ' �: r ' \ t'. '-.C, ,.'_ _ __. ._ .� . ..,.r� , � House Number- � .. �-�n_.,..♦_ >. 1�:.�.__ ..._..._.,_..•_-... ..�� . _._. . �. . .,_ .,� � . , . Correci&Posted � � . 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