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HomeMy WebLinkAbout1576A 1577A (9) i � , .,., ______.. ._._. _ __ . _ _ .__. ... _ _ �_-- _ . _ .. .._ _.. .. WORKERS'COMPENSATION DECLARATION , �� � � .. , . ;-. _.. .. . . , .. .. . „ ,.,� � .--.. _. . ._.. � .. � •. . , � 1 hereby affitm thol I have a tertifimte of consent to self qpp��CATION� FOR����BUIL�DING� PERMIT � ��� insvre,or o certificate of Workers'Compensation Insurpnce, or a certified c p lhereof(Set.'3800 lab.C.)- � �"'.- � ���- "� -' "� �" - � � -- - - -� �- � � � ' WCP62�SY5241 � �`reat�American Plan 2A COUNTY OP LOS ANGEtES BUILDING AND SAFETY PolicyNo. � . . ..Company . .. ._.. . .. . . . , , � Cerrfied copy is hereby(urnished. FOR APPLICANT TO FILL IN BUILDING O� T „/ � nooaess v U.(it. Ceriified copy is filed with fhe couny building inzpeo- BUaDiNG 'tiondepartmenf. � ADDRE55 20840 East Boulder Lane Dote 12-22-86.'A�� � ' °The"Wm: �Lyon;Co.--. ..--Walnu.t ... .... ..-- -- .. .91789- - . pplitant CITv Zlv ' lOG4LlTv � '� � CERTIFICATE OF EXEMPTION FROM WORKERS'�� � '��-�� �-- NO OF eL�GS.- � NEqResi � ...� ... . ._ ._._..,.. � � � � � � COMPENSATIONINSURANCE�•� -�� �� SIZEOFL0T3e$OO SF M1II.NOWONl07 � CRO555T. (This section need not be�completed if the permi�is tor ane - �-- iRhCi��43760 e�oCK 20800-� �Ot NO. $� -��- °�ESSOR , . -� � � �. , , hundred dollars(E100)or less.) MAP BOOK - PAGE. PARCfL owNeeTHE_WILLIAM-LYON C0. -N�33-3600 us�zoNe n+w.P e I certify,ihof.in the perfoimance of 1he work�for which this NO. Q ' � } permil is issvad,I sholl nof employ any person in any manner ADDRE5519 COSpOrB t f�-P 18Zd- - � - -- SPFCIAL - - � � - -- �--� �- �- � � - 0. sa�as lo bemme subjecf to the Workers'Compensdtion Laws. � ��-� CONDITIONS ' � � .u ` - arr Newport Beach, CA nP 92660 - _ � Dale ....�_ ,._ . - �ApplitoN , . ..�. .:. .. - .._.. _ _ . _ ' ' . .. .�, d' ARCHITECT O TEL. O �"�QTICE TO��APPLICANT: If,�ofte making this Certifimte or �liales-Lan ston 547-0862 DISTRICT G UP TYPE. _. . _FIRE VR SSE�BY._ ENGMEER � NO. h mption,'yov�shou�d become�subject lo ihe�Workers' CONST.' -ZON , �� �mpensafion��ptovisions of Ihe La60r Code�yau musf(orfh- qDDRE55��7 S. Main $t.� Ste. 105, Oran E Q2... � . '�-�. . 6 wi�h comply�wiih such provisions or �his�permi�.shalt be .---�� � deemed ravoked..,.- . .. � � �� � COMRnCTOR S8ro0 AS Owner NE� . STATISTICAI CI�AS�S�IFlICnATIp�N • 1l� A(fi. C 00. Z . LICENSED CONTRACTORS DECLARATION.-, .� � --� - - -���- - �- - --- � .-. -. . -���. . -. . . -C1A55 NO.�biNEui UNITS� � � � I hereby affirm�hai I am litensed under provisions of Chapter9 noortESS NO. (commencing wilh Section7000)of Division 3 of the 6uziness ond __ , , _ _,.. . , . . ���_ _ _ .. SEWER MAP . . �• Professions Code,ond my license is in full forte and effect CITY � CL455 � -�- �-�� �� � � VAIIDATION - ��" . ZJ6SOS ...�.. „ ��. .,- . B-S � � SQ.FT. NO.OF _ NO.OF CHECK BK. PG. ' . . license Number � "'� '"Lic:Class ' Si STORIES - - FAMILIES � � ONE . � . - - . ' Tklf Wrtl. L OR..CO..... ZZ-L2-S6 . _... .. . . ' _ ' '_. NEW VALVATION_.__ . .._. � .. _ . " Y . � �ESCRIPTION OF WORK � S ,� D O � -� Contratlor '' - Dole A�D ❑ , ,� �1 5 7.b A �I om exempt under5ec. �iri lc famil .home construction AiTEQ .-� � � ... ,. „ ; �. . . .21 8.8P.C.tor Ihis reaion . . . REPAIR.. -f .. . . . ...-�-- -.-. . ._ .__ . . ._ .. .. . . _�� USE OF ' �Date:__ � � •2 11 f.�.3 .i .. .. . E%ISTING BIDG. DEMOI . . Si nature OWNER•Bl11lDER DECIARATION qDDeE55�hC W11118ID L OII CO.NO. H33-3600 .DATE� �'!g-`J. � 4 7•G�� 9 . .. _ . _. ._. FlNAL P .1 hereby affirm that I am exampt irom ihe Conlractor's Licanse I 2,3,��8 6 . Law(or fhe following reason(Settion 7031.5,Business and FINA - � � . �-� � ..Proiessions Code): . ._._.__.. .... .....__... '.--'. .___ ee N BY _ . .�.;�.rJ�.7�. � � BUILDING • � , 1, as awner of the property, or my employees wiih ADDRE55 ' �� � � � � 1 � . _. .. . . � ...... ' .,. . , , wages os Iheir sole compensotion,will do ihe work und ' � - � - �. �-. r � the sKUUore is not Intended or ofiered for sale(Seclion ����TY ' ' -' . , � e����G a � �7044,�Business ond Professions Code). -- --.. .. _.. . MOviNG.. .. . . . -. _- .--- . .TEt:-� �---.--... .. . -- � - - � . -. .. I,os owner of the propeAy,am exclosively conlmcting CONTRACTOR NO. � . �- ..�'-with licensed confractors ro tonsfrucf the project(Sec- -.- ._ ... .. _.. _.. _. -__._ _. . _._.. ... ... ., . .. _...._ . : ._.. _�_f,•Q 2 f_,Q Q�. . ADDRESS �.� . tion 7044,Business ond Professions Code). ��„ � I��,� RE�UIRED- YARD "HWY IOTALSETBACK .. . . ... ' ��'�.�__ � -.' -1. . ��3� �H.b. ... "�� "--'""'�--'-�� "CONSTRUCTION LENDING�AGENCY' -"�-�-- �--- - sei enCK PROP.IINE wiorH � - �� �� I hereby affirm fhat Ihere is a canstructian lending agency for FRONi . - � . -the perfo�mante of ihe work for which Ihis permif is issved � � v.L . . . . . - . . .. .- ... - . - . .-. _ ��. ��.�'�� � . ' .. . .. ...�.: (Set.3647.Civ.C.). SIOE ' . ... m ____ _'.._. . . . �. . . . Continental Illinois`Bank ` " P��� Lender's Nome ��- � ' � . - - �-� � -- . � � -_ . ..._ -.- . . ... - ---- P.0 Fee E . � Perm r Fea �� LDhV4 Ref.M . . ''„ _ _ _ _ „ _' - lenderiAddress 231 So. La Salle St.. Chic�go ' ' � J.certify that 1 have read-�his application.and s�ore that.the __ __ ..- - i:suo�ce Fee .S -�n�a viC N_.�`��a. - : -... '... :. � .. m bova Inf ' n Is cor . ee lo comply with oll County Investiga�ion Fee /�� � . .� g _ � ances and t pws relati to building[onsfrocfion. _.... . .-. .., To�al Fee � - LDMA Perm..M -._ --. . .. - . .� . G d hereby a�fho e represent es of ihis County to enter � u on 1 60 - tioned pr y for inspeUion purposes. �,s-�� �' SD O . � ' I o _. .. . - _ ._ '.'. __. .. . ... ._ . . .. . ._ . __..... _ _ _. ._ ___ .. __.' .__ i (� _. . __ . ..._. . � �� � L�ry SEE REVEKE FOR E%PLANATORY IANGUAGE . � ' ..,. gnofureo Ap -conrorAgenl. . .... ... . . .. Dote... ._._ . .._. _.._ ... . . _ . ._ _ . . .. _..___. !_... _......_ _ ..._.__._. ._..�OO i � PLANS TO APPLICANT INSPECTOR'S NOTES „01YNEil2-IIUILDER.DECLARATION ' � I hereby�affirm thal I am exempl from the CoMrattor's , ' �To: � i .� . Rcturn�d ' � : . .. � , � � � ���iitenie,law�for�.tha�:following r'eoson:��(Sec. 7031�.5) � �� ' - � �Approved ' ' BusrnessanJProfrssiansCode:Anytilyorcoun0ywbicb No. Date � No.� �.Dafo•� . ,�. . . . - .. � . ... . .� r.,. :_regi�ires o/�ern�it tn rnnstrucl.alter,inorronc,Jenrolisl. . . . —..or re(�air any slructure;prior to its issuante,alsn rcqu ires - _ ' . ,, , .,,. . � , t!e afflica+rt for sucb/+eimrt to file a signed slalement . " - , lbat Ge is lrrensed pursuanf to tGe pronisinnt of,the Con- � ;i i r-,� tractor's l,irnntc Lam(CGaJiter�f/commrrtring wifL Sco ..."`;1�,.' '`I ' :'-._. .._ : '.. : � -� � - -� ' �- " - -----"-��-- .tinn 7000J of Di��iainn 3 of tGc Dusinrss and Pr%ssions � '` - , ., .� -.�. �.". ., .. • . � . �:. .. �. •�.: Codel or tTiat Ge is ezempt lherefrom and ti e basis for tbe " ..� ' ___..___' ...._ .._ ... ____ _ .._._... _' __._._.. . . __. . � � - allegcJ cxemption.An,y vinfntrors of Settion�7091.5 by �, � '�..� ': � �' Requlrod '�.' � � ' � ... . � .. . ;. _� ..:._'_.: .�._. _ . . . an.Y arrlicaat fnra permil subjerts the arf�licanf to a trnil � A rovals.. -Dafa Hetdved - P� � Yas No or Approwd � . .penalty of not mmcYfian/ie�c bundred do!!¢rs(iS00J.J:, ...I � . • �...�.,�.� . _..I_.._ ."�`. ".:. � . � ��--- - � -- - �� � ❑ I,os owner oi the property,or my employees wifh .. . ..,... � ,,, � . �,..,. . . ., � Wa�er Cerlificote � -� ��i . . _ � ._ . _. . . . ,_ . woges as 7heir sole compensation,will do the work,ond �. � � � � - --� —-''-�' � �� �-- - �- -� " - -- � � �ihe svuUuie is�not iMended or offered for sole(Sec.7044) Heahh Departmenl__. . __�' -� . . -��--� � � � -�-. �- �--� -- � - - . .Dutineu artJ Professioni Cadc:TLc Conlractor's Litense _. . . ,-_; ,�,:_� �: .'.��''.: ..�. l.au�does noe opfly tn an oumer f prnperey u�ho buildr FIrc.Department _ . .._.. _ . . . - -� � - - ---- � m imJ�rores lbereom,and u�bo does sucb a+ork bimsel,jor : .' . � ' i,�� .-i; �..- ..',I.�. . ' � tbmugb-Gis oum em/�Ioyees,.rroniJed,IGot sucb�irrr-. Grading,_ ' - � � �1 ��- � � � . :.prnrrmenls ore not�in�ended or nf/ered for saJe.� � . �, , , . ,.,_ . , „ _ , , '���� , -�.boweoer,tl c building or improa�entent is sofd utid�in o� � �� � � �- --�- -" - � --- �- � � '�-.year oJ�comQlelion, !be nwner-builder�wil!bave !Ge Geolo9iml � . . . ., ,. . � . ,... .. . . , - �� bdrdrn oJ proving t5at br drd not burld ar irnpror.�e fnr ' � ' . . _ ... . _ _ . . ___...... .... : Pedestrian Prmeclion�� � � ' !he purpase of suleJ.- ; � ... (Fence)(CanoPY) . .. ' ' �. � . � ��.�.� ... . . ..- - - � �-- -- ..--._-- -. . -.-.�! ,� ❑..I,as awner of the�propeny,am ezdusively conlydo- ting with licensed controclors to conslruct the projec�(Sec. � Speciallns ecfion� .- ... ... ...... . -.... ;_. � . . . -_�.-�. .... ..�. -..�� .- ��� Profess Cort aclor4 � 7044)Qusirtess pnd tons�CoJet:TGe tr P Lirertsc Las dnes not o I to an o�m�n� crt u�bn (Conc.)(Masonry)(Welding) - � �� ; ��; �- , - hPy rnfprnp y �. �'.� :. � -� � � � "�-�builds-or inrproucs�lbercon;and u�hn contrarts for sucfi Lot Drainage � .�, i•-� \.,�.� . -, ...._ _ .- _. ._ __� .__. �..._. . Qrojecls-u�itfi a contractor{sf�Jire�srd rursuant fo !6e , C��i . . , :: � . ... . . . � ... -Cnntraclor'sLicePsc�Lauf.� ���-� �-' � � Parking . - .. . . �' .. . . ��-. .... . .. . � .- - ._ ... �._ .._ .._.. ❑�I am�ezem t under Sec ,8.8P.C.fo' . r ihis . �� - - ---..._ .... ... . � . .. i reason , . , ... .. ..__ __.. .__ ._ ..__.. .__.. _ ..___..___. - , . .. , - . . Date Owner , , , �.� . ., . . ; . ... __�___'.__. _ -_ .,. _- , -.�.-- . , . � :. _... � ; , . ._ . .. . .. . ... Approvals ' Dafe Inspector's Slgnafuro; � - . � . -. ' ��. INSPECTOR'SNO7E5 '�� - Location— � _ . . . . . . . ,: . � � (Selbock&Yords) � � , �� � ' � . ^� Favndalions . �7/ � " - � . . . . ; . , � Slab , ., .� . .. . . . _ . Frame . �\ � . . . . . . ._. r . . ' _ .. . . _ .. . . . . . . � e�e�9y in:utaro� $�-� j' � _-- ---—:_. . :..'-- _ __ ;_. ... ,. -. _ r, _ > .. lalh/Orywall— . -_.. ------.__._----------._,._.. i _ . ' . . �. . _. ._'...._.._.. Interior .-_.. _.._..__. ._. ' i � . . . . . . . . . . . . . - � . . ;r,_ . . �. Laih—Exterior � . , .._ . ' __ _ \\l.. . . - �.� _ . ._ _ __. . _. . . .. _ . � ,, . , . . ,,- ,,.�. House Number— . . - ,. •.�.�.. . _ . -:�� . ... .-.. . . , '. � _ . . . �.. , . �. ._.... ___. ... ... .. �,.�..... �. ,. i r� .�� �. ....... .. ...� CorreU 8 Posied � �- - _ . . .. _. . . .. .__ .. .. . .._,-. ^ti .�. ,... Final— _ . . � . .. . . ...., _ ., ,, . .._. ___. _ ._ .,_ ,... .. _.. ._ . .—-- _—._. ._._ . ENeronFronl . .. _ , _.. :. ... .t'. ....;•. � . �;�� . .�..:. ��� � �.. .,�,� �.. . ,, `.;� . ' — '.f . . .. . . � . ..-_ . . � ' . � .. � .�'� . , , . - . i :., -� .. .. .. ._. ._ .. . � .� . ----"`��-I �j� � . �, i