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HomeMy WebLinkAbout0872A 0873A _ _ - -- . _. ._ __ .. _.._... _ _ _._... . _ ...---- - - . _. WORKERS'COMPENSATIONDECIARATION APPLICATIQN -�FQR�.�BUILDING -PERM T � -��� �;�� I hereby aff m tha�I have�a cert ficate of consent�to seif � ��� �nsure,or a ceAi6cale of Workers Compentahon Insoronce, � , or o r ifi o re f(Sec.3800,Laki.C.)`' � '. . ..... . .. .- _ . . .. . .. - .. . . .-'. . - �yf.�t„�'`�.��, P .� `�,,�. COUNTY OF LOS ANGElES BUILDING AND SAFETY P6Tc Nd Com onys���t�� ... Q� Cerlified copy is he�eby fumished.? �. .�'. ��, FOR APPLICANT TO FILL IN 6U401NG R ! ADDRESS �y^�y+��C Ar ti fie d copy is f le d�wi t h t he a ou n b u J d n g'i n s p e c- B U I L D W G � � ' u '�tion deparlmeM ....�. �I G '. .,. ADDRE55 � - . . `.- }. ;� _. . _. . •. .. . _.� � ' Dote��ApPlicont��s�(]V 1��� OT ( r�a 1 � LODUTV ' � � � , ' � CERTtFICATE OF EXEMPTIOM FROM�WORKERS'� •"- � - - � - -� -NO.Of BLOGS. - � riF.nREST ('� ``\ � � - � ' COMPENSATION INSURANCE � . SiZE OF LOt NOw ON l07 CRO55 57. y)I�OQt� v�7 Q Q (This seuion need not be�compieted if Ihe permit is for one - -�-- �- -- - � n55E5SOa , - �� - � hundred dollars(SI00)or,less.J . .; � . , TRACT� BIOCK l0T NO. /�qp Bpq( VAGE' 7ARCEl ' TE� USE ZONE �P I certify lhot in the performance o4lhe work'for whith this � �� OWNER - � �--NO NO. ' ' � � ' � } permit is issued,1 shnll nof employ any person in any manner _ C/ - --� S�ECin�� �--�� . -� � -----� � - � �- - ' o- so as to bemme subject to Ihe Workeri CompensaHon laws. ADORE55 � -!-� - COND�TtONS , V r._ ..;..� . .. ..� . „ � ...�.�.... .. , .___. ._..._ . .. _. Uote �. ��..�. APPlicant�. : .. . _ _ ... GTY �p _. ._.. . .. . .- , .. ,.�. ,O NOTICE TO'APPLICANT: If, pfter making�ih�s Certifimte of ARCH17ECT OR TE�- DISTRICi GROUP. iYPE NRE PROCESSF�9Y _ ENG�NEER N�. �pNSLLL����^^^ ZO � G Exemptian,��yoo shoold become sub�ect to the�Workeri �Q ` 1�1� �\�,..,�� � � µ� Compenso�ion provisions of the Labor Code,you must forih• pDDRESS � -�-�-!� � lJl�''V\lL N with comply with-tuch.provisions or Ihis permit sholl be ��- ^n TEL � � � STATISTICAI CLASSIFI TION ,� APT. CONoO.� Z deemed revoked.-..: . . .. � . . . � .: - --- COtarea �'� 1G. L��J� �`JN �. - . , ._.._.. . ..._ _ . ._ . LICENSED CONTRACiORS DECIARATION '� �LiC. S� S. �5 NO.�DWELL.UNITS 1 hereby affirm thvt I am Ifcensed under provisions of Chopter 9 a0o E55 IYO. , (commencing with Section 7000)of Division 3 of�he Businexs and _ .: t. - p� e� ��R�P . , ��""' ' Protessions Code,and my ficense is in(all forte ond effect. . CIT CLA55 V � '--' BK; ���:'-���--- "-�T- " '-VALIDATION -"� � , � ,. , " SQ.FT. NO.OF NO.Of CHECK � " ' ' -�� SIZE��- � � STORIES � �� FA IIIE$ � ONE��� ' nse N ber � Lia Class'����' '� ' ' � � �� ' Cbn?a"��C,���� _.. . . .. . ❑ ..VALUATION.-'.� .. . �,- ..__•-- . . .. � J ' - DESCkIPTION OF WORK - NEW R�^ , . ❑n rac o ote . ADp s�ly�{Q � � , ��, I om exempf under Sec. . . .� .., '-' -- ' ALTER ���"' '...�. ..' ' . .._ ,�. . , . . �. ..'B.BP.C.4or this reason ._.. . REPAIR ' s ... .-`.-.. . ...... . ....' "'-...-..--" '' ' �--� . _ ._ _'. ... -... .... USEOF ' � � EXI571NG BI�G. DEMOL _..__ . .____ . -��� �'-. _. APPUG4NT \ TEL ry� ... ._ �'_� . s�9�ow�a� FINAL•. •, � f�� � OWNER-BUILDER DECLARATI PR� �'� � ` NO. 5✓ ..DATE�r-L.:� 0 - - -- —cQ87,2A - -..!hereby offirm ihat I am exempt irom ihe Controctor's License � , Law for the following reason�(Settion 7031 5,Business ond AD � � � � 11 � �� FINAL - ' ��' '��-- � � � � ..".. _"_ - . "Pfo(essions Code): . _..... . ..._ .._..._ _ . . PRE EN ' 8y .. 4.. �ri� � �a 2'�j. BUILD�NG '- I, os owner of the propeny, or my employees with nooeess _. ,. .1. :�J$25 � wdges ds�heir soie compensmion;will do the work"and .".... .. . . -- .." . .. . -. .. _ ..- . .. � ��.. . '-❑.. the srructore is not intended or offere'for sale(Section ..._ t�`���r - ,. ^�+t t�\e '...'� - - � . ..�..J�c$� �. • ---.. .�044,Business and Professions Code.- �-- " MOVuoG ---- .--. .. _ TEL.. .. _-- J••1 d.- -�- - --- � � I,os owner of the property,om exclusively contracling COMRACTOR NO. ! � O�j 1 (�_$7. . .-wi�h licensed coMracton to-construct the prolecr{Sec ..-.-.. ... ._._.... . __.. ._. ._ . .. .. . -. . ._ . ._. _ . - - fion 7044,Busineas and Professions Code). ADORESS � �' � r 0 8 7.3 Fl � ' ..__ ___ _ ' REOUIREO- YARD- HWY- - TOTAlSETB CK �' . : ,� _ . � i CONSTRUCTION LENDING AGENCY ��-"'�- " --- SeT BAIX � PkOr.lwE WiDiH � ��-�� � - � - �� �� � 1 hereby affirm tha��here is a construttion lending ogency for FRONi � # - `'� • , • • . -Ihe performance of iha work for which this permit is�issoed ...-... --v.l.-. . . -. .. -.--- . . .. -- ... ... .----..-_.. - .. ..- . ---- - --�- � -- --' (Set.3097,C��.C.). SIDE ' �� �V � . m '._'_ ._._..._ .___._.._ .. _ .. _ . ' . . _ . _. .... ... ._ .... ...__..."'_.. _ _.. ._ .. ' . P.L. ' � Lender s Nome f •+5 5.5 0 - (�� � LW.M Ref.N � �$ .. _ ' .' __. _..... . ._.. . _"_ " " P.C.�Fee S.'. ' -[}iJ Germit Fee . �. O ..� . . '_ ' �`-��.J-O V � � < tender'a Address � ' . � � '�" � I cenify thatJ have read this aPPlitotion and s�afe that the . __ . _ --.--.__.- _. - --iss�on�e Fae. -.. � . � � lomo..aiC N...._.._ . ' �G� �'9�8 7 � . � .'_ -. .. .. ��� bve information is torrect.1 agree to tomply with all County Ime:eganon Fee c � ' � ' '', . �nces and State laws relating)o.6uilding consfruction, __'_ �Tmol Fee J� mMn Perm.p-.--�--- - -' �------:�=���� ' __. .__._ .._.._ ._. _ .. . . . �� � . .•by authoriza reprezenlativ Ihis CouNy to enfer �'.- � ve- enti fo� speUion purpasesry. i •/�� . .�U _ . . _. . _ _. __... . ... . . __ . ___..._..._ ___ . _.. _._'_ _. . ..' ' _ . .. _.._ . __.. � ' j � SEE REVFRSE FOR EXPLANAiORY LANGUAGE �/ �arvreof pplica r genl..__.... ._ .. ..Dale . ..____ ... ......_ _. . . . .. . .. .. . _,' ._.___. .. ._.._._. ._�_' .__.. .._. .."_ ...._.. . _ OOi ' �PLANS TO APPLICANT INSPECiOR'S NOTES i; OZM1'NE&DUILDL'R DECLARATION . , ., , . . . , I here6y affirm thai I am exempt from�ihe Contractai s To: ��- � � , Return�d r� , � � -: � � . � _ '' License Law�`to -the following reason. (Sea�7031.5) �� � �� ��� � - ' Approved � _ � �liu:rnessandPr f ssmx<Gode:finycityormertlywl�icb No. . Dato No:'� - Dat���� , - � � � ��. � �� . , . ,'-.�reguires o p¢m�it tn construct,-after,'improre,derwdlu7i, _ . . , 'oirepairprsyiliucturc,prinrtoitsusuanae,alsorequires . �"��.. " - ' 1 . . . . • . . .. , the opplican�fnr ru�b peimil!a fr'!c a si,qnes statemenl . , ': . �-., , ,i ;.- .. .. . • .. . "�,� r �- ~'�..:. 1- � 1raclori l ic��La�(Cb�ter 9J/nrnrr exnn�urth Sec•-.. - - - -- frnn 7000/n ie�ision j�o il e Business and roJetsrons , r . '��.� ' .�� , .."_ _��•l.r^ . '.. , �.__; '- �CndcJnrtlbtGeisrxenrflfberefromondlbebasisJnrlGc , �_ ._. . ._._ ._.. . _.-. ��..._ -�. - - -- �- - �. .- . alfegrd cremption.Aqy violarion af Section 7031.5 by ;_' ._._ . . __�. _RaqvGod-_ . '� DafaR�csir�d .- .. . -- - - .., . .-.-'�- .. . anYahhlicant/orapermrtsubjedslbeafplicantlorsriri! Approvali , a�APP�o�� -, ..,�,enalty of not morelban five.bundrcJ dollars(fS00J.J: ��• �, Y�� No _ ... _ . . __ _ . . � . ❑ I,os owner of ihe propert�,�or my employees wit6 .�.,, � . .. ; .��� . � Woter Certi(icote .. � � � _ .,. � _ __ � �, � , _. . .wages as their sole compensalion,will do the work,ond ,� � : .: . . :..r. . ... � ��-��-��� � - "---��- ���� ��-�� - � '�� � � ' ., the structure is,nor inrended or offe�ed for sole(Sec.�704a) . . ' --'. ; '�,. ,; '- Healih Department _ ._ ._... .. _ � ��.�:�.�-. . _.�' �-� . �.-.� . :- �+,, �� . �, . ., .. . ..Qusinesa and Pro)etsiont Codr.TGe Contractor's License � � � ,. �. ' Lrsu�docs not apply 10 an owncr njproperty w!o burlJs :� Fire..Depar�mero _.... � .._ ,____._. . ._ ._. .. .. � - ��. � -� � � �� � orinrprot�estl�crcon.andwLodoesaucGu�orkGimselfor � � . � � - � � . .tlrougG Gis nu�n employees,prorided.7Lat�tutG�im- Groding ��'� - � ' � � ���prnnenrenls arc not intexded or offereA Jor sale. If, , . . � Gou•caer,tbe building or improvemenl is soJd`uiel ie one , , .,� . , . .. . .. _ ._ .._ .__. _. ._. . _ . . _. � Geologiml .. . , . �-� -.�., . ,• . . _ . . ... ,., . _, ,.. . .- ' year af�omaptetion. the�nunenbvilder,u�i!!banc tLe ' ' - ' � �' � "" '��`��f �� , burden oJ pmring tLat Ge did not builJ or imrroe•e fnr (Fence)([o�oPY��on, ���-,-.- .�.� ��,.�- - �-�. --. �� � � �.-_. , ��:,�..� ._._� , • .__ . . t�❑µ�o5ornero(thepropeny,'am'endusivelycoNrac- i , . � � � .;.. 5 ,;t�., :�f'� . . - �linq ithli�ensed convaaors ro construct�he��projeci(Sec. �., i.. .. ._.. '.-�_ . . -. _.' . ... ..I�.� �" . ' ..+,�.j'-' '..:-. �70A4J,Business and Pmfessinna Codr:T/c Contrdctar's Speciol Inspe[�iori� � (Conc.j(MasonrY)(Weldinq) ' . . ...- . .. � �: -_ ._.__ ._._.' ._. ... __... '.._.-._____. � Literttel.au�Joct nntPhfJy 1n an oinrierof pr�cr{y u�Lo - �� ' ` • � �����beildi-o/ir�prnres tl cr¢nn,and u�bo aoatrrtrJs for such, lm Drainage , •._. .1 . � , . i ''_,, ,::. . --.--- - . ..'�''_y ` .` �\1 �. .,. 1 � "Co�rslracinr's l.icensrll,a¢�s{sl Ircensrd pu�idarit.'t���be.: � . Porking . ' . _ . ____... _ ._ ... . ._ .. . _.-.. -. . . .. ... ' : . ..__ .._ __ .... _._. _. � ._ i_.. � .. . . . �- t , _ ❑ I om exempt onderSec .B.BP.C,fo this , .—___.___.__. ._ . __.. ,., reason . ; . ,. . , . � ... r . "' - � � _..._ _ . . .. _. .._.. .,. . ., , Oate --Owner . � . , ..... .�- � ... '__ . _' . .. _ . . .y, l .t) ' _- i-�f_.i.r 'f _ . . . � , APProvels Dafo " Inspecfor's Sfgnature�- �J"� I l�:�,� � � 1'�.:!.�e!�::'1`, � � � � . � � . .�-. _ �-.-F: �NSPECTOR'S NOiES-' � lomlion— �ll� � i!'�/iL^s. . ._�. .. . _ . .• . ... . . . �Seiback&Yards)� � � '-� Fovndaiions L'l/ - ��//O _ " ..: . . -. .- ' . -__— .___ _._ .__ . . ,.. : . � � ., . . - . . ., S�ab . � - ., - � - ...._. _.. ..._.__.. ------. ._ __. :� .-:.�.' -. . _.. ... . .. . . ��;. .,. .. . �. ', . Frame _CJO � . . . .... � .,,. : .. . . ;.�. . . . , , Energylnsulation ___.�_ . . ._._ __ .._____;.._.___. .__ . � . ... . . I ._I .. .� ,._ � . . �. . . i.. - .. . � Lath/Orywall— .. _.._.._...------.._.__--_ -__. � :" .. ._.... -'__._...._ __._. . INeiior � ._....----..___ ___._._. .._s • � . . - . � .,. . Lath—Exterior �� ;;�.. � .. ... . . . . � . '.. ._ .___. . . .,-� .�,�� . ..__ _.. _.. ' . . . � .,... � HouseNumber— . ........_ ._....____._..___: ..__._ . . ,�, . . -. _ .._...___. . . . . Correcl&Posted ,. . . � ��� .. —_ . ___ ..... . __ _.. ___ .. . Finol— ..� , . . � � . . ._ ___. ____.._-_.-.-. .- . .. .__'. _.._.. . .__ ._____.___ ._._. En�er on Fron� , . � . .. . . . �.� . . . � . . . .. ... - .i. � " I - � �_ '� ", _