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HomeMy WebLinkAboutNo Permit Number (217) WORKERS'COMPENSATION DECLARATION � . n I hereby af,;.m r�a�� �a�e a�e«,f��a�e ot�o�sa�„o se�f .� APPLICATIQN �-FOR �BUILDING �PERMIT s insure,or a certificate of Workeri Compensation Ins�rance, � or o teriified topy�hereof(Sec.3800,Lab.C.) �'��• . . .COUNTY OP LOS ANGELES � . BUILDING AND SAFETY � �cyNoR�S 09 26 2lcampany ROYAL INSURANCE C0. Certified m is hereb furnished. BUILDiNG PY Y FOR APPLICANT TO FILL IN ADDRESS O `. � Certified copy is filed with the county bullding inspec- 6uitoiNc tion Clepar�mBM. ' . AD�RESS 1024 SOUTH�BREA CY �ocnirtv-- 3-6-a4 NEAREST ' Da�e Applicant ALLAN J. HART ��rv zia caoss sr. a � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. A55ESSOR COMPENSATION INSURANCE SIZE OF LOT SEE PLANS NOW ON LOT 3 MAP BOOK PAGE PARCEL (This section need no�ba completed if tha permit is for one U�E zoNE hh4P hundred dollars(E100)or less.) . Tf2AR - BLOCK ____ LOT NO. /,_� NO. �� 333 ' '7EL. � L 1. SPECIAI 7- I certify that in the performance of 1he work for which thts OwNER NO. - �..7 CONDIilONS C permil is issued,I shall not employ any person in any manner � �� � � � � - OiSTRiCt GROUP 7YPE FIRE ROCE D BY � so as to become subject to Ihe Workers'Compensa�ion Laws. AODuess y GONST. �ZyO�N-E V oL � Gy— L DOtO N�A � qpplicant N�A - CITY Z�P STATISTICALCLASSIFICATION . APT. CONDO. O NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECi OR TEL � �. � U Exemplion, you should 6ecome aubje[f to the WOrkers' ENGINEER NO. � QA55 NO. � OWEII.UNITS a Compensation provisions of�he Labor Code,you�must forth- qpoRe55 SEWER MAG � wiih comply with such provisions or this permit shall�be � deemed revoked. [ONTRACTOR NO. � BK. PG, - VALIDATION LICENSED CONTRACTORS DECIARATION LIC. ' I hereby affirm ihat 1 am licensed under provisions of Chapter 9 A�DRESS NO. VALUATION (tommencing with Secfion 7000)of Division 3 of the Bosinass and LiC. � Professions Coda,and my license is in full(orce and effect Ciiv Ctt�55 S .. 184669 so.�. No.oF NO.OF CHECK license Number Uc.Cbss B 5¢e SrOeiEs Fw�,iues on,e =�1 G 5.Q Fl s Contrac�orSPENCER & JONES pa�@ 3-6-84 DESCFIGTIONOFWORK ,c i�� N� ❑ t! • • • • •1 �I cm exempt under Sec. N/A ��/v� '�t� qDDR � FINAI ' ' '�C.5� B.BP.C.for this reason . . . . . REPAIR � DATE -�"1'8�y , • • °����� . Date: USE OF p��� FINAL �-- � � � EXISTING BIDG. � BY G a 0 6—8 4 Signature� A7GlICANT TEI. OWNER•BUIIDER DECLARATION - PRiNi NO. _ _ I hereby affirm that I am exempl from ihe Contractor's Licensa ► ' � Law for Ihe following reason(Section 7031,5,Business and ADDRE55 � �� - - - - � Proieasions Code): . � .. � . - � ❑ BUILDING , _ I, os owner of the praparty, ar my employees with ADDRESS wages as their sole compensation,will do iha work and ioCnLlTr the siructure is no�iniended or offered for sale(Settion .- � . 7W4,Bosiness ond Profassions Code). MOviNG TE�. � - I,as owner of the property,am eaclusively canimcting f MRAC70R NO. with licensed contractors to construct the project(Sec- qooeE55 �tion 7044,Business and Professions Code). .,. ._ . . . ��REOUIRED TOTAI SETBACK FROM EXIST. CONSTRUCfION LENDING AGENCY SET BaCK YAR� HVJY FROP.LWF wiotH , �hereby affirm Ihat there is a construction lending agenty for pkOM � � the periormance of rhe work for which this permit is issued o.i. iSec.3097,Civ.C.)• . � � sioE P.L lender's Name NONE $ e Lender's Address � P.C.Fea E Permi�Fee � I certify thm I have read�his applimtion and state�hm the - � issuanco Fes 0 S Sabove fnformation Is corrett.I agree to camply wifh all CouMy Invevigation Fee S g ordinances and Smte laws�rela�ing ro 6uilding constrocfion, Toial Fee � . b and hereby autharize represematives of ihis Counry ta enter . � upon the above- Enrio�ed-praparty for inspedion purposes. . � � � - G:'��� 3�-G��� ' SEE REYEKE FOR F%PUNATORY LANGUAGE . , � � Siq ra of Applimnt ar Aganl pate . . ..�i � ".PIAiJ�TO wPPLILANL � � ' �'INSPEC70R'S N07E5 � ,. � O�ti'NLSLUUILDGF2 DFCI,ARATION _. , . �I he:eby ofF rm that I am exempi from thc Contrauor's . , . . „. . . . . . . . . , . . ... , To: _Rcturnad .. , . .. , . Licenso Low for Ihe�foliowin��reason.�(Sec: 7031.5) . . .. ..� ... � Approvod .�Gxsinoss and Prnj^as?nns f.odc:Any aity.or manf}'u�bicb Nr� -""--'Do4o�..-�- -- No: —�Dufa-"---- --- .. . . ... . .. . .. '.��-rcqr+irrs�a/�rrisilfo�constrrlrt,Ff:^r.iu:prooc,'denroJisl, . „ . . . . . _. . ;. ..-__' - � _ ,.. . . . . or rrfairrtny strtrc[urr,f�rinr 7n itt irsuar.cc,al.cn requires ;_. . . __. . ._ _ .. .. . . . _ ... ... ._. .. _ . _ ... ._. ... ._ _.. '__ � �'�,, `.._ �.. . � . .� thr aphficunt for suc!perml!to frlc a signed sta(cnrcri! � � � � ""` � -�� " " ' ' �� tl et 1 c is Irronud/�arsuant to tbe'/�rorisions of tbc Con- `_ _-. ._.__.. __.. ... . .__.. . .. . .. .... _.._. . .. .._..___. . .. . _ _ ._ . � � �� trarfnr j l.rmnsr l.a�r(C.bapter 9J(ton:nrcncing u�itb Scc- . ---�ion 7000f n/f)i��rsinn j of tbr�U�sbiess anJPiofcssinns � _ . - . CoJcJnrtl:itbcrsc.rl�r.if.atlrr�/ronrarsdJli�basisJortle � al/eged errmplibr.tir.l'+'inlutrorr ojSeetran i031.5 by ' _...�.. �oqutrod� Dafe R�colved• � ' -_. �' :.� '. . . ..:'..u'r�cn�alidxutJnrn.j�cnrri:suGjectr�tbrrrrrlicantfoaCi��i! ..'__.___A..:ove}s -' Yas No.. __. _ .,: -. .._ _ _ : � �._ � _ nitY o�not ninre 1L:n: �or Approred pcn � �j're J undred do1larr(SS00).J: - . -....., . .. ... .. . .. . �� .. , .::❑. I,as owner eF�he propsr�y,.or.my employeos wilh Wa1er Certificate`, ' . � _ , ,. �_ _. . , �+'oces os th-_ir so�c compensclionjwill do fha work,�pnd . ����'' � .. �, �. �: � - '- �.�fhe structuro fs iio�Inteniled or offered for sale(Sec 7044) Heallh Department � -'.� -_ .__ - _ - � - ' . � - � ; �.�,�,�; Uueinrss ar.d PrnJrssiovis Codr.Tbr Cw�tractor,'s Licrnsc � - - -� - �- . - � _ Lou�dacs nnt ujplv to an o�<•ncr oJproperl,y u�Go builds FiroDepartmont � . . �'�- . � . _ ���rrmfYO!�C41I.�errorr,-crrdu•Lo4nrrs•�cGu•orkhinrselfor - - -- - -� . • � - � . '. . • •-, . � 11_rrnu�/,'lris ortrc rnr(ilvYccr, J�roridcd tTia!sucG irn- Gradin9 . � - . . ., ..... . � , . ..... . . . � p�n��arrcnl, arc �:�1 iictcr.dcd nr ffcwed for safe. If, . � fio�e�ei�cr;lbc'Evif.'in,Gnrrny�ioreneoutissoldeoilbrnona . ... ... .. . � .. "-... , -'...... � ' year nJ.comflet nr•. tba oarrr.5r i!:! tt (7 bac�e tGr _ Gcolop cal ' .. . . . . . . . . . . . � � .. .... . .„ ,. . . .. _ _ �� - hur�cr,n ro� ag lL�ut/ a'I i.nl I,liilu or nn rqe r or Ir r.,.� J Pedeshian ProtcUion . .� . .,�:e1 e/+zirpose af saleJ. . . . . .. . . . , . (Fence)(Canopy) � - '- ❑�.�I,as ownerof th.property,nm exdusively controc- ' � - , tirtg wilh licensed mntractoa to mr.st utl the project(Sec. � Special Inspedion � . .� :.- - --�-` .� : . . -- � ------ � __ 709a1 G:uinos�nad Prn/essicns Gode:TL,r Contrecror'a , (Conc_)(Masonry)(Welding) � � , _ Lirrr.sr l,am Jacr o�nt e/+/>!v to ar:nu�ner of j�r�rrty u�hn ' .- - �- ' '" - �- - ' -�- � � __ huild�ar br;hroras tl�r n rr:f rrl n rnnfr'acts for rac! Lol Drai�ec�e- j '' � . �� ; -. ,�.� �,� ���� .���.. (r jecls iritLt c ntm tnr(sJ lirer.sed pnrsaant to,�ll r r : _ _ _ .. . _ _ _ _ :�„�,�,<<->:s .�.,,-«r.�:,i. - Parking , . � . . .., ... � . _ . . . .. ._. .. �.,,., ,,., . - �-� - - _ _ __ _ '.. . . - �- �-- �- � ' - �---- �- � ' - . . �❑ Iamexemptunder5ec. .8.&P.Giorthis C - .' _. ._.._ _._ .. ..------ ---- _- _ .. , . _. _ . . _.. _ . ... . ._". ,050� . _ ' � _ "'. " I �" _'____'__.-__. _ _._._.._.__. .._..._.._ . . . Da+e �Owner Approvcla Dcf: Imp�cler i Sign�turo . . . . . IP:S?'QO".'S N�JT55 - Localion- __ '_ . . __. . _. . . . . ._. . � __ (Setback E Yards) �� ' . . .' .. . � .. , . Foundotions � � - � � � � - � � - Slab _:. -. . � . . . . . Frame . � , , . . . . _ . . . . ,. . - • Energy Insolation . _ .. . .. ' . . ...� .:, ,- ., . ..,.. . :., . . �� Loth/Orywoll- � . _ . , - � ' Interior . '. .�� ' . � Lath-Exterior . _ - . � __ .. .. . ._.. .. _ .. . . . .. , ,i . � House Numher- \ , '�, .-___. . ..-� :. � �� . ., �� � .. , . . .. CorreUBPasted � _. _ . ._ .. _. _ .__ _.-____.- � �,.. .. _. , . �. Finol- . . �. . . � . Enter an Front .. � . . . . . . . ' .