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HomeMy WebLinkAbout0895A 0896A (4) WORY,ER$'COMPENSATION DECLARATION � - - J"� ,I hereby affirm ,�a,I have a certifica�e o��o�=e�,,a se�f � APPLICATION :�FOR BUILDING PERNiIT � Insure.or a certifica�e of Workers'Compensation Insurance, ,LI or a ce�tilied cmy�he.eof(Sec.3800,La .C.J _r � COUNTY OF LOS ANGELES BUILDING AND SAfETY P❑ol�icyNo.--� �0 Compony � < Certified copy is hereby furn�shed. FOR APPLICANT TO FILL IN qpogEu nL� nf�,(.q� � � � Certified copy is filed with fhe covnty building inspec• BUIIDING �7 tion depa�tmeN. ADORE d� � CC. • Da1e ApplicoM� CITY ' 2i� / IOCALITv CQ...✓P��., �G/�i RTIFI TE OF EXEMPTION FROM WORKER ' S¢e OF lOi NOW ON�LOTS ' C OSS 5T. /✓�Pi(� � COMPENSATION INSURANCE (This senion need nat be compleled if the permil is for one ASSESSOR hundred dolbrs(E100)or less.) TRACf BLOCK LOT NO. . Mqp BOOK PAGE PARCEI � TEI.�j USE ZONE O? /�r�7t 2 I certify Ihat in the performonce oi the work tor which Ihis OWNE NO. �' �� .ti� uJ -�� � ��1•• SPECIAI permit is issved,I shol�not employ any person in ony manner ADDRESS��U !�L � CONOI710N5 � so os to become subjecf to�he Workers'Compensation laws. O CITY ZIP / S V Dale ApplimM � . � NOTICE TO APPI�CANT: If, ofter makin �this Certifitate of ARCHITECT OR TEL � DISTRICT GROUP TYPE FIRE PROGESSED BY O 9 ENGINEER N�� CONST. ZONE h Exemption, you should become sobjetl lo Ihe Workeri - . /� �'` V Compensation provisions of the Lobor Coda,you must farth- qDDRE55 �� T,1._ « ith comply wifh such provisions or this permit shall be �- deemed revoked. , TEL. / STATISTICAL CtA551FICATION APT. NDO. � CONTRACTO NO. UCENSED CONTRAC70R5 DECLARAT�ON . . Cy�C. QASS NO.�OWELL.UNiTS '- I hereby affirm that 1 am licensed under provisions of Chap�er 9 aDDRE55 w C'JNO. �i�iZ . (commencing wifh$ection 7000)o(Division 3 of tha Business and LIC. ��R�'P Professions Code,and my license is in full force and eHecL O7Y A. CLA55 � BK � VALIDATION � SO. T. NO.OF NO.OF CMECK li[enseNumber���liC,Class� S2E S70RIE5 FAMI�IES ONE VALUATION DESCRIPTION OF WORK NEW Canfracto �N Date �.� /' �f� ,y ADO ❑ 3 � �� ��8 9.�J a �I om ex mpl nder Sec. .(!T �^�i" rN�'»"�/ ' � � ALTER �. • • •�3 B.BP.C.f his�ree n REPAIR s . USE OF I • •2 S O O � - EXISTING BIDG. G DEMOL '$i nat � . APPLICANT - TEL. fINAL +� 7 �+ � c z 5'O�� '~ 9 OWNER•BUILDER DECLARAT N � PRINT e.✓ NO.�D�-/ F/ DATE I(/ �.J�� O g.2 O�S�I I hereby affirm that I am exempt from th Contr tar's License qDORE55 �0� f L !65 � Law for the followi�g reason(Section 7031.5, Business and FINAL Protessions Code}: N � - SY ❑ BUILDING . I, as owner of the propeny, or my employeas with qDDRE55 wages as their sole compensmian,will do ihe work and ip�q��iv � ' �0 8 9,b A Iha structure is nol inlended or offered for sole(Section � 7044,Business and Professions Code). MOVING - TEI.� {�. • �• • � � �,as owner of the propeny,om e.clusively contracting CONTRACTOR NO. with liceneed con�ractors�o construcf the project(Sec- qooQEss � � b •3 h.7 5 lion 7044,Business and Pro/essions Code�. � �� �,�" _ CONSTRUCTION IENDING AGENCY SET�BACK �YAR� HWY ��TAV OtP.LINE� WIDTIi ' , � a �3 C 7 5� I hereby affirm Ihat there is a construclion lending ogency(or FaOrvi . - - Q Q 2 Q�-8'] ihe performonce of the work for which this permit is Issued a.L ' � - � (Sec.3097,Civ.C.). S�DE �.L Lender's Name S LDMA Ref.M 1O � � G.C.Fee S P�rmil Fee � �G•� lender's Address � I certify thm 1 have read this opplimiion ond s�ate tha�the issoa�ce Fee �U"5� �orna PiC M ' � abova in(ormalion is mrrecl.I agree to comply wifh all Coonly Investipotian Fee 3�,� � � $ ' and State laws rebfing lo boilding construction, Torol Fee l�hw Verm.M and hereby uthoriza representalives of this Co�nty to enter upon th ove-mention roperly for Inspacfion purposes. �' SEE REVEItSE FOII E7(PLAHATORY LAHGUAGE � SignoNre ot Appli<an�o Agen te - . FLANS TO APPLICANT INSPECTOR'S NOTES � �))5'�I�.K-fiUII,UI�,k�1)liC.l.:\kA.��IU� I I. .cby nF� il-:�I c c _p'I ��.���Co.�.a���.�'s � � � Toa �. . � Retumed�.� � � .� ", . � � : ' � (. , �.;� . • � .�' . � 1,, l<e -� Lnm f 4 c ,fnllo � :I r � Iti� .� h�l 5� �- Approved . . . 13 . .��nd 7 r,J�.�cinnc(:ud��iln� -(�..in�un h�hi;/� - .,. . .,.,, ....- No. Dnic . N � ..` Daro . � � � .�.: �.. . <. .� �� r l�r�� /�.�trr-�„�„nsrn«r,eRcr.� p,���+'n�.� . ,!.i '--- ----- � --- � �--- — .__- ---- .... , : . ,� :.� �{ , , ; �1 � � ; , :' .. .. . . , rrr Yrl p n„rIm/�,r �! rr4 t �> �, r.r„ s� _ -1 i. - -` - -- — '' rfr � ` , ,7(at! s! . JJ r� n(tni,ip r.� 11/ (..r � � � i!, �1]\��_ . . � t�r!� l.ia . � f.u� (.l�a�Irr 9 n ; _. .` �� r� I .iI n�4 -- .._ � ` ' ,�S. ��.: � . � / � �� a �d 1 ��- _. .___ .__... .. — , .., ,.. , !r n��UflJ,u/Ui�i��,�n 1 !t! .rri�'c.rnJ ' /.� . ;, . .. � _ ,. . . ., . '�'.. . . . .I.. �. � �'�� .i� .�` � .�, .�ti::•.� , -_.. ..`'C !(�lurdw''�L�b'isr.u�nrf�t! re/ ,�l.a�td„•S -r rd,r. �-- � - - . .. � ... � � � � - � • _. _- ., !f��Jer�>rrpri�rs. �ni � !a� /1e 1 1�31 !� - Reyuired� • ��.•`Dat SRe<civod -. .. .. -.• �, � . .-... . . - -'�' � c Pfl.dnt/�nurion ! hJ ! d��Jj1�-nt! ✓ � �! I; App�o�ol ---- - o�Appro:ed _ .. . ._ . � . .. _ ... _ _. .. _ . ��-P� ultt /n.ir nu�.r�Fu rl .! d d J f! s(�5l�0/b . . . Yes No_ ' . . � --_ —. _-�_- _— ;���- i . I,oz o -ner of rf� p opr.ri� or my rmploy .� ��, F�` „ _ ��„ � � , C . � ,�� .-.'� � �' ..�;. .�_, . _.. .. -..-,- . , . .. . , y+ngo:ns.ihe so�e coriF nsnt nn.�r n d:iFr.�nr� aroi ... , ._� .. . , _ .�"_ .. _ . _ . _ ... . , . .. . . � . . . .. � . �� - � thc s�•ucture is not inlcnd�d o•of(ercJ 40�sale(Sr< 7U4d) i , � . ., ". HF�'•io ii�pn.rn.r��r-.. __ .... _.: _�: :��.; _._ ._ . _.. . .__._ ... . .. ,� .. . . . 1,. . _� - , Busirsru a>.d Prn/ru�ura•.CoJr:.7hr Cnnn.r;��or.�f -, -'1`' ,..`,,, '� � l.um dn�•s nor np�lr ro Nn m<nrr a/propr�r�r.1,�hu�Lls Fi�F Drpat!ment . . . -. � . .'. . . ��. . . ' "_or nnfrnr�'s 7hrsr,r.�,�n�!I<'l�r,do�•s.�'��.1 v��,ri�./,�r�ttc!/�rr .. . . . . . _.. _ :r,.�,,,�n r,�, „«� �,�,�i,,,�•,•,. p.�,�•;,r�d rr,..� : � < <- G��¢o.�< � '�.��-� . . . pmi crnentr «rr nnt irctcndrd or u//rrrd /nr s 1 //. .. .. -� bnu e�er,d�r 6vildrn.r ar iriipru��ernent is n�ld�nthui nnr . � � � ,. . ... .._. __..... ..._._. (;e�oloq�m!• � ' I . . . � . � 1'��r n(erurrpl,•tinn, tha mr rcer•FuiF.lrr u i(!ba�r th�• �-':�`.,�.� . � r F,, _ �F�rJrn n(1'rorini'�hr,t!•r did n„t 1wr1J nr impr�,r r fnr Pedexfnan Prorechon� . . , . . , . ... ,� , � C ` ' , t! purposr�/ ¢!•J. �. ... . . �P•v,•;� \iS':'�� \ ((�nce-1�Conooy) ' �\ � �� '�" ' - �� I,a's owncr of ihe p ope�ry,om ex,li.lve�y'cnn�r��- `� , ..�\`,,.,`.r_,`i 1 ting wuh I�:.m�sed mnlrocturs m construci fhr prcie.t(Sec .. . . . .�:..� •� . 5rn:�.l I.�,vecYe�, r .._�.�_._. . ..� .., . '.:..,, .. .. i �., � -'.`,,�..- � �; 70a4)1Sucinesv unJ Yrn/essioru Cnde�TG� Lrmfr�erfns's iCnnc �;a�ascnrv)(LVelding) '. .. ..,... �� . ___. . � _ . '--. . ._ .`c ---. -- ���� .. - .._ l.irrrs��Lw�d��nu(a/pft!t �7 rti•ir<rrJpro),rrtt u�bn I �' ..,.;. _ ' . � � ' � b ffsy c !! r ! rl i� r�nt.J r.J� ' .ci Dra�•;onn I �.�'. . �.. " ... ;._.. . ___ ..... .. . ' "_'..___. _....._._ _ .. .( � /q`i� !y .a ,� t� O rrl .� tr [Hrf)> �u:� t � �d� :,�i�' � , rtn<i<1r,r c L�u x.�e I iii.J: ��- , � P:�king . . . � � � . _ __ _ .. ._. . _. . ..__ . .. �. , . ..., I am e=emp�under Sec. .B-AP.C.fa f��; , . . _____. ._. . . .__ _. - . . , , ` ' � '1� � reoson .. � ,� ... . . . ��. _. . . . .,�,��'S�� - . ._ . ._ . ... . .'____. � _'_'__�._ . . ' , " _ . ' ._' _ , , � . Do.e 0�., . , - � .,".? �.��'� �. ���,���+�. �\ ... -- --.. � _ .. � I � . . ..._. . . �r _ --. . . . . . ` _ ._. . ._...�___ .. . . Approvols �o1e � Inspecfor's Sfgnature �'.�`. . _. ,��\. i .��,',.,t.,�:1'j\ t�'.:�, � � � . ._ �NSPECTOR'S NOTES.' ' � . . i . --- ---1- .�:��,�� _ _ __. . . . fS�•t..:t n Ycrclzl ' � ._._. .__._ ' ' ' ' .- i . . Founa�t�r,ns� 1. " . _____._. _. . .. . „ ' � . .' . . .. � ... �... ,.. ,. . ,. . , . ,._.... ... � S�ob ' '� � � �. � .. . , _'...._...__._._..._.._._ _ . _ _ � . __.- _____.. .._ . .. .. ....... . �.�. ;' � �.,.. . ' i P.r.... . � . .. � . . � ;. � . . .. .. . . . � EiierqVin•:uln��on �.� ' �I _ . ._.. _. ._. .__.:: _:._. ...._. '_. . ...._.__:_ . � ,. ' .. .. ... .. .. ... . . . . _ I � I i i taih�D•vwall - --�-- ... - .- .-'_ . __ . . . ..._ . . .. ._---- . � � � - . - In ___. _ _. .. .._. _ . � '� � .,' .. . , - r�r nr '. , ' �. latn-Eai�nor ,��..�.. . � , ,. � , � � � � . .__.._ .__.. __ ..__.__ ..___. .._. _ _ - � . .. . � .___ .. ._.____ _._.... . .. ' ',I ,. . .' ' , , . .. ,. —' . _ _.�. ..... . _'_'__.__' .__._. .,'_"'_"_ __. ' �, Hovs^N.mh.:•._ . . . . _ . ... . .� .or.ec!h Fostcd � �. , - , � _ . -. �. ..� . �.., , F�nal - . -_ _. . . _.. . .. .. .... .. ___. . __. , ' . . nl�r cn fr�n� 1� - �� . . ,, ._. , . . . . �� i r � � . ' , _. ' _ . .. � . . .. �•'� � _� �� f-._.�J1.,1 J':'.'_._- . . �. � � _ __�. _ ._... _ .._.. ` ♦