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HomeMy WebLinkAbout1400A 2102A (7) WORKERS'COMPENSATION DECLARATION � ' _ � I hereby aifirm that I have a cerlificate of�o�,e�,�o=e�f � APPLICATION �FOR- BUILDING PERMIT insure,or a certificate of Workeri Compensation Insurante, ar a certified copy the/reof(Set.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Po❑IfcyNo./ ., �4� Company �_�l� Gv�� BUItDING .. /1._ _,C� Certified copy ts hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 ��:f'!f ,I/�f/Certified copy is filed with the county building inspec- BUiI�iNG p � fiondepartmenf. ' ADDRESS � .� J� LOfALITY �/' �� /� J/ '/ . NEAREST � Dma ApplicantY���-^ /�7�/h�i arv �/f� ��1� Zir � caO555t. � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS. A55ESSOR �COMPENSATION INSURANCE Si2E OF LOT NOw Onl l07 r.w7 BOOK PnGE 7ARCEL (This section need no�ba completad if the permir is(or one use zotve nv.P hundred dollars(§100)or less.) T�R BLOCK lOT NO. NO. // 7EL. SPECIAI Y I tertify that In the performance of the work for which this OWNE �CI i NO. CON�ITIONS a DISiRICT .GROUP TYPE FIRE PROCESSED BY C) parmit is issued,I sholl not employ any person in ony manner _ CONST� �� so as�o become sub�ed to the Workeri Compensation Laws. ADORESS . IN �. 0 5� 1l/ 0: � �ITY � 21P '�' `, Dafe AppliCanl STATISTICAL CLASSIFICATION . A7T. CONDO. r ARCHITECT OR n lEl. U NOTICE TO APPLICANT: If, after making this Certificote of EN�iNEEa l� No. - � C�ASS NO.�DWEIL UNiTS W 'Exemption, you should 6ecome subject 10 the Workers' T � . 4• Compansafion provisions of Ihe Labor Code,you must fonh• qDDRE55 �L-G�C�f� �S7f1' P-S� , SEWER MAP �� with comply with such provisions or fhis permil shall be -�' � TE�• 1 VAIIDATION deemed revoked. - CONTRACTOR �/✓ NO.) ���f J BK� �� LICENSED CONTRACTORS DECLARATION LIC. I hereby offirm thot I am licensed under provisions of Chapter 9 ADDRE55 3 L-'S7�JCi(/� nlo.�-/��� VALUATION � (commencing with Setlion 7000]of Divisio�3 of the Business and —, �, �� �/ LIC. -/ g �✓ Professions Code,nnd my license is in full force and effecr. Ci7Y ��s.�'+7.�TC�N cu55 '7"� � 6 , . - '/I� /��7_ � SO.FT.. O.OF NO.OF ' CHECK License Num6er� '�" d lic.Class`-�� 512E � SiORIES FAMIIIES ONE � � _ �� ao.oa �F A1� fj/!.�' 7-/7-Y5 DESCRIPTION Of WORK NEW Contractor Dale • ADD � �• •.• •23 �I am exempt under Sec. -��"�`�-� -�-7�� �77��nC'({' AITER � FINAL ( • .3 2 9 4 B.BP.C.for rhis reason �" �C� ��E �a �REPAiR DATE � USE OF -� O FINAI � • • •J G 9�l c=i Date: � E%ISTING BLDG. � �I �T/D��_ DEMOI ❑ - � � Signafure �9<A PPl7 NTT �.-�c-RI1/ /.�r/ NO. '�/1_7'J"� I BY t �7.� 7�8�J OWNER•BUILDER DECLARATION �� I . 1 , I hereby affirm that I am eaempt from 1Me Contractor's Llcense � qDDRESS (�SJ�S e ���/J� � Law for the following reason(Section 7031.5, Business and Professions Code): R �� I, as owner of the property, or-my employees with qDDRE55 $, �. wages as iheir sole mmpensation,will do ihe work and � �2� Q 2�i the structure is not intended or offered for sale(Section ��A��T� � - � � � �� � . . . � � 7044,Business and Profe:sions Code). � MOVWG TEt. , - � . � I,as owner of the ro ert am exclusivel [anlractin C NTRACTOR NO. � � • � P P Y. Y 9 J e •49.25 with licensed confractors to canstro�t the project(Seo- ' t x tion 7044,Bosiness ond Profeseions Code). ADOREss B 8.�� �Jr c> REOUIRED TOTAI SETBACK fROM EX157. ��g^P J CONSTRUCTION IENDING AGENCY SET BACK VARD HWY pR07.LWE wiDiH , S I hereby affirm that there is a constroction lending agency for feoNi � � ihe performance of the work for whith ihis permif(s issued � P.L � � (Sec 3097,Civ.C.). � Si�E : - P.L. m Lender'a Nama � t1� $ P.C.Fee 5 T Permit Fee , 7 Lender's Address / � I cartify�hat I hwe read this applicotion ond atate that the � heua ce Fea .�b� � ebove information is torrect I agree to comply wilh all County Investigation Fee ^ r � � . � g ordinances and Srate lawa ralating to building construUfon, Toio�Fee �7 YS 6nd hareby authoriz�Qpr ntativas of this Coumy to emer � � upon3 above- erntio opery for inspectfon purposes. � ^ /� , � �� -�^� SEE REVERSE FOR EXPIANAiORY LANGUAGE $ipn9 ure of Applicam or Agen�� pofe . � ��0� � iLi�.I1�iCAF:'iICF.P77 � . � j 1'r . � i:.'_t� �`_f�'���- , .OR\c1 UILn P�CL6P T'IOti. . , �. . � _ _ ._. .�Ferco f c..�r t �s�ri a�.I ir m tt c Contrector's To: .�.I j .T.clorn d . . .. � . � y . . . . Liccnsc l�r.t f I�c f�I o� n.� r n on .�S �7031.;5) .' . ,. . 7 -.i� .1 �.�`.. _,..A � l C' � �' rtt� rr .n[}uddcG � t. � � •ovc 1 (`...�• . _. . .. . - . .��.._ __t��..i, r 1 n .�' �. � No. � .� .U_�o . . ... �T.�. -. �D�r.n .- � _ . � . - rc r..�. ,. . i� ,r � •`dcmolisl, -�-- ------ ' -.. -_-...,..:_ � _ pn,•miys c i��/+rr i r r� irr'uBorrqurrrt _.—. �_._"_. � r:�r� _ _ _._ _- - - _ 1--. __ _ - - - ._ -- - ' � . � � -. t���eppG��s^1 j .rl fe.v+r t Jl�u s qacd rtarem.�nr - --- -_--_. - _.. ._ ___ ' � tia:b�ic li�evurd pa.rr��.rt to t!c t,rnnrriant o�fl c Cors-. . .._. ..`_._� .I.__ _ .._.. ___. ._ -� • 1n::1nr'sl.rcn 7 'rr9/(cnnnucr.cinqrcilbSec- � !,r , �': , . i r - / , . _- . . I . ---fi J l00J u;U . � ��f 7b�-1J .'ness an3 Pr fcssions i �- -: .. ' ..i i ;.i..•.I . :, : . ,. . , C 1J t.�!! r r. ���t�h !. - cv�<<1hrGrsisforthr ' .� ...• � - . � . .�. vb 1 ..� .�t � � �n � S un7031.56� i'_ _ fi ...,�.��. _-.I- Ycs �'cM1�. .�_Da}� ro�ed I �..'_... �.,�. I .. -.- . . ._.�_. . f,�.:)f!l,.c r.c r I ' .7 '�,!cFrt fn a ciri: - � _,- - - -- �t t ��f� l �rs(;'SOOJ.J: __ , ___. . . .r cf..c:propu ly,or n em loyoc�s.with Wafer Cert iicutu '� `. . .� - .� . . , .. � . � , , � wcr.^:s as t6r t. �.c m,cnsar�on,will dc thc wcrk;and ,. . , . ' {."..I I - - ; � � ,_ , .�.� . . �... '- �__ �.�tl�.i str�ctu:o i,nc.�r. .r,ilcd cr c{f..�d fcr:cle(S�c:7044) . �•____.. .......__. _.._ . . ..,.. . � �� -�. ., ' �r F r. � , n•�trcc(nri l,iccnsc Hedllh Depo:l-'cnt �_.:_ _ �_ . � .s � � � . .. D . . . . s Cr:f:Tf�e C .... "--... _ .... __..', ..- � � - _.__-._ . . ___ _ . _.. . . . � . . - . !<.c�a__r.�t.��;r.ti t:,_r,n::�--r o/P:r:pc:IY wbo builds Fire De artment ' . �.� �... �-• ---` , r r.".v.�' .!- s :�cL i�nrk hi�iiarllo'r ` ' ��� 1 r l�Ir, .i P � _�._ •� :. l . ,... � ., ... . � � __ .._ . .�. ._, --. ..____. : .� . _ . . . � ?ror•y'h�nev ae T en:(•Ir�e , j'r�ie i<+,d tl at'a¢el Gradin� . . . . ��. . • � . � . . . . _ _ . �.. :.F.n .t. �r t-��t r � �� '.n/f��rrd f�r sal :I� . ._ .�. . .. . ., . _...,. ... � 1� - � 1��.,:. ,�'.(�.r r � � .,�:��<�:tic�so!duit7�r:nrre , . ... .�� . �,� . .- . ._____:'_ .'.-. , _ . Geologim� , . . -_.. .. ._ _.� � . _� -^— . . �� �c��r•r »„ t?.� 1:.i11cr u•il1�/2�e tle , � - � ,�jj'i� , ,'.,,-p,���e��r Pedes!rion Frotecticn � � ' , . . . .r1 1 rpu..o/ 1 I � . .. . ;,. .\, ; .� C'\. . ( _. . . . . (FenCe)(ConopY) . ..� ' •. �_. . . � . '. .-__ . � . . '. '. I� I,n_n n�r�.,hc�,rcr y,r.r escl�,:velNcontraE- .. -..'..� , _ _. ..--'---_----- . . -�ri � -�dl,I!o.; .c-.n•r---�^:�_-c�;trua tli-�ProieU(Sec. Speciallnspeclion ; �, � . �. .. -_._ ... ��_�'__ __._. . � ... .. - ' ._'.rC .1, . ..I1 c� -.;. Co.'r:lheCur.tracfn�3 (Conc.)(�+tasonrYJ(Wclding) ��. , . . - . ... . I. .f .. �ttt � o�.�::rrnff�rnpertyu�lo _� �.:. _._.___.. __----._.... ... ._._. _- .. . F;/l,nrr ,,, .�ct�r,-� .,_r:� i.F��r,�r.trm�!sfnrtuch , . . . ,. i, .. , .. -' � "- --. (, . . . I . Lot Drninag� • � _�. ... . � .. , .J . �� r � ,,, .. :-.r- !..r nrt to L�br ., u ' " ". ____. ' .1_ _ .. ..._.. .__-,v.tr...��� sf.�. ,,. 1,.; . .. . � � �. , . . ._ _ _ _ _. .. . � ��.. : ' � ' . _ . Parking : � , .:: . , � .. . . . . - '• . . . . . , _.___ . ..._ _.. __ .._ , . .. �.. __. --.-' �.. .._ ..-. .. _-.0 .'1 o r�c :n;�.un.:_r..:c.� .GSP.C.for fhis . � . . .. . .. � . . _-'—_. ._ .. . . ._ . ..._._ _"__ __. ___.__ . ., -.._.__'—� ____. _— ' _ � ' i. _ ._.. "_.. _... - - � � r< �� .,... , .. , , ., —__ � _. , .. . .. .__ ___—_J- _ . � ;,�. . . .. , . �.� � .. ._ .._ ___ ._ . ___ - � � � r- �_.'.. . . . � . _ . . . Darc " - " Ow .. hpprcvcl; '� Cctc � In'cc:or_ „ u... F—. .. . . . . � ,. _ � . '". . . . . . . .. .-, ______= I_ _____- _ ' ^ r_. _"_. . _ �� ^ ' Locatian f ( . I __._ . _ ._.__."_. __.. . ..._.. _..._... . , . ,- (Setba k E Yards) ' ' ' Foun�dot . . '� � ld OJ� ��Q..��9-`c/ . ( �T -. ..� � . �, �.. . _. f'� Slab;, � ' . . ... � . . �.. . I , .,: �.. . � , -,. . .. . - Frame _ ; •:.. . . , � ..� �...' . . . _.. ..n: ,-. ,�. �,_. ..,,..�.:-,�. . . -- - -. ._. ... _. . . . . �. Encrgy Insulo'ion . I . ' �. ' , `,..(.. . . _ . ' . .. . ,.,- -_ . •__._ .• __.___ __. _. . .___ . _..... .. �.� ,. � "i ' ,. _ Lath/Drywall- �� � . . . ' . � � .. ...., .... ., � Interior ,I ,.. _ � . �. � . ,�r �.'o',�:'.-,_: ., Lath-Exterior .{_-__`. _.__._..,: ._'."�_:�_... __� '.• . �.., .� ... -_ . .._.'_.. ____._. .. ......___ . ... ... . � ����I �- House hunbcr- , � ., � , � ,.....:. .. .... . ... . ..., .,, . . . CorreUSPas'ed ...___._.- � .-,_._..:. .' _ .:._._. ._ .__.. ._ .. .... . .-.� . . � . , , . .. Final- � � � .—. _-- . . . �. ' _ . . _ .. . , ,i�.i _' Enter on Front � - I .. ., . . . . . I , —__._—___-___ __ -_�-____ . .