Loading...
HomeMy WebLinkAbout1239A 1240A WORKERS'COMPENSATION DECLARATION � �� - � I hereby affirm ihaf I have a�e.,,,;�a«aF�o�=e��,o,e�f - � APPLICATION FOR BUILDING PERMIT insufe,or o cenificare of Workers'Compensaiion Insurance, o�a certified mpy thereof�Sec.3800,Lob.C.) COUNTY OP LOS ANGELES BUILDING AND SAFETY PolityNo. Company � � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BURDING � Certified co is filed with e c onr uildin ms ea ADDRESS PY 9� P � BUILDING I 1 � � fian depatlmenf. ADDRE55� �Ai � Dme_I�,iS.Q�[�Applican �� C 21v � � i ��� CERTIFICATE OF EXEM N FROM WORK S' � NO.OF BlDGS. ryEq T � COMPENSATI INSURANCE � . SI2E OF lOT NOW ON LOT CRO55 . (This sectian need not be m piated if the permit Is for one TRACf 6LOCK lOT N0. AUE550R hundred dollors(f100)or 1e35.) MAP BOOK PAGE PARCEL TE� USE ZONE hL1F � I cerfify fhot in the performance of the work for whi�h this N NO. permit is issued,I shall not employ any person in any manner SPECIAL . � so as to become subject lo ihe Workers'Compensalian Laws. GONDITIONS � . . , a �} Ziv �� . U. Date Applimnf � pRCHI7ECTOR TEL �� NOTICE TO APPLICANT: If, offer making�this Certificote af DISTRICt GROUP ttPE FIRE PROCESSE�BY O ENGINEER NO. Exemprion, you should become subject to the Workars' CON;�`, ZONE � V' Compensation provisions of tha labor Code,yo�must forth- qDDRESS �- �t Y�— '3 4J with comply wilh a�ch provisions ar ihis permit shall be � . L, � STATISTICAL ClAS51FICATION AP7. CON00. � deemed revoked. CONTRACTOR Z LICENSED CONTRACTORS DECLARATION ���. . CLASS NO. 2-z-- �WELt.UNITS v I hereby affirm that I am licensed under provisians of Chapler 9 ADDRE55 NO. (commencing with Section 7000J of Division 3 of the Business and ��� SEWFR MAP � Professions Code,and my license is in full force and effett. CITY GLnSS VALIDATION S0.FT. NO.OF NO.OF CNECK BK. PG. • LiCense Num6er llt.CIO53 SIZE STORIES FAMIUES� ONE . VALUATION DESCRIPTION OF WORK .YX� Controcfor Date ADO S s�� 2�'�� �I am exempt under Sec. ALTER , �• • • •2 3 8.8P.C.for this reason � s REPAIR pa,B: �5E oF � • •�a 2 5 E%ISTING BLDG. DEMDI $ignature APPU T ���� re�. FINAL r • • •3�,2 5� OWNER-BUILDER DECLARATION N DATE I� ��'` Y I O.� Jr—S 7 I hereby aff�rm thot I nm eaempt from the Contractor's License ,/ Law for the following reason(Section 7031.5, Business and A G��+ FINAI Professtons Code): � 6y �� C 4.�}� OBUIIDING #. . . . . ' I, ps owner of the properfy, or my employeas with ADDRE55 wages os Iheir sole compensatian,will do the work and � , rhe sfrucrure is not(nranded or offered for sale(Sec�ion ��`��T� � • •5�5 0 704C,Businese and Prafessions Code). MOVING TEI. � . � � I,as owner o(ihe praperty,am exclusively conlrocting CONTRA�TOR NO. • • •5�5�� with licensed contraUors to construct the project(Ser qpoRe55 � � � tion 7044,8usiness and Professions Code). I O.� S—S I CONSTRUCfION IENDING AGENCV ��gq�� YARO HWY fOTAVROa IINE WiDtH I hereby affirm thal there is a cons�ruc�ion lending agency for FRONi Ihe performance of Ihe wo.k for which this pe�mit is iseued p.L . . (Sec.3097,Civ.C.�. SioE � P.L , Lender i Nome � Lender's Address P.C.Fee S 3�2 Ve.m��Fee �.S•�a ��"/+Ref.M � v - I cerfify Iho1 I have reod this applitalion and sfofe ihot ihe issuonce Fae /J� L�MA�/C N ^ va informofion is correct.I agree to comply with all Coumy tn.esi�ga��on Fea ces and Slafe lawa relaling to b�ilding conslrucfion, iaol Fee S�� lpMq perm.N d� reb thoriza represanfalives of Ihis County to enter p he a-mentioned properly for inspection purpases. � , __ , �� SEE REYERSF FOR E%PIANATORY IANGUAGE Signaruro f Applitont or Agent � Dole , PLANS TO APPLICANT INSPECTOR'S NOTES ,�-011'NIiKd3l41.D1i12 UL'C1.ARA'1'(OV -� � I here6y aff�rm ihal I a empl,from"the Conrractor's To: � ... . , Refurned � . � � . . . � � . . . � � � license law tor IFe.followmg rc6son. ($et.�'70J1.5) - Approvod . . llasinrs.cnndPreJi�srinnsCnJe:AnvdlY��r:u¢rtfi•u���icL � No. Date No. ' Date - . . � . -• `. reyvi -a u j�ern�i!to ronslrucL�ftrr,iinproi•e.8ernolich. - -- r<�rni nny srruotu.e.friur t�,its ise�umice,alsn roq�.r•rr , l..: , 1}�-'' ..� � ` '.�,.�, .� ' � � � � � � - !Lc�p/�lite.�t for such permit tn/ile�n.rr,�nrd s+arernenr -'�� '' "� i't , . � _.....-. � . �... � .- ._ . .. , . ._ . ._ .. . ..tbo!bc is G.rnsrJ,punuant!n thr pnre�isinns n/!I�Con- . �. ': � Y ��� .�� .__. .` ! -•� ,r.1{'� r .� .� . trailnr'al.it�t lL� r�Cl�a�tcr<)�/�'u enrm,C��.��7 Sc'a. .. . ..'' ._l�l�•, r;;'A � .. `<!. ., ,.a . .,� � _, �.�:'.`_ . . � .,.�� �{ i:;� 5 �., �'C.rdrfn}1�J(�f r�'e rt n}pt�lberefr.�n�nn�7�!�hYli/urthi � . ._ . � . • � . . . , a!le,qrJ�.rerriptrnn.Anv ianlatiors rf.Sechon 11H 7.5 hti . . .. . �''Ruquirod � � ' .�Dat Received �- ...._. , . . ... .. . _.- . -.. . � un�appJit�ntforapernwsuhjccls7Leapplicrmf�na.i�i1 .. . - .. or A roved '_...i. ...^�., -... ., .' : .._ .�i.�_ r s as their sole wm e oal on:w�ll do��,r3(`5���1 J: . . ppprovols PP '- ena!!5'n anhntnrv`!b�� rr�l und ed d!!J � ." Yet No � . . - �J h I h Wo1N.Cenif�m�e . ... . . _ � � - .- . - .- •...., ._wngP p me�York a'nd � ���-� �- ���, � �.�. ,-t .•, ,_the struaure is not iniended vr offe ed{o sole(Sec.>Oaa) � Heolth Oeponmenr-..-- .. . - . ... ...-_.. .._.� - .- . � . .� . . .13usr�iexs an�t Prnl�'.�sions CnJe:!!�c Canfractnrs l.icensa � � � ... �\:".,',ti� :,1:'' - :,`�.`��.' �� l.au��lnrs nnt ufflt•Jn a�:n�enrr nf prnfrrlv u�L,�hurRlz +,. , . „..' ��` �� r i rnnrs t!erenn,and u�bn�Joes sarfi u�urk Limscl ur F��e�ePanmem _. . . _ _ __ � . . . _/' _ . / � . fbrouRl bis�oen,empfoyres. prnrided tJut sucJ irn- . Grod�ng . , .. ' . /�snrrrnenls arr nnt inlendrJ u� rfferi•d Junsule. !/, � bn�ree�er,tbr bnilJing nr in�f�rnncment ii suld uitl in nnc . .. . _. _ _ , .. .. _ . , . . . . . Geoloyicnl ' � . . . ' ..,:. ' . . �.T�ur o(�mmplvtinn, the�uu�nrr.lailJer<ri!! /ora�tbe . �. �� ' ... �'..�.'`�.�':�-�•:_.,.' --�..,+ _ burJrx nf J.rncin,�tha!be Jid nnl h¢rld ur inrpror r fnr � � Pedestrion Pro�euion. � . - . _...� .,tl a•(�urpuse�r/.iulej, , .� . . (Fence)ICanopY) � . .." .. -. ..._ . .. .-.. . . .� .. . ❑. I,asowner of Ihe properly,am eKdus�vely mniroo - , Gng wrth Gcensed comrauo�s to<onstruc�the projeu�(Sec. Spe6al Inspec�ron . �-- � � � . � -� . . .- . ...-. -... 7044)Ui�si��ess and Prn/rstinns CnJei 7'be Cnnfr�ctnri (Conc.)(MosanrY)IWelding) ' � � .�. . : ._ .. . . . ._ . .. __. 1.iren�e I,a�oJ��os nn�upf�ll'!o un nu�ner f(�ruferh•u•bn �huilJs nr i+nprores 7lrerenn,unJ ad,.i anntrucls f�i•such � rn crts wit!a ��n�rncen s lirenscA urtuant ro !!c LoiDrainogel �'r'"; ..c .'_�L , _, �...�� �� ��..+r . ; .• '..' . _. . . P J 'r rIJ P � " �� . '� - ��Cnntruatar's l,icense l.au�f. . .... . .. , Parking. . . � . , . . __ _ _.. ._ . . . _ . . _ . . .. . . " . . . . - .' . . ❑ I am eaempt undcr Sec. ,6.8P.G.fo�this " � ' , � reason. �... . . . . � � , .. �� . �...., � , r. . , -p — -- ---.__ . _.._ _e . ... a�e Ow ��.� r.,.\.� l , 4�:�,�':}.... ,." .._. .... . _ _ . . . Approvolt Dafe InzpaUor's Signa}uro �, \�� :)�`�'�� �'�.`�_4::�^.�.�,S.�', , . . . � - � � � � � INSPECTOR'S NOTES � � lcconon— _.__. _ . . ISeiback 8 Yardsl � . . - � � Foundo�ions � � ... .� . . . � � ,� . SI�b .. � �- � � irame _. i . - . . . � . , � ' . . Energy Insulotion -- . . . . . � .-._. . . - . .. . . . � , , . laih:Drywall- ._. _. _.. . ..... . .__ . .. �... .._. . �' � , ���e,io, /� iv�', . .. . , ��. . , � ; . . . � • loth-Ex�erior . . .� . - � _. .. . . __ r'�_�,,.��r.,l . ., ...... . . . ._. '.. I - -_' '•.. _)S�1`.=•.��.;. House Number- , -. _ . ._ ._ . , ..._ . . _ - -� -- - _ . - � . - - . � . , Conect 8 Fasied � . � . F1nol- _ . _ _ .. . . . Enra•on Fwn+ . . . . � � . (1 . *� 1_�ti'� . . . . . . -��.'. "_ ... ... �, " \��Y`+, '�,,.. 4 �