HomeMy WebLinkAbout1241A 1242A WORKERS'COMPENSATION DECIARATION � ��Sw�bo,p"�e„f�o�,eofv;,oke5-'�om�Pe�Sp�o�=��;�:a��e` APPLICATION FOR BUILDING PERMIT or a cerrFed"copy�hereoi(Sec.3800,lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Company _ ❑ . BUIIDING r Cenrfied copy is hereby iurnished. FOR APPLICANT TO Flll IN ADDRE55 C.� �Certiiied copy is filed wilh e to nty buitding in:pec- BURDING p Y � � ipn depariment. AOORE55 / ` , Date,�_ApplimM a7Y �� U' ZiP LOCAUTY f���v CERTIFICATE OF EXEMP FROM WO ERS'� NO.OF gLDGS. NFAREST � COMPENSATI INSURANCE SiZE OF l07 NOW ON LOT CRO55 ST. � (This SeCfion need not be co pleled if 1he permit is for one ASSESSOR hundred do�lars(5100)or 1e55.) TRA�T e�«K t0`NO. Me,p gpOK vAGE PARCEL p O. •/wO USE ZONE N�.4P I certify Ihol�in ihe performance of�he work for which fhis N�� }' permir is iss�ed,I sholl not emplay any person in any manner A � �(,` CONDITiONS a, so as to becoma subject ta the Wo�kers'Compenso�ion lows. V Date APPiicant C�T ZI � NOTi[E TO A7PLICANT: If, of�er moking�this Cerli(icote of ENG NEERT�R TE�� DISTRICT GROUP 7YFE fiRE PROCESSED BY O NO. CONST. ZONE �"' Exemption, you shoold become svbject to the Workers' -� � � 3 `U �Compensation provisions af the Labor Code,you must forth• pDDRE55 � "� p� with comply with such provisions or Ihis permit shall be TEL. � STATISTICAI CL4SSIFICATION APT. CONDO. (n deemed revoked. CONTRnCTOR NO. �Z � Z LICENSED CONTRACTORS DECIARATION � �i�, CIASS NO. DWEu.UNiTS � I hereby offirm that I am licen5ed u�der provisions oi Chopter 9 ADDRESS N�� $EWER MAP ' (mmmencing with Section 7000)oi Divisio�3 of Ihe Business and LIC. . , . . Professions Code,and my license Is in full force and effect. CITv GLn55 eK � VAtIDATION - - Sp.FT. NO.OF NO.OF CHECK license Number lia Closs SIZE STORtES fAMitiES � ONE � - VAtUATION ConhO[f0� �Date OESCRI7TION OF WORK ' ' A D ❑ s � � �I am exempt under Set. qL7ER � � , � B.BP.C.for Ihis reoson REPAIR ❑ s <1 2 4.1 F USE OF Date: EXISiWG BIDG. D�a �• • • •2 3 SignOlVfe AP7LPRIM TEL F4NAl t C OWNER-BUILDER DECIARATION � � N � � �� DATE �"Z�;`r � I • •G G.FJ� I hereby affirm�hat I am exempt from the Comracror's License � q0oRE5� �y LY� R�• FINAL . • _ law for ihe following reason(Section 7031.5,Businass and S •�`�&� � Professions Code): � � Y . � aunowc I p,1 5—8 7 I, as owner of the properly, or my employees wilh aDDRE55 woges as their sole compensa�ion,will do the work and � ����TY � �1 2 4 2 A ihe slrucfure Is not inlended or offered for sole(Sectian 704d,Business and Professions Code). � MOVING � 1E�� � � � � 1,os owne/of the properly,am exclusively contracting �ONTRACTOR NO. �*• • • � with licensed contractors�o construct the project(Ser � qDDaE55 � • •��.7 J� ' tion 7044,Business and Grafesaions Code). , CONSTRUCTION LENDING AGENCY SE�OnC� YARD HWV TaTApROP urKiE W�DTH • • •8 6 7 5 cSi j I hereby affirm tha�Ihere is o construttion lending agency(or FRONT .Ihe performance of the work for which this per '�is issuad . e.i. I Q� S—F7 7 �Sec.3047,Civ.C.). �� 51oE Y P.l. Lender's Name C� /�/��( �7 �^ LOMA Ref.M Lander's Address � ' P.C.Fee S (/%''�+� Permir Fee !G�2 J ► . I certify thol I have read Ih' applicolion and srata Ihat Ihe Issuance Fe U-!�v LDMA P/C N - abo informafion is corrac�.I ag�ee lo comply wi�h oll County Invesiigo�ion Fee f or � n s ond S�a�e laws relaling lo b�ilding construUian, toial Pee O G ' '� tDMn Pe.m.M he y a rize represenfatives of Ihis County to enter p n a enfioned propery tor inspection p�rposes. !Q•'C'j� SEE RfVERSE FOR FX�UNATORY UHGUAGF ignoturo o! plicont or Agen� Da�e PLANS TO APPIICANT INSPECTOR'S NOTES .����5'Nh:lt•Iil11LU1{R UtiC1.ARA'I�IOV � � . I hereby,off�rm Ihal I om e.empl From 1he Contra:tor's Ta: � ' � Returnad ' � I. � ' , . . � . . . ..���ense LGW.f0� Ihe (ollowing rcason.•(Sec. 703L5} APProved . Aueinrsc andJ'rvJessions Cndc:An1'titporiiiunfy u�hid� No. Dafo No.� •.. Dote . . . . . . � "- ' . . . reyubes a pernii�en rnnstrud,ultnr,imrrnrc;dornulisL, .-._.. - ..-.-1; .� . �..,',., .. — urrcfarrunp, ire,rriur t i its ia imirr.�!r rcy�irrt � _ lrurti _ 1~� '�.�\ti ~ �;�:� �\ `a. . � .. ' � . 1/�•�f�A(iwnt/ur r��rf,h�rnrit ln filr'a s�qnod stdtrmrnt ,� .' _ ' '- ` ` '_ . `. --- : tJ�t 1 c is fit�nrcJpu�i�<Jnt tn t/>�prnt i�innt r�d�v Cpn. .�y':�.�. - ':V '� �`1:.` �..�, e � ..i�..1 �,'�,,) lra:lorkf.ri,ry�elvv(GLaphr'JI(cnnrnrc•nrinGm�th"Scr• r � � . . . `;, � . � ��: . . . . . _ 00 � n ` \���>.e �.;...1, �., . � " •,.\\\� .�, a, , � -,� .. ---tion 7 Q�^/�U +•(q 3 n/t/,e Uu qest�anJ P� tssi ms , . ..1 - _ _ ._ �' _� �\..�.:1 J•..__ �T.Jirr�liail�eiC.ril,Nffflcrr/mmLndfD.hniiv)orlhe �� ' ��'� " . allegrJ cxqnipfinn.AnY:r•i��latinn f S�cb�,n�lU3Lq h� .. .. ,. . ., . .. `"�•. ,. ,��.�d � ��' � � . .' : . - . . . .-. . t• �ora �erniilsah'cc�fllv¢ frcu��fn�iirrl .. . - . .... Reqmre p t Rrceived - �� an, uppLcunt/ i ) pT Approvals or Approved, . �prrc,rlty n/nn!nrn �ti an/irc h��ndrcd J„rr���,/ssuo/./. . - ' Ycs No - -- - � - � - - � � � � - �-,,-. _ �. ., �J I,os owner o�the proprrty,or my cmployees wnh . V:o�cr Ce.t ficnie __. _. . - - � -- ^- �� . . . . _ woges as their sole rompensolion,wJl do thc work,ond � � t1• --�'�� � . rhe slrucwre is no1 inlended or offered io�sale(Sec 70d4j - - � : `..... �a . `"?_j 1 .t;.'..�.:'..}._,._� Hra.�h Depor+men7 ....... .. ._ - .. � . � - , . . Ur�rinrsa anJ Prn/essiuns Cndc:7-be Cnntrai tori(i.�nse �.. � .��_. . i1� l.ou�dna<not app/��n Jii o¢nrr nf�.����.«i��L,�bur(J� ':`\•�". .,.... :r�.' � <ufrr� rnres tLerrnn, �nJ��bn dor.c vacb�nurF�/,uuc�!ar Fi.c De.Pariment . .. . .. . . . . . . ' . �� � ��Irsn�! [,is n¢•rs rmpfqycee.�prnriJeJ tl�f�surl rm- i - - rurrmrnts�'are rint in�endrd nr rrJ r sala. !. , Grading � �� ' �- . . ��� '''�1 nsr��r rq rL,e l:.ildin r rm i �nf�ra au6l��oill in.�� Geo'aglml 'j � '� . . � _� . . .�� ... .�, t.` -. , tr¢r o/�enmfletinn AtLc r un'rr buildcr uifl 1�e�c•�tGc .. __ ! - �-�i. . � .� _.. . Lurden n(psnrin,�thai l�e did nor fioiLi or im�riirr Jur . . . 1!c/ra�nse of saleJ. � � " ' - Pedesrrfan Pro�ecnnn � � - _ . ._ __ ... ._ _... . ..�: � I..as owner of thc � ..- . �Fe�ce)(Canopy) � � � -� �� � . ❑ properry,um etclvs���ely cwr.ror � .. . .._ ..'... .. _._... _. . �nng wnh IK�nse.d contmcbrs to construc�tF,e prolecr(Sec. Si�fC�al Il15PCC110� • .. . � ' • . .. JO4d)UlafillP53�Hf�PY(I�f3.ifq115 Cude:!1 c Cnntro�'tnr:s (Concl(M11osonryllWelding) . � _- __ _._ .� . . _ ._ .. _ . _... � .. '__ l.i�cnse(.u�oJnesnulJf+f,JyfoannwnrrujPrnferfi'.¢�bn � , � -.1,��..�.��,.i.� h4ilJs or i�nprores I!xre�,n,und p�Gri c meruds Jur suc/ . i lor Dro�na9e -�-' �"' . ��j� - � - .._ -•. .� �_-. ... ---. ._ Qrnjrrfs with a Cnnlrurt r(J lirerisrJ fursssanl.fo fbc - ' •- { ..:� .,�_y..�:`�.y Cr�ntrrtcfoh.l.imnsrl,a�o/.-- - . . . Porking . �� '_ ....__.__.__ ._... .P . _ . :'.� .. . . ' ❑ 1 am eaem t under Sec ,6.87.C,for�hts ' reoson � . . ' !��'� . _ ._. i_.i/�'`."1)'� 1 . .. . .�_Daie_� _. .. . - -. Owner ; Approvals, , Oato InspcctoriSignafure • `-1�� 1��5='� s��_�.�, .. .., � � . . . � � - � INSPECTOR'S NOTES � � locn'lon-.�. _ ... __ . ... ISeiback 8 Ynrdsl' . . .. ----- -- - - . .-.� ��; . . . .. ' .- �. Faondnnons �� �� ...... _ ..._.__.. ' , .. .� . . �. . ,... . .�.. Slab . . . . � . ..____.. � . . ., . , . Frame • .: :, I � ' .. . _. . . � : . ;- . Energy InsvlaGon , ...-... . _ .. _. _ . . �. . ... '. ... . . � . , . Laih:p. . � . . .. _ � .. . . ywoll�-- Z_�1 / . ._.. ._... � . ' ' . ����,;o, l. 1 _ �` -,,�,,\ � laih-Ex�erlor . . . . . . .. . - ., .' .-. "'.' . . ' . . . . __ '__ ... �., .. . ._.,_.. ._ .\ . . . � . . "'. _ . Ho�se Num6r_r_ ' . �- ------ -- - �---�- - . . . . _ . , ' Cor,eci&Pos�ed � . . --. _.._ . .-- . `..� --`---�- .. , Ffnol- _ ' , . . .- . . ., , . �. � . . , fnrer en Front ' � � � . - , � � � . . . � - „ . . . � .. - � . . . . . �.��.��•��, `.'\ 1 ! � . . . . . . , . .....'�_ .• ___. _ ..A-..._ .i;`!.. �� �y`` ���. � �,