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HomeMy WebLinkAbout1215A 4185A (6) , _ _ �__. Y _ _ - -- --- - - - -- - - yyC1RKE RS'COMPENSATION DEGLARATION . - - � • � � I h�iSy affirm Ihot I ha�e o certifimte of�o�;e�,�o se�f � � APPLICATION FOR BU�ILDIIVG� PERMIT f� insure,or o cenificate of Workers'Compensation Ins�ran�e, or a cenif�ed cop Ihe�r�'qJt�sec.3soo,i/ae.AC/.��/��/'�,� COUNTY OF LOS ANGELES BUILDING AND SAFETY (p, � �Poi'cy N��,��V 'Company�I lili f�F�71�—`_' � ' , .Certified copy is hereby fumished. FOR APPUCANT TO FILL IN bUILDING ��� ��J ❑ ADDRESS Cerlified copy is filed with rhe coonty building inspeo Bw�oiNG // r�t �ion deponmenr. Ao�a¢55 L�7T�/ L:^ Oata �.'-Lr�� APPlicant CITV ' I[����{/ Zlv LOCALITY W L tY ��./ ' CERTIFICATE OF EXEM7TION FROM WORKERS' � SRE OF lOT 7 h ��^•G�NOW ON�LOt � NEAREST ��COMPENSATION INSURANCE G CRO55 ST. (This sec�ion need no1 be complaied if the parmif is for one - 7RACT � r Q� BLOCK � t0T NO � �ESSOR hundred dollars(E100)or less.) y �P b��� PAGE PARCEL OWNER { �j(� � �? NO. � USE ZONE � AN F I cerfify�ihot in the performonce o1 ihe work for which this � l� � —�/'/ K� NO. r Z O— permil ii issued,I sholl no�employ dny person in ony manner qDDRE '�� I✓��-G ��'� SPECIAI �, so os to become subjecf to the Workers'Compensation laws. t 0 UV 4 COnIDITiOrvS 0 �' arr . /t h ch q2 ziv v Date AppllcaM � [� i ARCH17ECT OR 1Elp 4 ry7/ DISTRICT GROUP TYPE ��FIRE PROCESSE�BY NOTICE TO APPLICANT: If, ofter moking�lhis Cerlificate af ENGiNEER . / Ikb NO./��+"�1S/b �p ZONE � Exemprion, you should become subject to the Workers' /�, ��/^� Compensotian provisions o!�ha lobor Code,you musr forth• qooRe55/G L,L� ��� T_ GPLF�,7 �Q F'�� V W wifh comply wi}h such provislons or,this permlf sholl be deemed revoked. �L TE�� Q SIATISTICAL QASSiFICATION APT. CONDO. N ,, CONTRACTOR�/�� (� (J NO. '3�J Z �IICENSED CONTRACTORS DECLARATION ���_ q RASS NO.�OWEIL UNITS . I hereby uHirm that I om litensed under provisions of Chapter 9 Aooae � . � „a NO.+L�7�g 3 (commencing with Setlion 7000)o(Divis�on 3 of�he Business and � ��� !j ��R�P Professions Code,and my litense is in i�ll force ond eHect. C�TY G —6D(i < CIa55 LJ BK � VALIDATION �� r� ��� [�'� � 54.�. � NO.OF NO.OF ( CHECK License Number�L 0 ���,��pyi�,�„_� SIZE STORIES � fAMI�1E5 ONE �1� �nC����,(� ❑ VALWTION� `1 211$A Contratlo I� �/L(i�� [G.^�l I—(J� DESCRIPTION OF WORK NEW / --2� Date--�-- s �I om enempt vnder Sea ��N ADD a � , ��� � �2 3 ALTER e.av.c.to�Ihis reason REPAIR ❑ S. I • 1 1 2 6 3 - �Dafe: EXISTNG BLDG. DEMOL ❑ � • • 1 1 2.b 3� SI nctura� `a�� _ ' APPUGNT '! n`'7� r/�� TEI. i /�g � � 9 PRIN7 !/L��(NU h�'w h' NO. ��7 j FINAL � '^�C., 0 8 31—8 7 OWNER-BUILDER DECLARATION DATE � 7 �hareby affirm�ha�I am axempt from tha Controctor's License �' '�� L�y� taw(or the following reaeon(Section 7031.5, Bueinese and ADDRE55 FINAI �Jq, �� � Profesalons Code): � - � � � � - � �� . By �. �V"� - ❑ BUItDING ...__' _" . , .- ... J I, os owner of the property, or my empioyees with ADDRFSS wages as Ibeir sole tompensotion,will do the work and � - - - � Ihe struc�ure is not intended or offered for sale(Secfion ��`��TY --- � ' :2 4 7 8 5 A 7044,Business and Professions Code). � � MOViNG - TEL " � � •��J�� OCOMRACiOR NO. -__ . , I,os owner of tha property,am ezclusively controtling �, �� �' � with litensed comracrors to cons�ruct the pro�acl(Sao- � � � � � -- � •• � �-3.��� ADDRE55 tion 704d,Bosiness and Professions Code�. �a�2� —8'] . CONSTRUCTION IENDING AGENCY SEi�BACK' '�ARD HWY T�TApROP.uNE WIDTH ' I here6y affirm�hot�here i:o construction lending agancy ior FRONT ihe parformance of Ihe work for which this permit is issued 7.L. . . . � ' (Sec.3097,Civ.C.). SIDE � P.L. Lender's Nome � ' - � Z` �� WM4 Ref.M � � lender's Address P.C.Fee S Permu Fee� . � , � � I cartify that 1 have reod this opplicolion and stata fhot Iha . Insoance Fee l a'�� IOMA P/C M '� � . above informaiion is corract.I agree to comply with all Counry in�esi�gauon Fee O $ ordinances and Slaro laws ralating to building construcfion, 7oml Pee J � �Q LpMq perm.N .. - � R and hereby�authorize representotives of this CouMy to-en�er a upon the above-mentionad property for Inspetlion purposes7. � . � � , Q��� �Z—�`/ SEE RFVERSE FOR EX►UNATORY IANGUAGE � Signoiure of AppGconr or Apent pote - � otia,tir:it-uini.uck ut:c�.ne,�riv� ' PLANS TO APPIICANT INSPECTOR'S NOTES �herrby or6rm i4a��am ezempi fron �h �Cnnr.ucior's To: � . .,,. .. . Returned" ,. � ' .� � . ` Licensr Law far�fhe followinc� �ea;on (S.c. 7LJ1.5� �APProved . . . IJ�uirtrss urtJ 1'rr f•s.rinns C.�ndc:i1 nV rilt'nro�unfv�rGi:/ No. �' ���`.Dafe No. - 'Dafe� .. . ... .. . ''. , .. . . .. . �cyuirr's u p<•r�rrt l..r�invnirt.iul[rr,impr.�re.dernolis/r, , � .. - - . . . . . ��puirunv t r pri rf i! .• : 1 'r s � '.C4 j' '��, .. ., .. •..�� � ., � -.. rGe���rli:ent/r.r ild�pern�it�ln/Ir�e�iqi�l ldtywrrrl . .. �,. _ '__ .__ . �.' � _ . , - _ . , , ;� �, ! ,cicG:rnc�-Jpuiu�nrtn�brp � ' • . . {.... �ti..,<.� .., ' ti�� iC .. ). _, -� � ... .i.: �� .�-�.,. __ �trul�oril.irenu•l.ur(Cha�lcr'JI(anrcnrvn�i�,Cui�l.`Scc- , .. � ..':.�. . � � � ,' •'�- .i.•: � tion 7(IQU/n/Uiriri��n 3 n rl,r upinrs. nd 1 ro r v,ina .. � ��. ._ .�� . . • . � ,.. U /s ,�. . . . - � ..CdJcJ rir 1G�t(�e i�.rcnrpt rGerr/r�mr«nJ�l !�aL/nr�L+r . __ _ _____ __.. ._. _ � . . �. ... .. .._ � � �-� �__. _ . . .. - . , �fl�grJ cxcnrpei,in.Anv rinfa�inn�/�,lrivinn i(i3 L S h�� . -.-- ----- ---- -Required- - �DafoRaeaiwd� .�. .. .-�� -��'� .. .'..�:'��`.. . .. . _ . . . onYaQplirdntfnruprrn�ilse�hjrrtsld�eapplr���n1lu,�iiril � . s or Approved �,. ���. . �. . . . ,�penuf(V o/na1 nan�c lboa/irc/undn•d d,>x�.,/<9n��l.p , ADGroval .. �Yos .No . . _ _ . �:.. . . __.......... . . . . . . _ . - - .. _ �� l.as owner of the propr.rtY•o�my eMployees wqh �'. • . 1:'o!cr CcnAicatc_ _, �'•� _' ' ___ � _ - '-. . - ' ..... .- - .. .._- .. � -- � . ..�_ ._. 9" p .will do ihe worV,and w❑ s os.iheir sole com ensoi�on . � � . ..the s�ruU�re is noi inlended o�oFferod fpr�sale(Scc.IOd4) � '�� HenHh�DeFnrrmen��... . ..... ....='-- .'�- '-'-. '. ,,:`,. ..'--. . _.. .-."� �- . .' . ,.� . (lusineasunJPrn�P[SIOtO'COIICf�II�CGONfIJC(U/�tI.ICfI1SP � . � . � l.um Jne�no�upp/v m wr nuwrr n/prnpr��v u�l�n 6urLta ,� Fi�r�nparrment -'---- -- ._._. _.;.__ .. ... ...._ . .�� � _. , _ - . � , _ imprnrv�tla � e.l+doessv�/uurl.linrse!/.rr ur •rr rn,arsd ,- . .. . , , .. . .,� '�. . , - lLvou,qG (�is�nr<•n einpliit'�'er. pr��•idcJ tfint.su:G i�n-. G�ac6ny � . , . ' prnre�neufs are nnt irsfanJeJ or ..//rreJ fur ralr. !/. ��� �, � - ..'bn�rorr,tE,�hrdlJ7RX or i�np..� nrrnl is ruG1��•i1!m nnc . �, , � �"�. Geoloqiml '� � j ' " . ��.�.:. - .... � . . �.,,` _ . � �mfle . _ _ _. �. �- _ � ru .. . . . �. � .. ' � nu�nerbmlJ.+r u ill hrtrr tf,e I , .. yrur o�rr iinrs, tl r .. - � . .. ,. . .. _... � hurJ�n n!pr n irr,y�Gnl l�c Jrd n„f huild nr inrprnrr,/nr . Pedesrnan Prorecnon ... �� . . � �' � ;� � 1be f�u hr�e�e n/xufel. � - - - .., - .: ..� -, ,. . _, . �. ,- . .. i i. , (Fence)(ConoPy) � `.� . ' --�-�. �-. .. ... . -. . ..�.. .. : .��"..- ... . .., , �_: I,asowneroflhepro{eny,timerduslvelyconiroc �iinc�wnh iicensed conuauors�o conirrua the pro�eu�Sec. . ____. ' . .' ' _ . �. ._ ._. _ _.' . __7.� • ___� � Speaol Insp�cGon `---. . .'- � � � . � 7044)Ilresinrxs urcJ Prn/e.v . L��Jr:77c Cnntrurtnri �. �Conc.l(Masonrv)IWeld�ng) �� ' � . .. . •� �: .� ��. � .�_...�- - . . l.icrnscl.a:oJnrsnn(a/�f�lVl�Kuuuro�vrr/�+rn�,orfi•u�hn ; ,._ .. ; . .._. ._ _. ..._.. .�.. . __-._ _ ._. . . _. . _ . - � - builJa�nr�irnprnvrsilereon,pnJ-���bn��nntractsJnravd� Lot Dramage .'. `:.: ;. ; � �� , �-'-- '. - .. . .- .'� . .;_. ._ .. .+priy«s vilh a i��ntru�tn+(�J 4 e is'rJ prrrse�su! !r. fl e � t ..C�)t1lTRtI/If�S r.ICCR.4C�.dlf�. � _ • Park�ng . � . . . r_"_ .. . . ,.. . . - , �I 1 om e.empi unde�Sec. .6.8v.C.fo�th�s _ _�_-. _..--'._.. ._._.. . ._. . , . � � �. ', , . �� reoson ... . . .. , . . _. ___ _ . _ ._ ._ . . . . � . ,-. . . . . . _'_-_- ____ . . .. . _�.__' Dale � �Owner � APProvol� Data � 1 spacior`:Signoture ;•�} ' > . . � . . . , ... . . - - � � - � 'INSPECTOF'S NOTES� � localior �. ��_q ,p�l� ..-�,.----.---f___.. .__.. . . (Se�back 8 Yards) �'V � �y"- . . ___._. . ,._-_' _-__.-. .-..--_- '. ' �. ,-. .- . . _ ; . ., �� ._ .__ � ,., .. Foundntions 2Z�{�( G "___. ..._... .._ ___'._ ... ._. � � . . ,.. :,.�. .,. .. .. ,. . . . ' 'lob - . � 1-�Ol� .__....__ _ �. _'___'."."__" '_'__'._.c. �_ .�: . �, ... . ,.. .�- .., . . � .. . � � he � � �.4 ',� OJ V �--� _ , . - � . �� . . . .. . � . .. , ,. . .. , . � . ,Insulation ���z,d �,t��'� . � .____..� . ..._._ _ ..,_.__. _ ._ � _._ .:, . . .. . � . �., - � . V' 'ilyall._ ) . . ___ _. . _._ . . .. .. � �(� � - - __ ., � ' — - - _ _ _ .-- ���e . . . . � - � .� .. . . . ._ . , -� . .----- - �--,- , . , . . . 'umbti .. - . . .__ .. . . ..__'___.._- __. . .. ... . .. ......... ... . _ ._. ___ ._ ____ .. , _ ._._ Posr��. � � �� .. � � � . . . _. . .. . ._._. . ._ .. .,_,., . . . _. ... . nl I ' . _ ' . .. . . �. . � . .. 1 . : �� ,_ ��