Loading...
HomeMy WebLinkAbout1003A 2171A (5) WORKERS'COMPENSATION DECLARAiION � . � ' f'� � I hereby olfirm �har I hove a certificate af�o�,e�„o 5��� � - APPLICATION F�R BUILDING PERMlT �� � ins�re,o�a certilicole of Workers'Campensafion Insuronce, �� or a certified copy+hereoi�Sec.3800,lab.C.) COIINTY OF LOS ANGELES BUILDING AND SAFETY Po���6�3G4 Campany Nc9R'�«5��. xELL.G`� '�L�L2�C. ❑ FOR APPLICANT TO FILL IN euimw� Cenified copy is hereby furnished. � ADDRESS � Cenified copy is filed wifh the coonfy building inspec• , � gUnDiNGl [� lion deparfinenl. A�ORESS l L'{Z1�rC Tc� D� . Dale ApplicaN � Ci7v ' DfVb �9�ti� ZIP IQCAIITV ` CERTI�EXEMPTION FROM RKERS . NO.OP BlOGS. NEAREST � COMPENSAiION INSURANCE � SIZE OF l07 NOW ON L07 CRO55 SL (1 l (This seUion nead naf be complefed iF fhe permil is for one . ASSESSOR hundred dollarz(E100)or less.) TRACT - BIOCK lOi NO. MAP BOOK PAGE PARCE TE�'2� USE ZONE � I certify thaf in Ihe performance of the work for whith Ihis �- OWNER� - N �J L CQ NO. 2 A. NO. ����✓� permit is issued,I sholl no�employ ony person tn any mannar AD�RE55 . � n t=G V(�QQ $�j' SPECIAI '�+ so as ro become su6jen to the Workers'Compensation Laws. tON�mOrvS U Dme Applicant � • . [ITY (�r-f...GS. ZIP � � �nTIGE TO APPLIGANT: If, after makln �Ihls Certifica7e of ARGHITECTOR Tft. DISiRiCT GROUP tt7E FIRE OCESSEDBY O � amption, you should become subjeat toJhe Workers' ENGMEER �*' NO.��4 $�3 �pµST E V �ompensonon provtsfons of the Labor Code,you musllorfh• qDDRESS � Kfkihif�l V G � I Q 0. wllh mmply wifh svch provi�ions or �his permN ehall be �TE�.1 STATISTICAL ClAS51fICATION aPT. C 00. cA deemed revakad. [OMRACTOR 7II� NO. 3 iSOC � � Z UCENSED CONTRACTORS DECIARATION . ���, �_a� M55 NO. -�WELL UNRS I hereby affirm�hat I am licensed under provisions of Chopler 9 ADDkE55 �j C NO. ��R�P (commencing with Seclion 7000)of Oivision 3 of�he Busfnassond C,.�, �''�- 2�2� CIAu +/ • Professione Code,and my license Is in full force and effecl. CITy t'� gK � VALIDATION �h��LIC.CIoSs�Ib. 5�'FT. ' NO.OF NO.OF CHECK licensa Number SIZE STORiES � iAMttiES ONE /�l{/atJ (aV7O� S���{C{.(3CZS• �/Z�IQ'7 DESCRIGTION OF WORK ^ l'A 'fION NEW .V�f2T�q�N O, Cororottor Date- Y� SI ADD S J / I�� �1 om exempl vnder Sec. Qr 1 QE (NKLG1� q�TER , c 1 0 Q 3 A 0.8P.C.for this reason ySC"�� ' REPAIR � _ �r•+ • •2 3 USEOF ' .��208 Dafa: E%ISTING BIDG. DE/r1IX � Sfgnawre - APauG4NT AVrYf K NO. 'Q��SOO FINAI � OWNER-BU0.�ER DECLARAiION �RINT L�AN DATE 3'�- '�V � •5 5 2 0 8 c=.� I hereby afFirm ihat I am e.empt from ihe Con�racror's Ucense ao0aE55arL 3 C�N �PfU-SC ST� UR� • FINAL � O�i'2�!`�$7 low for Ihe foilowing reason($ection 7031.5,Business and Prolessions Coda)� � - - - � � BY BUILDING � I, as owner of tha properfy,or my amployees wifh A�DRE55 wages az the�r sole compensmion,will do the work nnd � � � � , Ihe svutNre is nat intended or of{ered for sata.(Section ����TY 704d,Businesz ond Professions Code). � mtOviNG - TEt. � I,as owner of the property,am exdusively controcling CONTznCTOR NO, wi�h licansed convactors io mnstruct ibe project�Seo- � nooae55 � � - � � lion 7044,Business pnd Professions Code). , , � CONSTRUCTION LENDING AGENCY � ' SET�6ACK� YARD HWY i�TApROP LME w�orH � � �2 i 7.1 A I hereby otfirm that there is o construction lending aganq for FRONT ' fhe performonce of the work(ar which thia parmif.is issuad . C.L �`+�"" • •� (5ec.3097,Civ.C.). SiDE " � •��Q.0 6 P.t. lender's Nome • . . . � tDMA Ref.M •6 6 0.0 Q� . . P.C.fee S S SZ _ va,mu ree (n .S?� � , 0 9,2 9—8 7 Lender's Address I tartify Ihof I hove read Ihis applicafion ond state Ihat Ihe lauance Fee ���S� L�MA FiC N . above informa�ion Is correc�.I ag�ee to comply wifh all Couny Invev�9arion Fee � ardinances and Sfate laws ralofing to butiding conetrucfion, to�ol Fse ��.�� tnM4 v.��,,.M o hereby authorize repreeen�ativen of fhis Govmy to entar pon e obo�e•men�ioned properfy fpr inspecfion purposes. CMQ�Q� ' �/Z�J'IO�, SEE REVFRfE f0�E%tIAHATORY tANGUAGE iq iuro of Appl��on�or Apen� paro - . 1 PlANS TO APPIICANT INSPECTOR'S NOTES � �U11'NIiK•Ul�II.UItR UGC.I.AHA-PIU.V 1 hereby ofLrm d�at I a mpi from the Conrca-ic�'s . To: �. ._ . . . Returned.6 . �. . . �� . . .. Ucenze,lav.•,tor�Ihe follo ng mn•,on.�..l5ec.��0�1.5; . Appravad � . Ilusinrssnrcd!'ru/cs onst:ndcAnl'ci���nr.nunh•irGieL � No, bet¢ No: " Dofe.., . ,.. .... ..' ' ..' . ` ..� rcyuires�prr��i(fuf<�oreclrurt_�lyv�.'inrpro v.Jemo(isR, ' � �� ' � .�... �,rj�1.� �i '.:�. . �„" . - ' � � - � . .. . . ,./. �� .�. : ; .� :: �7Lr ahJ�hcant f�r sarh� mit(o/il���n si,qn�J aEelr vrrsl ,� __ r n I._ __ � � .:. ... ..� t - i :. .. . ._. :. .__ _ .__'_' ..:. .' ____. . , .� .. � � - - !r ! r �d( a . fl p� • � n. I7lr , n oh�t.r is n n�• ,u�u nt tn nn r��, � � � ('p . �r . � �`- -�. ' '.�: ;� �.�.7; .; tra.lnrilirrnsrLau Chaptrr')Jf�,mrminun��reel�S��. �_. � _.. ._ . _ .. ._ . t ! ..,,�_. .�_. ...�_._ ._._._ - � . .'_� •��.:.: .. � _. .. �.�nJcfnr1tl+ut�bei,�cr�nJ�trtl�rrrf..�nrunJtl�h islrrfl�. � � ��'' �Reqbiied -�1.?; ..,�.. .. .._.. ..__ .�. . _ . _. . .�_. . ..� wn}d�licunllra nmilsub�oJelEr,arel6ran!(Nunre! - - D fo Raceivad . PP . P°� l PP i Approvals '��.. ` or Approred '"�prnultp n/nnt nrnre tjan/inr h���drrJ J��1lu.s(S500JJ� _.,. . '�Yec .No ._ _ ... _ ...r . . __ .. . . . _ . � - . , :::.- �.-.. . ._. .. �_� I,as owner of the properiy,o,my nmplaya�s wi�f. . . � Waim Cert�6w!e _.` �. �.�__:��:�� ___ .. . ��-.: ' -- �. .-. .- . .-• _... . . .... �... . . �.wo9es os Iheir sole compensonon..w�Ii dn the wyG,and � - . �--� , � ,.. ihe sfruUorc Vs not intended o�o{fered�o•sde(Sec.70d4) Heolrh Depanm�nt-. . . "� . .. . .. ... _ -.�..--- . �. .." .. .�� . . . .<.B��siurss uad Prr�/esaion�Cudr:7he CnnUaunr s l.icrnse . . - - --_ _ . . ._ _. + I.uu�Jors not afplv ru�n.iorrscr a/pmper�v u�L���1��i1�l.c F�.c Depar�ment - ._ . - .--. _ �. . . ,. or m�prnr c�l�ern�n,und s!�>du�s srs�!u,rF l,irro.��•l/nr .. _ _ ��:, � . . �- . . -- :t1>ru4c(� hi:�nirn�rrrcptqper,.�prorrJcd :tar suit h-� G.od�ng.. . .�. , , � .- prnirmenrs n�r nnt intendrd or �i/JrrrJ/�r snfr.' - :� .. �S� .. �Gn r.-fbr build�n,y n irnrrn ruent ivsoll uyfhrn onr Geolog��cai �i � �. '' . . . . �� 1'rar�nf cnnrpfe�i,in, tln� nu nerbr+J,far irrf(finre tGe . _. _ . .. _ -�t . �1 ' _ .._ . . HurJrn nlprr�ring tGnl!�e d�d n,�t hrulJnr�iorpmr�/nr � ' -, --... ;I ,�p p ��,�rsurrl. �[ Pr,desvinn Prmecrlon- . ' .. . . . . IFe�ce�(Canopy4 ' � � � ��� � � � - � �" " � .� � onovmrrofthepmpeny,a e�Jus�vely,-,e�ddc� - � � . . . , , � Jinq wnh Ilce��sed coNrouors fo coo,Y�rucr t6c pro�cU 15c:. ' � . : : . . � . r ..- : . �r�mi Ins._ _ _. .._°._ .__ �_ . . . . .��- _.. . ; . . . 70sa��fiusiuec�and 1'rnkssonru Cndr��lbc Cnntr��tnr's Sp� pnUlO� " I.fCiR3fLYl1�JOf3nul,�i,( �tnan`nune ru r( u�bn (C nc}(Masonry)(Weldmg) . . . . . � ._..__ . - . .. . . . ... .. __. ...._ .— . _/1} ' -' .S�Ih P•r . � - � huilJs� rr,orurrr lbrre��n;wiJ u�Ln a�nnHaots lu.s�.f. . _ . , ��-. . . . .. ; - . � r.,'rcti-.u'i[!� .rrrrlraat�� li�ensd�l�unn�ial 7ri!he lo�Drainaae . .>' ; , '. . � ,. . . ,.. �-- .... _. . .. _ ..� . _..._.. ._ ... . � !A 1 a if�l P . . �� ' �: ..' � Cuntrador's 1.� i�e CairJ. .. . ._-'_ . �, ..�:,�'. . ;�... . - . . ,. , . . � . Farking � ' . , . ._....r .__._..____. ._ .. . . . , - , � I om e.empt under Sec. ,B.BP.C.(o��his , .. ._ . __ _ .. .._ �. _ .. ' '' � reoson ' � ... ... � �, <'. ... ,. ..._. _._ _. . . . Dv�e O ner i�,. , _ � ,. .. �- . . . . ..- � ., � � - . . .. . . . . ` Approvols Oalo Inipector's Signeluro � �' . � '` � ..` °�, . - � . • �,�. . , • � • , � '. - ... . . INSPECTOR'S NOTES � . . Loconon- ...__.___ .:. ....__ . _..... (Seiback 8 Yords) ._.__..__._ . - �� ���, . . . .. `" Faondntlons � . ! -.. . ��. _ . . . ' Slob ,. :. . Frame � . . ; .. . . , , . . . . , . , � . '_� ._'_'_'_'_ .. _''_ __ . . . �� Ene.gy Insuln�ion . .. .. ... -. ...� .,�. .. ._ ., . .. . � La�h;Urywo1L. . __- ____' . ....___ � . , . .. � _ .'. . . , . ' Inicr�or ...�.. .. i � . . • . . lnih-Exter�or , . .. .. . . . � . � . . _.... ___ _. -�� �� - - , S . _ __-__ __'. . .__.. . � ... , --___ '_.__......__. ._. i ' , . HcoseNomber_ ,� .. , - . ._._. _. _- �.._.... . . �__' ��. . .. . __. ..__ Correct 8 Posted � ', � .-_... _._.- - . -.�.. ..... .. , . .. ..� � : . � __ . . _._..____.. . i�nni.. , . . ,.. � . . . . .. ,, . . .. .. . Fnier on Front ! � � � . ..