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HomeMy WebLinkAbout0960A 1234A (5) � WORKERS'COMGENSATION DEGLARATION - � � � , � v,oFfirm fhol I hove o certifimte oF�a�,e���o=a�f APPLICATION FOR BUILDING PERMtT � � e,or o certificote of Workeri Compenzalion Insuronce, �-or a�cerfified copy fbereof�c 3800,la6.C. � � COUNTY OF LOS ANGELES BUIIDING ANO SAfETY PolicyNo�q �Ilq R—Compa - � Ce�rKed mpy is hereby iumishe . . FOR APPIICANT TO FILL IN BUILDING AD�RE55 2�z a/ ..,..,E ,�,� (�/Ceniiied copy is filed with�he co�ry bullding inspeo- BUUDWG . �� � U Iion departmenf. ADDkE55 Daf Appli<anf Y 21P LOCAUTY �s�.�'�r rT '��(j CERTI TF OF EXEMPTION FROM WO E 5' NO.OF BLDGS. NEARESi . a COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS S7, . (This secfion nead not be completed if�he permit is for one a.` ASSESSOR hundrod dalbr:(E 100J or�e55.� 1RAC7 � � BIOCK l0T NO. ')• /�,pp gppK PAGE PARCEI TEI. U ONF �N+P I ce�fify thor in�he perio�mance of tha work lor which�his OWNER Np,� p� � ��� permir is issued,I shall not employ any parson in ony manner SPECIAL . � so as to become su6jeat to the Workers'Compensaiion lows. - Aooae55 Oc''t� CONDiT�OriS � � . .. piY � ilp V Dofe �Applicanl ARCN ECTOR TEL. � NOtICE TO APPUCAM: If, offer making�this Cerfilimle of ENGMEER � DISTRICT GROUP iYPE FIRE GRO EDBY � Exemption, you should become aubject to Ihe Workars' ) CO i. - ZONE f— Compensotion p�ovisions of ihe Lobor Coda,you must forth- ADDRESS /.d W wlth comply wiih such provision:or this permit shall ba . . TE r p„ deemed revokCd. STATISTICAL CIn551FlCATION AR. CONDO. Cn COMRACiOR Q , � .= LICENSED CONTRACTORS DECLARATION� ���, CtA55 NO.�� � DWELL UNITS_ I hereby offirm�har I am licansed under provisions of Chapter 9 A�DRE55 Np, � (wmmenting wiih Section 7000J of Divi3ion 3 of Ihe Businass and . G�G SEWER MAP Profcssiona Code,and my license fs tn fuil iorce ond eHect. Ciiv� Ctn55 � eK �- VALIDATION 50.FT. NO.OF NO.OF CHECK License Number LIc.Clo s_� SIZE � - STOHIES � FAMILIES- ONE � VAWATION Canirnctor �r X(� �ESCRIPTION OF WpRK EW ; ij C/� at Q ❑I am exempf�n er Sec. 2 -r� ! I G d AIDTER , �0 9 b 0 A . 9.8P.C.for�his reoson 6•b alS'� �to� REVAiR ❑ S � #•• • •2 3 Dafa: ExS NGBIDG. 3��X GS�: �7S DEMO 1 • •27,6� Signalure � APPLICANT TEL FINAL OWNER�BUIL�ER DECIARATION PRiM N DATE ��( (5� ••G Z 6�� I hareby affirm Ihal l am exemp!From Ihe Contracror's License � � - • taw for the following reason(Sedion 7091.5,Business ond aoDaESS FINAL � O H�� �'—B B � Profasslone CadeJ: �� -� � gy <� ❑ BURDING I, as owner of ihe property, or my employees wifh AODRE55 ages aa thei�sole compensalion,will do the work ond �«ALiTY � � "���� �he struc�ure is nol inronded or offered for sale(Seclion .. • 7044,9vsinesa ond Professions Code). - l�pviN� � � iet.� . � I,os owner of the proparty,om exclusively contmcting COMRAQOR No. � �wifh licensed comrocrors to construct the pro�ect(Sea qODaess - � � �ion 704d,Business and Professions Coda). . � �C�2'�4 A CONSTRUCTION LENDING AGENCY � SE�BACK YAR� NW1' TOTA�ROP LINE WIDiF1 1 he�eby affirm that ihera is a consiruction lending agenty for FROrvt � �r• '• • •� the peHormance of�he work for which Ihis permit ia issued � - P.�. . (Sec.3097.Civ.C.)• SIDE .. f • •4a00 P.l. Lendei s Name + • s(i�O 0� / IDM4 Ref.M tendei s address � P.e.�f"s `Z .b'� P`"'"'�F"° , 0�x 2 9—8 F'S 1 rorlify that 1 have read this applicption ond stafe Ihm Iha Iss�a�ro fee I�MA riC N obova informotion is mrroct.1 ogree to camply with ail CounN Invasngo�ion fae ordinonces and Siaia laws rela�in �o building tonstruction, , toioi Fee � �� LDMn Perm.M �and h ab ze represan � es his County to anlar , er�ioned ert inspeciion purposes. . - � . ' SEF REYfRSE FOR F%PIANATORY UINGUAGE .� ' " Si9 lure pplicanlorAgen! .. . . . . '" ,1�,' �� n\�`� ��, I � "'r., . PLANSTO APPLIC0.lIT - INSPFCT02'S NOTES ..OR'tiliK-f7U11.UP:K�tn:u.n,.,..._... 1 he�e6y aflvm thni I am exemp�(rom the�Cor To: - � . Returned .. � � �. . ' . . � ..licens'��La..• for �he follow�ng r ., �Sec.` , - � � Approvad .�� :,�D�ur e.nnJl'rn/ s.� ns<�d Rnvnt�or unttiuGiw. No. � Date Na. �- Detc� � � � ' � � � ' - �� r..�gulr. �(�r,rn5r1 f n.cfruct� k �np n J�.�uliah, .�=u,..��r��:�a��s«u�i,,.�.r�r,.�;�;�,�.�.«,��;.�,;�r.«.���,��,�,��, ' , \ i. . � � . . . .. tbc�ppfi.wit f�.r uch pornrit tn Jilr a si,CnrJ slatrmrnf � , . .. .,... ._ a , . . �... „ . . ..� .., _ _ .._�. ...-�, � �, , � / , 4- _ tJ�t be is b.<nsrJ arsuant t��!e pro�isrnns., 11 n . - _ . :�l'�� �l �>}.�"� � � , ��� �'`�,r.� trnclnr'sl.rcen<r Luir•(C/,dplrr')I/�rnr�m�n<rnq u.i[l�1�i: ' .. . . . ... _. . : .' . .;�� : � .. . . � � , , '. �r�.n roa�//t�r„��.,�,i nI�t��rru:rn�•,s� J r /�:.s���,,.� � . . _ � . . .._ ' . C: :�t��� .- y ..Z_i..:�a}�,`�.'l�. 1 i y \l . .`-:-:.�.•.�'GHIrJ nr tbut L����2x�n�/�t�bcr Jrom�nd((.�bn S��Lr�b,� ' � � ' uf]e,Qed i�xt�nirtiqn l�nv I�in/t ���.SfYt 7(131.$�hi � .. .. . _ Haauirud . ... � . ._. ' ' � ._.. . . . �� � unv'ah06.u��/,�rnp��.ndtauh� r d�rappl� �� a.- i!�. APProvelt - �Dafe Hecaived � � � �., ;`7 ���Yes No or Approved .' -:.. , _ -�prnalev nf nnPrnnrr tFiun/ii e 1 nJrrJ J eflurs(,f SOU))• Wo�er Cen��Kcare •� �. '•.�.'.� . � ;''.,", ,.;, ,. �•.. ... . .. ..::t..,.��.....� ...��, ; �i., . . w ges as�he�W soleocoi++penso�o,w11 do theawo�k.alnd � �.��� � S: r�\a�+. . the stroUure iz noi intended orofFered for sale(Sec,7041j Heo��b Depanmenl � � - � - - - '� �-• � - •�+� � -, � � � - � Ousbivs�and Prn/essions Cnde:77>c Cnn[r.�c tnr's I irense ,� , ,.._�..,p�, « -�\ � i �.� Lau��/oe�nnt uppl�lo�rt nu�ncr nJ prnfrrh�e hn FurJ,ts . � . ..t . _ . .. . , , or im rnrca tl erenn�anJ u�l n doe.c ancl u A hini��el ur fire DePnnment _. ._.. ._.... _ ._ . -... . . . „ .. . . , ._ ... �' . � . . � . tGruqq/ G�a�nun rrnplu.�ree.,prnr�deJ tlut�rr.ai ir Giad�ng � ' ,�'. . .prneemenn rtre not iNended or n/fesrJ fur saJe. f/, _ - . . '��[mu•errr,tE,ebuildinXorimprnncmrntissnldiri0binnnc ,,. . . . .. _�. , .. .. .... . . . _ _._ _. ... . - . _.. . . .. . . . . . . G ol icni .. . . . TPar n�cnrriplehnn, thr uioner.hwJJnr iri(J ln��v tbe � °y � -:i���)S,-�� t., ...�� • �� r�_� . - burdc�J fro�inF tbat[�e Aid nat build or irnprorn fnr PedeslnonProte<hon . . , . - . . � � . y.., -c 4�, . -�, s ;��'.�y ��� ' the(�nrnosenl.iule). - .� � (Fence)(Canopy� � � - ' - ��' r`� -- � � n I,asownerofthepropeny,�amerclusivelycentrao , �- � �ing wnh licrnsed con�roUo�s to�consrruU ihe projed(Sec. ' � . .. .. . . . . . i 70a9��Uusineu and Pro%ssrnns Code•Thc Cnnvuctnr'a Spec�ollnspechon ' . ��.' `'�� . .. . . (Conc.I(hlasonrY)lWeld�ng) � ... - .. _ . . .. _.. . . l.icrn; lauJnesnnl:thJ�[1?nm��u•�c7of(�rnJrrt�u•Ln ��� _ . huilJ1 np n e Y!.F � ond�•l,n ui 1 1 Jnr suc! 9 .. � c.�t _ y..P�,� t .;rh�p� ,Cu e�rj<)!!e\n:�d p Iu�r ro fb� Loi Droma r �. - . - � . .�L'onrra.lor's I.ice se t.hu•l.� ' - Parking � � . .. .... . . . . _. . i� � . _. . .� . ' � . .. �: _ . _ . �` '' ❑,�Iamexempiunder5ec. . ,,8.8P.C.Iorlh��s ..reoson �� -.. . � . . .- . .. ,.. _; , . . . -'. - .. . 4'yl ,'�, � � •. •� ,.. Dafe . .. � � � Owner - ,. : • . . � -�-. � J�.•a ,s �.:.�\7�;rV, .�? ��.f,.c'._ _ .. _... _ _. . .... . _ . _._ � Approralt� . Do}o InspoNor i Signolure . -�•�\,, `.y..��'t��i i �.,? `.��`,-1 \1 �: � . . . . . _. � �� INSPEC70R'5 NOTES � locmion- .._. .. . . . ` (Se�back 6 Yords) i -� �� � . � Fo��doi�ons � �, � , _. Slob � ' - . , � � �. F.ome' . . . . . . _ . . _ _ . Energy Insulmion � � .-'�...-. . __.. .. . . . �,_. . ;.__ .. . -� � ' . . lo+h%Drywoll.. � '. � ' . � � � -- '� � _.__ . _.... . _. . .. .. � InteriDf . .. . . . . . . lo�h-Eaterior � , _ . . . _ ._ _ _ _ _ . . . . ,. -... .. ..._ _ . i � . � . House Nomber__ � _ .� . _. . . . , . '. _ _.. . .. _ . _. . . _ _ . . _ , Co�re<t C fos�ed - � i���, , � � finol_ .. , ... ._ . ._. _ ..__ . . ._ . . . Ente.en Froni ' . . '� � .�. . , . �fi tsvE- l f�• (.�_r--------_. _ _ y � a � c�--- � � � �, ,, ,r�� ;::�