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HomeMy WebLinkAbout1396A (7) .��crva�auON DECIARATION - ' � I hereby,c!(rrm Ibaf 1 have o certificate of mnsent ro ielf APPLICATtON FOR BUILDING PERMIT � insure,or a.ertifico�e of Workers'Compensa�ion Insurante. o�wce�u��ed copy ihereof(Sec.3eoo,�ab.C. COUNTY OF LOS ANGELES HUILDING AND SAFETY PolicyNo��n�Company BURDING � Cer:�fied copy�s hereby(vrnished. FOR APPLICANT TO Flll IN • � Cenified co s filed with the count buildin ms eC• p��E� � tion deportmeM. � - y 9 P AD RE55 Y Date�_Appliconf t t�v �p�q��i CERTIFICAtE OF EXEMPiION FROM WORKERS � NO.OF BtDGS. - NEaxEst � COMPENSATION INSURANCE � ' SIZE OF l0T NOw ON IOT CRO55 5T. �' (This setlion neecl no1 be tompleted if fhe permii is far one rRA� - BLOCK l07 NO. � �ESSOR . hond�ed dollon(51 W)or les:.) . MnP e00K PnGE 7ARCEl TE4 U ZON� MAP I cerlify�hat�inlhe par/ormonce of Ihe work for whi[h this OwNER - NO. — �.�p �.��j 3.�j � permit is Issued,I sholl nol emplay ony penon In ony manne� pDDRE55 ��� OEND TIONS . so as ro become subject to the Workers'Compensotian Lcws. O CI ZIP V Dme Appliconl � � f� NOTICE TO APPLICANT:�If, ofler making�lhfs Cerfificafe af ARCHITECTOR TEL OISTRICT GROUP iYPE FIRE PROCESSEDBY O Exemption, you shouid bacome subjeci lo Ihe Workars' '��- ENGiNEER NO. �pµ5i. 20NE U Compensafion provis�ons o1 Ihe labor Code,you must fonh� qpDRE55 ' � W wilh tomply�with such�provieions or fhia permit ahaU 6e � Q.� T � STATISTICAI QASSIFICA ION A71. CONDO. !n deemedrevoked. . � -� CONiRACTOR � Z UCENSEO CONTRACLORS DECLARATION� - �i�,�� 5 -C1A55 NO.�DWEtt.UMTS__ I hereby offirm Ihot I om licenaed under provi5ioas o(CFwpter 9 ADORE55 NO. ��R�p (commencing wi�h$ection 7000)01 Divlsion 3 of the Business ond ���, Proiessions Code,and my liceme is In/ul�force and eHect. Cm S a• tin55 BK� � � YALIDATION . f�� �7I SCJ. . NO.OF NO.OF CHECK LlcenseNum6er����7� LIc.C�as`� SRE StORiES� iAMil1E5 ONE � � � VAIUATION . � eonnacrort(,/lE��Jrsu.or7'1�tra�e Q-1-F?7 DESCRIOTIONOFW K AD s �C�Ov ❑I am exempl under Se<. - � , ALiER 8.8P.C.for fhis reoson . REPAIR s Date: USF OF . � � EXISTING BLDG. DEMOL S'onatur APGLICAN7 E. FINAI /� Q �� 3 9.�J R OWNER-BUItDE LARATION � PRINT � DATE v��O 7 , I hareby eifirm�ho�1 am exem from�he CoMractor's License � �• •�• • � Low for the following rcason(Section 7071.5,Business and A�DREsS f� FtNAI \��...Y/) � .�.4 4.2 5 Profassions Coda): - - By �/ /C"J � I, os owner of Ihe proparty, or my employees with n�DRf55 • +� a Q Q 2 5� . woges as their sole compansai�on,will do the work and i�i Ty � Ihe srrutture Is not in�anded or oFfored for sole(Seation p 9,(�$�8'] ' 7044,Bvsnen ond Profess7ons Code). �-� MOViNG - � - iEt. � I,as owner of ihe properly,om e.clusively conlro<ting CONiRACTOR wilh II[ensed[onlroCfor3 lo Con3lru[f iha prOjaCf(Set• ADORE55 �ion 7044,Business and Pwfessions Code). � CONSiRUCTION LENOING AGENCY � SE�BaCK Yaa� -HWY TOiAORpo IiNE WIDTH 1 hereby affiim iha�tbere is a consh�ction lending agency for FRONi ' . Iha performance of Ihe work for which Ihis permil ie iseved V.L � � � . (Sec.3097,Civ.C.�. SiDE t P.L � Lender's Nome lOhtA Ref.M � � � P.C.fre t Pe�mit Fee ���7� , / tender's Address p � I cerHfy ihar I have read Ihis applicafion ond store thol the . . . lamonce cea !�`�� IDMn P/C k � �l obova information ia correct.I ograe lo comply with oll Counly i��eviqouon Fee ( ordinances and Stale laws relafing lo building construction. .. Taol Fee 1�J LDMA Pe.m.N � / and hereby authoriza represen�o�ives of this Coun�y ro enier 1 upon Ihe obo�e� c ned perly for inspecfian purposes. / `j���C'T���C�'I 7� / .. . . SEE REVERSE FOR E%�LANATORY LANGUAGF . 1 /r r Signoturoo4Applico Agent pafe 4 � � � � PIANS TO APPtICANT INSPECTOR'S NOTES �."�'���"'""""-��� . . I hn.o6y oHv.�i�L��i t o e.empi Irn�n ih�c.on�n,:�..��, To: Refurned � . � . _ . ' � ' license'Ln�N�f r��he�.follo g re.,. '*�r.c'703Y.$1 . , . .. : Approved � !)u r�rn nnd l'r l dnns Cqde�::ln�.•rrtl'nr a�urtf��c:d:/ No. Oate Nof ., .�ofe� � . ...�. � .' . ' - ' '. . ' .rrynirre a perniit!��rn.irhurt..+Itnr,iu�f•r��re.,drmoli<!�, . - urrepuirandst�urtr�n•.prinrF.iisis.�4anrc:u4�url�qui • �s, - .,i-',' ,'�t � ' , .. _ .. . .. �G�appli.,�nt/or.vu�1,permir to Ji(r rt sieneJat.�prne>i " - -��� eGa!hr�is L�rns�•dpinvmnt h�fLrnnmisinns��/fLr<Sri- . / . . _ . /-`r J .._�:� .: .��_�" ..r..l;�� . '.��, . frminr'.il.ivoncrl.air(Cba��trr')//couimrnain��ritl�l�-c'. . ....._ __ ._.. .. .._. . . � _.._ �._' ' ���.-t. .._ ...,._! '. . . . . _ _..� ..__ ._..'i..�.. �•..:-I::� CoJrjnrl t'bat f.�.��.«de3 t 1 d�r Husix���� � d l �Jrca„�R�' ; . •.�_. - ��' ,. 7.�� �:.Roquired,._ �-')DatoRecelvad-. ' .- __. '_ _ . .... �..__._ ._ .. . '_. . _ ��rcfla�pli.ant/nsaprn�ts�h�r,rstl,apflrh(t3uf�rr( . _ __ APP�ovnls � or Approvod -prnu h�n/nnt mnre lfun(�r�J.undredJ�!(ai�/SSOU).1:. � � Yas No � '��� ,i �� . � . . -. .__.. _.. _ . .. ��_._.. _ . .. ... - -�-� - --� � �.• I.as owner of the propr.rly.or my emnloy.ee�w���h i WoinrCon�Lm�e '' '• • �. � . . � ;..��. . �_..�.._.___. ._�:,- . _lf•... wuges om�ensa�o . .� , , s iheir sole< n wJi do the wo�4,m�d . _ . . _.. ._. ... . . . '. , , .. . lho s�rvc�vre is�noi imen ed o�o��ered fo to�e{Sec,7U4dy Hcol�h Ocpa'riment�.i�' �._ i..i�:`- �.. . ..� ..��� .'. . _-- --. ...,--=�..-- . .:: �_ ...•��, . ,_ ._ . . �. Uruuirri und Pr/.srio�i�CuJr f7rr Cnnt,�'tar's l:nrnsr . . .�_._.� � !.a �J �not uppl�f �n n 1r�,>r���, 1��FuilJs � .. -' . �.'� ,• ,,.,.. .-�. nr r r r � s eLur und ee! d a surb u L 1 inrscll.>r fuc0eoanment ._ . .._ . ._ _ _ � . . - - . . . . / . . . . . � �" !br u,Gl�bis-n(n-�r,n/.�lu��< .�-,���nridrJ ihat aurb�; Gr�ding . ..� .-j+ruremrnls�or .n�t inf.nJ d �r: f/cred for salr.!/. � � l�n�oe�er,tfre brnldixx nr nnp m eni<•nt is so(Jiri�!in n.re ... ,_ . , , . : Geologicoi ,. . . , . . - - ' .7'ear n('rnoirJefinn, fhe nu�nrr-Auildrr:rifl.Gatr��tE�¢ _ .,. . ' burdrn n/prnnin,��bnf Gr Jid nii�hni7d Jr irnpmr�fnr tl�p�rpt,sr ol.i❑lrl. . . . Pedes�rianProlecnon �.. . . . . � :� � � . . � ,'. .-. . ... . . . �Fen<ef�CanopY} . . . ....� `'..�- `t�' ''. � ". .��� �. - � - ' .-. �., � ��I_ Casov.n�roftheprope�ry,'am�c*d.is��clyconrrcic�: � .� . _. , �: . . , . .. . ' liny ih I�c6 scd caniroclo�s i�co si ci�hc proiea tSec, , . ; � �. .._ ..__.__. �__. .. ..�._ , . ;� ...�..: ��. . 70a4)U�sn+ei�.inJPrn�•ss r��Lu1r: 1'UcContrv��a��r's Spe<mllnspeciion� .. . .- . . , -��� • � � (Cenc.l(hlasonryl lWeldmg) :' ...... � . � �� . . . �,. .,.-.��� . l.itrnsc/,du�du<snn�dpp(�fnun�nu�ii�r'nfPrnperlt u•Ln . . . . . .._. : _. __ ..._.: ...� ,. . . _.Fui7Jx or irnp.u�ri�Lrrei�n.-un,!�rhn runtru<<i fnr-irerJ lot Dro��no9e .• �.� '� •��. ;_..._ .._. .-_.. -_- \�. . . . �/+nrjrrts w,ith a r ot •d.pr a l4�r t r/J 7�rns� su rcf tu , .�Corvtrrsrtnr's'f.i�em�<l:ar�f: - . -..J�' . Po.king . . .._.... .. . ^. . __ _. . - ..� . .���.� ...._ . .. . ... ... .. .. . . . � . . , . . .., . �.�� [j I om ex�e pi under$ec� .Q.BP.G.fo���h�s � ._ .._.__ ......... _.____ .. .. _�-. . . . � �easan . . . -.. _...... . �. . _.. _.. ._ ... . . . Daie - �.'On•��er _. , . . � .:��.^�� �S� �r'i r�. . _ � . ... _ � .. . .. � . . Approvnls� Ua10 �. Inspe<fori Signafure _ . '� - ��".� � - - �� � � • ': INSPEClOR'S NOTES� � Locn�ion- � � -- ISethack&Yards) . . ���--� Faondanons ,. . � ...-.� . .- ,�..', � . � . . ..,, , Siab . � � , . . .. .. , � Frome . � . . . . . . . � . . - . � . .. . - - .. i i , �. � . � . .. ., ...,. Ener9y Ins�lni�ion -'..:...'___ . .. ._, . ... .......__ ...... . � .. .-.:. ;�:�. �� „ . . i lmhiDrywolL- ._�.__. . .... __ .__.___� .._.__�. ___. ,..___. . . �' � _ IniCliOr ' . .._.__.... . . ..... � � . . .. . Lnih-E.�er�or -. , . � . .. - _ . . ._ . .._ . . � .� , Hr.useNom6er_ .. . _.._. ._. .�,'-_. ._. . .. ___. ___ _ . . . __ _ Conecr ft Posted . . .- ._.. ...- . - . . ..- .. • . � � i � finoi.. .. .. _ . ._. .._..�. . ... .. _.._"_ . .. . .. . , . _. ._. __ _ __. Ente.�on from . . .. ..- � . . . , .. . � .. . , _ _ . ' , . . � �„'—.-_ - . � . ' ' , �