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HomeMy WebLinkAbout1734A WORKERS'COMPENSATION DECIARAT10N � . . � � I inzurebar�afccrtif caffe of Workers'rCompensal on Insuronte" A P P L I CAT I 0 IV F O R B U I L D I N G -P E RM I T � or a certi£ed copy thereof�Sec.3800,Lo6.C.) /j���//� COUNTY OF GOS ANGELES BUILDING AND SAFETY PoliGyNo. �`3 7 Company ��"'�+' BUIIDING � Cerri(ied copy is hereby furnished.. FOR APPLICANT TO FILL IN �5 ^}�Y ADDRE55 Certified copy is filed with fha tounty building inspeo- BUiIDiNG f /� �� fi d parlmeni. ADDRE55 J f/WC-� Date l� Applitont�_ C�iv f z�a �� �OcquiV CERTIFICATE OF EXEMPTION FROM WORK ' � NO.OF BLDGS. � NE4REST � COMPENSATION INSURANCE 51ZE oF lOi NOw ON l07 '/ CRO55 ST. (This section need na1 bc tomploted if 1he permit is(ar onc TRACf ��3 BLOCK LOi NO. � '�ESSOR hundred dollors(E�00)ar Iess.J haP bOOK PAGE PARCEI 1 TEI. USE ZONE OP �� � I certify�hai in�he performance of the work for which this 4�'NER nl0� .(? permif is issued,I sholl not employ any person in ony monner qDDRE55 SPECIAL �yi so as lo become Su6ject to the Workeri Compensation Laws. CON�ITIONS 0 U Dale Applicanl GTY ZIP � � ARCHITECT OR TEI. DISTRICT GROUP TYPE FIRE GFOCESSED BV O NOTICE TO APPLICANT: If, oflar mOking�this CBflifictll8 O( FNGiNEER �`� NO. CANST, ZONE h E.emption, you she�ld become subjeer io the Workers' �3 ��) Compensation provisions of tha labo�Code,you mus�forth- qooRe55 �V �+-� with comply wdh auch provisions or this permit shall be TEL. �_ n STATISTIGAI QASSIFI ATION APT. CONDO. (n deemed revoked. �ONiRnC�OR NO. .�JJ "7 z LICENSED CONTRACTORS DECIARATION ���, �7n -7 CL455 NO. DWELL.UNITS � I hereby offirm that I am licensed under provisions of Chapter 9 nDDRE55 �l ti NO��O /��7 (commencing with Setlion 7000)of Division 3 of Ihe Buziness and ��� SEWER MAP Prafessions Code,end my litense is in full forca and effect. CIN � Ctn55 BK � VALIDATION 2 50.F7. ' NO.O NO.OF CNECK Li[ense Numbef ✓����� LIc.��ass SIZE � STORIE FAMILIES ONE � VAIU ION OESCRIPTION OF WORK NEW � Contrac�or � Date � ��p �Aoo S (J1'� ❑I am exempt under c. 6�DQ ���� �. ��G' � � � n- /. ALTER :� 1 J U I` B.BP.C.for Ihis reoson � Y^1. f��iG� CiJ1r�� REPAIR � s Date: USE OF (� EMOI �;• • • e • � EXIStING BLDG. .� `/ APPIICANT TEL. I � �Q�2 'Jr Signafure � FINAL OWNER-BUILDER DECIARATION PRiNT 1%' NO. DATE � I hereby affirm that I am exempl from the Contractor i License � . . o(i 0,i F? Law for the following reason(SeUion 703I.5,Bosiness and AODRE55 � FINAL _Q Professions Code): . N By ��� 2 .. �i ❑ BUIL�ING ' I, os owner of fhe praperfy, or my employees with ADDRESS / //� wages os their sole compensarion,will do tbe work ond i���TY � `� '. � �'G�O �L��/r Iha sfrutture is not intended or offered for sale(Section 7044,8osiness ond Professions Code). MOVING TEL , � I,as owner of the properry,om exclusively comracfing CONTRACTO/R NO. wirh licensed cantracfors ro convruct the project(Seo qooRESS( � tion 7044,6usiness ond Professions Code). RE4UIRED TOTAI SETBACK `,T CONSTRUCTION LENDING AGENCY s�T eqcK YARD Hwv pROP.LINE WIDTH I hereby affirm Ihat there is m m�Lruction lending agency for fRONT � \�� Iha performance af fha work for which this permit is issuad �L . , 'C�� (Sec.3097,Civ.C.). SiOE . P.l. (`�\~'� Lendar's Nome � � �DNA Ref.M ,\y�`�; 7.C.Fee S Permif Fee \ ;��' g Lender a Address Vh g I cer�ify lhaf I have reed this application ond s�ale that the Issuonce Fee O LDMA P/C M , •.`\ above informalion Is torrocl.I ograe lo comply wilh oll Counfy Inveuigorion fee +� $ , ardinances and Sio�e laws ralating�o building construction, Toial Fee -p�- �DhU,verm.N R and hereby auihorize representatives of this Co�nly to enter �' ,� upon above-mentioned propqrty fo Inspettion purp tes. . � ' 9 a. SEF RFVFRSF FOR L7(►LANAiORY IANGUAGE Sipnomre of Applicanr o Ap n Date . PIANS 7D AFPIICANT INSPECTOR'$NOTES 011'tiliN-F31�11.D1?R Uk?CI,AkA'170.V I hereby affvm Ihat I am eKemp+from Ihe Connacror"s To:� � � � � ' Retprned � . License Law (or �he lollowmg reason. (Sec. 70�1.5� � ApP�avad „ Uresine�s nnd Prr frssiuns CnJc:Anl'eitp nr rnun�y�vbi.! No. �ale No. Dafo•. . . . . . . , reyuircs a(�ern�it fn rnnslrurl.ullrr.irnfrnre.demo[rcG, — ---�—- ar repair anpuructure,/�rinr t�+its ie�nuncr,alsn reye�ires - , • . . - . . � -- _ - � !Lc upplic.�nt Jor sud.prrmit tn file n siFnrd sfaternrnt . ,. . . - . . . . . � ' t5at!e is licenrrJpu�suunl to d�eprnrisrnns uf thr Cun-. _. �. _' .. . . . . . . ��: : '�'. .'. '.. ��� '. _''��,, _ , . lrnctnr's Lrc'ims��l,au•(C.Lapter)1(<nrnnicnoin,q u•itb.11c- . . . , trun i00f1J r/llia,•ision 3 ql the Husinrss and.P�o�rssinns . ' ..' .. . .� . .:.� . ' ' �. - ._�C.�JrJorU�atbei�iu�cn�ptlGerfrn.u4ndlGcbniio/ard�e _ . . .. . . .. � . u!lr,qed uxrrrrptinn.Anv urnl,�tinn n/Sra��ron 7Ui1.5 b�, � - - Rnquired - - .. .. .. . . . � uriyapplicant/�,rnrr.mrts,�bj�.-rsrGAapplrcun�tnuairi! Approvals Oolo Roroivod - . or Approved . penrsltT n!nnt.nnrr th�n/irr lirend.nd d„11�,..�IsSou)./: ; _ .. . � Yec No _ ..� . . . . � . __ . - , ��� I,ps owner of the proper�y,or my amployces wnh lVo:N�C��i,Lco��.'� � . . � � � - wor�r.s os Ihcir sole compensotion,wdl do rhe work,ond � ihe avuUure is not iniended or offered for:ole(Sec.70��) ' HenLh D�portmeni.. . . � - � �. . . . . .. Qutiness vnd Pru/cxsionc Code:The Cnntrur(ori l.rcrnse l.uir Jn�•s nnt afhle 1n un mrrser n/frrrprrft'u'G,�huil�G Fi�e DePanmeni � r -� . - - - - � , . orimprnrct thcrcnn.unJ�rl odnessurl u•urA:Lirr�se!/or � � fbrnv,�/r (iis n�rn emplqyres. I�roridc.! ll at sucfi irn- ���� - - � -� r trments�ar� nnt intrndrd nr n e d � salr. 1 l;.ncl:nq • - l'n' If��� f�r /� � .. . .. . . _ � . 1 airerer,tGe LriilJin,�nr i�nprourment is an7:!uitl in unr Geolopiml • � .�._ . , ycar.'oj cnrnplrtinn. 1Le „u�nnr-huilder u�ilf/nrr eGe . . . . _ !.¢rden nJ fronin,p thnt br did nn�!>uifd�+r i.nhrnrr Jnr PcAcslnan F:o•eU�on ' . ' � . .. . . . . lhrrurnr��c�a�salr). .. fFe�cel(Cpnopy) � � ❑ I,as owner oF Ihe property,am eaclusively contrao � , , . . �ing wtlh IicenSed conuoctors to mnsrruU Ihr,prolect�Sec. Speool Inspecfion � � - - . . . . ' � 70ad)llurinrss and Prn/e:ainns CoJr� 7'Le Cantracenr's �Cnnc.l(MosonrY)(Weldmgl � . . ... . .- . . � .. Licrn�r la�rdnrx nofa�rrly ronr�ouvirrrfrrnrerh�u�hn � . ' , . . hui7dt nr iu�prurrs�hrrrnn,mrJ u�Go cunfractr�nr snc! lo�Oro�no�e ". � . . p.r jrc�s u•itG a ennzr¢rtnr(s)!i<errsed fiiisusn� u t/e � . . . . . Cnrttraclnr's f.icrnsr l.au•1� . - � . . Po�kmg � . . . . , �� 1 am e*empt under5ec.� ,B.BF.C.for fh�s .. � . , . . __,_reason . . . �� - - � • . . . � , .� ' . Oote Owncr Approrals . Data Inspactor's Stgnafura � . �" � , . . . . 1NSPECTOR'S NOTES localion— - -- --'- ' . (5eiba:k 8 Yardsl � -�� - - - - - - ' .. ' . . � . L Foundatlons � ' " . . . . . .. . . . -� . ' - - . , ' Slob - _. . . .. ' � _. . . ' . , , . . �. . Frome. � � ' � � ' Ener9Y Insuiation � . - , . � -.. . .. . � .. '� laih'Drywoll-- _ .. . . . � . . � Imenor laih-E�ienor � . __. . _ . ..._.___ ..... . . House Numbe�__ . , � --� - - - - --- �- � � � Cc�rect 8 Posied � ' • � � i � � � ' � Final_ . . . � . ., � . . . .. � Enlrr on Fronl - - ' ' � " . . 1 .