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HomeMy WebLinkAbout0862A i _ _ _ _ _ ., .w,�.__,� __ �_ , , . i meure,or a certifitate of yyo SATION DECLARATION . ..._ .. -.p$],��„QQ'�/..:.$j,tTj,Ek/��. /r �- . �. . .� �..`. /..� ..� . . . ■■ �.. �� ORKERS'CQMPEN , . -.. . . ..,.. . , W � ,. l� 1 herebr offqm �hat I have ka sB�Compenstioq Insurance olr , .. .�:�j��J"�■ ■ �'4/"�■ �V� �■ O� ����D�■Y V/ �l �,\�� ■ . ... � 4 - ,a fartifled wpy thereof(Sec,.3800,tab.C., � � �� � �. COUNTY OF LOS ANGE4E5- � � �'�� BUILRING AND SAFETY . � ` PolicY�--�S�2 Compa� �BVIIDIMG-. . � C�rnf�ed copy y he:eby f�m�.hed.�xemorst Yndemnit F�R APPLICANT TO fILCW nooaess � C � - ��'Ce+tifled t6py is filed with tMe munty�bUitding�lnsper � . BWI�ING � �_. . � .; �. . . ... ' � rio�dePa�rm�„r. ' y. a,00zess 0-Castle Rock Rd � io�s+urv - , � oa�e 11 30 81 Rigic� ,fg. Compmy eiTv- iAmorid Bar zir 1 65 .,..' ceosssT. ` ; ��� NEAREST APPYi�e�� ,- NO.OFBLDGS. � ASSESSpR� , ' CER7IF�CAlE Of EXEMPTION FROM WO KERS' � � - - ' �� ' - f . '���� • .��COMPENSATIONiNSURANCE -���� S�ZE,OFLOT �NOWONL04 UEPZO�NOEN �P PAGf PARCEL� I �•(ihis aectian naed not 6e cerripleted if the permit is for one � TRACi . �- BLOCK � � l0T NO. � ��� NO. � hundred dollars���S100)or Ies{.�)� '. :._ . ". � i � - -. . pA ,�Q SPECIAL� � I�carfify,thot in the�perfarmonce of ihe�work fo�which 1M5 , � aWNER� eT�Ifl�R8 iSB >78��.6W� - CONDI710NS - � �� � � � Q ; �" ��` � ' � � �� " DISTRICT GROU4+ 7YPE FIRE� PROCESSEDBV, V permit is issued 1 shall n t em lo an .... .. �: •.� 7 5 ... ,O �`` , . p p y y person in any mnnne qDDeESS ' CONST. ZONE � � so as to become subject fo the Workers Compensation.Laws . � � ��� � 11C �, CITY� 18IIlOSlC3. BSI' � ZIP � 6 � O � DOte '��.� �.. ' Applitani -'' ''' $fATISTIULCLAS51FIfA110N � . .. :. APT. CONDO, i V i . ---. ARfHRECTOR . .. . ...FEL . - . � t W NOtICE-TO APPLICANT: Ff, aher fnaking tfiis Cerofitate af ENGINEER NO. Gtq$S�NO.�-LOWELL.UNITS_ - � �� d ' ' Exemprion, yaU�should�be4ome subjeet�To fhe'VJorkers . � E � . Compenw7ion provis�ons of the tabor Cade,you musf torth• �-"�� qpDRE55 � � � � � � �� �� ��� � , SEWER MAP �� - �. �� ,with%tornply.with such.provisions or this'permit shall be . . . . � � :deemedrevqked,,... �; � . , .,�� . �.; �.,....:�_. - . � TEt. p - BK. . ...PG, �: . ., 'VALIDATION' ' � CONTRACTOR NO: 6 � UL � , . j�-. � ' - ..,: LICENSED CON7RAGTORS DECLARATION �. � � � ���; •. ' , � � I hereby aff rm that I am-licensed undar provis�ans of Chapfer9 ........ AODRE55. � �. �.-NO. - �} 6 VAL � � - � � � � (commennng with Secuon 7000a of Drv4sion 3 of ihe Business and � . ��; � `�qp� . � � � _ Professions Code,and rt�y ticense Is in full fqrce pnd effeU ,, CITY�. e gg � �Q'2 CtASS C: S V(J � � '.;.1,rJ9�76 -, . �.'+'?C��,.� . SC�.EF1'. .. STORI�ES� FAMIL�IES O EK , . ... . �. ., . . �' - . �Li¢ense Number " tic.Clos� �� � '� - � � '-' � ' � ��,� .� -,. -. . �. . ,.:, . . . .,_ . . . . � S . . . , ' . . . Co�naclo._$i, ip d Mfg•'ComU�bllr 1I 0 81 DESCRIP7ION OF WORK Y vrlth Ri i ^�`N ❑ , � . . ... _ .. . . ❑ ..; . � I am exempt from tha kicensing requiremanis as I.am a � � TE BTBC� C186S nC�� ffi't2l,'�81 � A�D , �,��, � iicensed archiiec�or a"registered professional engineer ._,.. , _, ,�, - . ,..., „, , ,.. /+LTER ,'Q -.FINAL� , � �� � ,:�..aci�^9 in my.professional"[apacity�($ection 7051, �. ' � � REPAIR,-.Q �DATE �--���"� ��, . � � ��-' 6usinesSandProfessions�Code). � - . " USE OF � � �� . ���� - ' � . . . .... . . EXISTING BtDG.-�I'QS�.Ctfi11Ce..... . �..... DEMO[ � . .FIN L.� . � . � ; . Lit.or Reg.No... ... ... .. ..� �� Oele � . . APPLICANT � � tEL. By . . - � � � - . .,. . ._... . ..... .......�. . .PRINI`I . ...,. .... ,. ....�... ..NO. ` ; . . . � �'"""' 'OWNER-BUitDER�DECLARATION � ' � . �I here6y atfirm thot I am exempt from fhe Comrattor's Licensa� � � - �� � ' ' � ! ,.:.._.. .� . ._ , . �� .. . . . � . � ....laW fo!the fO��owi.ng feason..(Sectioq�031.5,�.BuS��ess and �-� - ' ADDkE55- - ��- � �� � '��� � '�� ���" � " �� - � � �� � - � ProfessionsCode):��,:. .' ,�:,- . � - PRe T '�. � .. . �. � ` � -�� ' - � '.. , , .-�... . ..,.. .. .,..�_.._ .. .... .�.,.�. BUIIDING. . . . .. . . . . . .,. - � .- . .. . . . . .I,�os owner`.of the properry, or my employees wi�h ADokE55 . � � � �wdges.astheirsolecompensarion;�wilidotheworkand ; �. �AiiTY, � � '.� . ,: ; '�. . ;_ � ..�� ...... . rt ... . -� - - -rhe strucrure is nor�nrendedor offered Forsa�ejSanion'"'�"'" � "`� �� ���' � -� � �- � �� � � � � . � . .7044,Business and Professions Code). � � � MOVWG� � � �� � '�1E1. � � � � . � . " ' �� ��� � � '-O�: I,as owner of Me property,am�exclustvaly tomracting'. .. coNiRncioa � .-- .NO .... �. � '.-.. .. '. . .:�., . . � . ;. . � .wifh(icensed cont�actars fa mnstrud the pro�ecf(Sec- ADDRE55� � � � � � ���� � - ' � ' -� � ' � -. ......Iion7044,�Business�ondPro€essionsCode). ,....�:.. . -� ... .. .�� . .. -. . .-. . .j.� . ' REOUIRE0 TOTAL SE78ACK FROM EXI57. ' �. - ' 'CONSTRUCTION tENDING AGENCY � � $ET BACK' VAftD HWY pROP.IINE � N1�DTH � . �•O S G 2'A. . the erforfmance of the wo kconstroctioniendingagencyfor FRON7 �- � � �� � �' � � � � �� . Y P p.. .. . ._._. . .,� ...... ... . .. . .... . � .' , . ..'.s �.'�� . � _(Sec..3097.Liv:.C.�.. . . ... -.. . �IDE...,. � ., . � -. . . ` . � ,. �fo�which this ermit is issuad p� : -.. . .,. ..... Lender's Nome . . � � . '.. � �� /� � � � � O .:. . $ . .. .., . ... . .. , . � . , .. . _.;, 0.C.Fea S. ,. ... . . .. Permit Fee . .(JQ . . .. . . ... .. , . . � •�� �3�], 'J�"O U. I . � tender's Address � � , �-p� , , . , , _ � � . I certify at I have�read ihis appliwtian and�state that the . ..�... , . . ... ... ��� issuonce Fee �•�,J G/ . . . .. . . .�r 2 Q� i�� � . � obov formation is correa.I_agree to com I with,oll Covm � � . ., . __,. � � . .AY. , Y ._._.. InvestigatlonFee.:.'. / ._. ' . . . '? ��'�. srJ ,.� � .... .. .�,. � ���ar � nces and Stofe lows relating to building cons�ruction, . � - ioml Fee l•:J V . � � ' � i . �� d- erebµauthoNza repres nt ' s of�his Co�nty to enter �� ����� � - �' ... p- 'the obove-mbiit'oe r� er� 4oP ins ection�purposes. .. . ,....,,. . . .......� . . . ... . ... . '. �, � �- ` 1 O SZ �' � � 3EE REYERSE FOR EXPIANATORY 4ANGU ��� � � � i � � AGE .; . . . ... , . n � � �� � Signoture of II n�ar Agent . Da�e . .�.. � � . � . . . . ,"�........: � ..,..�_...:, .. . ._ ......_..,.... . . ., :»...;.. .. �.._...:... ' _. ., . .. . . . .. .., . .. , ..._ . ._.. , � ..,. .. . _ , � ! Qri . . . . . . .. . � ' , , � � . . � -.. -.- ��raYLANS TO A4PLICANT ^ � ��'�INSPECTOR'S-NOTES� � � � - �OWNER-BUILDER DECLAftATION� � ''�1 hereby�affirm.that�I"am exempT from The�Contractor's �� To: � ` 4: � � �:� . +� �Rafurn�d ..� . .. .. . .�. ���.. �. :� . . . .. . ' . . � '. ''Liceiise�i6w'foP the�fotlowing�reoson:�'(Sac. 703T:5) . , " APRror�d ` ;BusimessaxdProjessionsCdde:Any�ityor;rountyuibrch'� No. .. ..�... ..Dafe..,.__. . No. .._�Daro ...�_ . . .. .,.-. ..; �:,. . .... � -_. . .....�.` ..::,�. � 4 � P �•�� '��►ertirasa'ermiC2o�onstract,olter,imrao¢;dernolish, � ,. , ' � orrFPait.anyierr�clure�Priorloitsissusnce:a&ongj�ires '-_ .�.... . -_ .. . .- ,. ��.� .� -.-. . -. .. . '. � �' .tbe applicas4 for sacb,¢ermit eo jile a rigned sratemena�. _ �.', � ,., � � ` ' � . �. :.ehat be is lic¢nsed pursr�oxit fo tbe fuoofsions of,tbe iCtifi-� � .... .. _�-..�... . ..�... � �.-.�_ . . .. ..., f ', _ i--- -- .. . . . . ...- J � �. ..•;.� .�.. ..�_. i.:;������censa Lam(Cbapter 91lmmrue»ceng witb S¢o- , . � ,; '.,. . .... . ....... .. . . Lf�Jiu�siox 3 ojtbe Brssiness andProfeasiors : . - , �a be is azempE ebereJroin and the bpsis jor tbe � ' � � � � ' � �' ' ..' . alleged exemQtion.�.Any piolateon of Seciion 7031.5 by ' ���� .. . . . . . R�quind DafoRseelwd : .. . � . � . ' . . . .:-:ueyapplrcpsLforapermlisubjettstbeapplicatt4toadvil . ,. L... Appi'$tlpls�. .... . � � � ' � �peaalty oj aaL neore ib¢n fine bundred dotlars(dS00��: ...Yes._ .,Ne... .ar Approvod .:. �. - - . � . � - � ,��,�•�•; . Q �I,as owner of ihe proparfy,or my empJoyees with . ;,.� ., , ,T, . .. . W.... ... " . . ".` ".�. .._... �. . ��.� ''��' wa es as tbeir sole com enwtion;��wil)do the��w rk,cnd � oter Ceriifitate - . . .. ,._ , • .�. . �..,,., 9 ... . . , P . . 4 , �� � ����-` - �• .. Ihe atructore ia.not intend@d or offered for:glo(Sec.7044) - - � ��$usineasandPro¢isioasCode:7'beContractor'sLicense , , -. ',ot . �,_ . � . : . Healih Depanment i. ... • � ��� ; .�':>." � ,.... . ,. � . f - �-., �. , law docs xoF appdy to an owner of property wbo builds _ , . �. ., .. . ...' Flre DepanmBm ; - , , . . ; � _�. -. ..or eqzproveslberaop,aad wbo doessucb�uork,bi»uolf or� �. , ;. �- � ' . _ . ....... � . _ .._ . . . � � e�.,,..tbrnagb bTs,owa emQToyees.:proolded.;tbar�raeb.lror•. . — � .�� Gradina .. .-� .. ��. ..�. ...�� �, . � � ; .��� .���provemewts.Fra sot;(nt¢rrded..or offared for.aale.:lJ,�� . � �'� � �� � -� ���- ��� � � ���--���� ����-���' � '� '�bowever,�tbebaildingori�nprovementisroldwiobino»e� � � Geologirnl ..�,,.. .. .�, . ..�, . .. �' . �..• �..._,� •: :-.._ ��a...,.-_. .. _...:� .' Year oj complet6ov�, tbe owuenbsilder�tutll'baoe'tbe � " burdexi"ojproving tbat be did uot 6r�ild or'impmoa jor � Pedestrian Protectionl '. ` -.' .�. �.�.�� �. ..�:-�. _ .. . �_�-� .;��� .,�..,�.. . . . �"� tbe psrpose of taleJ.. ... � . � � � (Fence)(Canopy) � . , � � �� Q" I;dsownerofthe�property;'cmexciusivelycontrpc, " �� , , - . � �tirg with licensed conrractoFs lo construa the project(Sec. � - Special{nspeefion . . . .. � . . . 7044�:Bgsiness and Profeuioqs Cade:Tbe.Controcior's '� (Cont.)(Masanry)(Welding) , � - 'Licess¢LawdoesaoEa¢¢lytoanbuin¢rofprnpartywbo , , " ' � r` �'�' •.� ' . <_ -: . . :�:.: �,;br�ttdsbrixaprov¢s.;l�ereo�,andwbocqxitractsforsacb� ,.. r ... , - �. '. � Lot Drainoge �.° ..... �, , . ` .. .. .. i, : ��projects-ruitb'a��tonlractoi{if liceinred�eirtrea�t io.lbe � , � -�� - .. . �� . ,' t�..: i ...�,.�,. ..,. ,.� � . . .. � . - _ _ -. : Contrdetors Lrcense LawJ. , Parking . . ':; , �.5 -.t t ., �..�� .. .. p _ ..�. ._ . .., . . . . ... __._. ..� . ... . ... .. .. .,_.. .. . ..___.. ..' . . �,...� ❑ '.+emexem tui�derSee:' . .. .B;�P:C.��forihis . - �-� , ': � :. . � ..:�1:.:,: :. reason� �, . , . , . . .. _ '.�1 .,. ,, j �„ � . .._ ...... ... .... .. . . ... .. . .., c _.. Date.._.__ , _ � _-'Owner' APProvdls Oet� Impedoi s Slyne}urc �'. . . ., .. . .-_.. > . . �.,..��. . ._...... . = ' ��. . . - .. � .. .. � � ' INSPECTOR'S NOTES'' ''�� . ��. � location- . . . - ��. ' ^ . . . �. . . .._. �:._..... .,.._.. ._.. ._ ... . .� .,. � .�,.: .... . . ..; � � (Satback&Yardsj' �� � � � -�� � � �� � Foundarlons . . . .__ . _._ �._ ..._. . . .. _. _._. .. _._ . ��:,�� .... . .. . .. . Slab . .�. .... _ . _ .. . . . � � - .. �. . .. . .� '. � �. EFrcmF � � � � � � .. � .,. � .. -, .. . , , � . _ . - � En�rBYMtulatiorY�� � . . . . . , ..,;. ,,. .. . .,. � ,.. . . ., .. .._. _.. . _._ ._. _ . _.. , ., ,.. Lat f.9 wa�— , � � . � � � � � � . , �hln'te ior � . . . - .. . Lbtli-Ezlarioc � ` - ;` �'� �'`" . � , .. . f. -,:".:'. .'_- .._ ._. ' . , ..,, .,.�,. Ho45e Numbe�-1 , , '.. �'__:� . . _ .__ .: . . .� i:. .a . ..�. i.. „ � .,.,.. . . , , ;� ... . 1 .. , . Correct 8 Posted . - . ..__. _. .. ..-.. ,. . _ .'.. _., .., ,., .. .. . ....� i , .. _ Final— � . ..�. ..- . . _ . . . . ,. . - . Enter on Front " ' � � � � ' . � � � ' � . . . ._ . \.'��,� . „ _ -, . _. - , I�!