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HomeMy WebLinkAbout1058A (5) _ __. __ _.�_.. . ' , WORKERS'COMPENSATION DECIARATION � �� � �-� - � � � �� � � � �� � � . � ' , �. �, .� APPLIGATIOI�I FOR BUICD{NG PERNI�T ' 1 beroby affirm thv31 hdve a�cerTiHcate of�wnsent fo talf - � + inauie;nr a eert�t'ote of Workers'Compensafion Inqorcneq � � ' orYa'eertifie�copy theieof(Sec.�3800,.Lab.G.} � � � � ' .. � � � ' � � . . � , COUNTY dF tOS ANGELES BUILOING AND SAFETY ; . polityNo. �... ;Company . .- . .. � � , . . . . . ... � .Certifled co is berebY fumished�.� � . � � . . BUILDING .,A� � '�• ., .. aY FOR APPLICAN7 TO FILL IN nnoaess ee ��� Certified copy Is filed with fhe counry building Inspec• BuitOtNG � '., _ ��[`� � . . . .lion deparfinent . � ADpRF55� � OCAIITY� � 7� � � � , NEARfST . � � � �Date ��4�ApDlicaN . CITY��� � IIP� ' CROSS ST.� � . �� � . .CERTIFICATE OF FJCEMPftON OM WORKERS � . ni0.OF BLOGS. , . A55e55oR � � .�COMPENSATION INSURANCE SRE OF tOT NOW ON LOT MAP 800K � GAGE VARCEt � �(This sedion�need not 6e-tomplated if itie.permit 1s e . � � ' � , � � � USE ZONE MaP . .p'3',� . i. . hundrod dolbn(y100)or less.) Taqa etoac tm NO. No. o .. ._ . .. . :. � �. : , . . .. .. . . . .. �TE4 � �� bPECULL . �., � > �f�eenify�har In the�performanee of Ihe work fo�which this � �`�/NER - O cOh�orttONs '�� � . n. � permif IS Issued,.7 shell nOf erqploy any person irt atly mnnner � ; � ' � -''- '- �� � �- DIST ICT � GROUP 7YPE �� FIRE PROCESSEO BY �V :o as to�become sub�ect ro�he Worken'Compenaatio�lowa. � A��u . �O� � COw T• � ..ZONE � Date�..' : �APPIitaM .... � �.:. � . � CIiY..�: . .. . � ZIP � y7AT5TICAlClAS51Fl TION � _ ... �APT. CONDO.�'; .�.O NOTICE TO APPIICANT: N, after mcking this Cenificate of -���� ARCHIiECfOR . _ iEt. � , Exemption, ,you.should becoma-.sub�ecl Jo fhe Workeri , ENGI R NO. M55 NQ.�DWELL.UNITS � ..�� d � Compenaation.provis�ons�of the Labor.Code,�yov mvst forth- . . , qppaEu � .�,.. � .. . � . ' ; SEwEp M,e,p . . . . p 'y�� with.�omply;with eueh proviaiona w�thie permlt"ehall be , ,� � � �� � � �� � � �z �deemed.revoked. .. � � � . � �ig,qMpR u �' 8K: .....PG, . - � .. . .��VpLIDAt10N i� - ., �-� UCENSED CONTRACTORS DECIARATION �` � - � I hereby dffirm rtwt 1 om licensed unde�provislo�a of Chap�er 9 qowtess � NO. � � YAWATION . �� � � � - � �� �� - � � � � � � (commencirg wifh Setlion 7000)of Division 3 Of ihe Basiness ond � . � LIC. � - . � �� - Professions Code;and my license is in}vll force and efEec�. � C�i1'� GUSS - � t ��I , � ... . �.- � � SO.W. NO.OF NO.OF CHECK �..- ' ... Litense Number-7� 9 D)J��� lia Claas�_ � g�ZE � STORIES � PAMIUES � ONE ; _ � ; ,:$�'�O�8� Lonfrattor����l�d'" pote DESCRIPTIONOFWORK � � N� ❑ . . � �' ,�_�� � r •i',� ,.... �. AAD ' ' � . �1 om exempt under Sec:� - ��� � l� �. . •-' � �� � ���� � � . . . � � ALTER Q . FINAL . . . .. .I 2 Z rJ.iQ . 8.$P.C.tor this reawn� . �..- .'.,,..._ . � , . .. .. REPAIR-Q � DATE �� � •• •�2. 'rJ�� _.. I�I "' � � � � -- �� USE OF .�FINAL-�� mfs: � exisritic e�n�. oenoo� ❑ Bv 0 7,O 1 �8 S ,�Signature � . . . . ~ APPUCAM �. � TEL :� . .. . . .. . . .. , . . - � - �- OWNER-$Ul4DER�ECtARATION .-. : PRiM NO �: � . .. � • ' a e.i�ca.�nit\ I l 1 henby affirm that I om eaempt from fhe Contractor a Ucense . � � 4d �� � ! r � � Caw for ihe foilowiny romon,(Section 7031.5,Business cnd ADDRESS ���—�--������ .� ��� . - , irofessions Code): � .� . � .. .. . ae . . � , 'Y '� . . ' � ' euauiNc ��s"' s\2 , `�' j i - A, as owner of the property, or my employees wtth - {�OORe55�� �J � �w6ges as Iheir�ole compensaflon,�will do ihe work and .� � � � � � �^+_��, �1 ! � . .,,� � ' � .�.Ihe atruc�ure is not inte�ed or offerod tor safe(Section ���TY � �-F7��?��V�q�-�.-.�i,�����}��\�}c-.�.� i+-��e-, - � . . � '�➢04-0,Business and Profassiom Code). .. � .. MOVING � �TEL. � h 1�le,r I('�,h,` �12�C.�"`�,{�Y•�°� . .. - O_ I,as owner of the property.am ezdusively conhacfing � MRACTOR . . . NO. . 1 . . . . . . ., , � . wi�h licenaed contrac�orslo tonztr�d}he pro�scl(Seo- � . . ', ^�`-\�.�o'��,�¢t1 t061s , . . .. � tion 7044-Business and Profeasiana Code) � A���� �� - � . . � . .� .. . . ... ' ��..� . .. �� REOUIRED TQTAL SETBACK FROM �ISL � '� . � . . �. . . .� . CONSTRUCTION IENDING�AGENCY - � gT gp�K " YARD HWY� pRpp.UN WIDTH � .,,,� ;,.1,"4 r �,.,..,�,� � � �, . I heroby affirm that rhere ia a conanuctiQn lepd�np bpency for �.pg�r . : . . . ..'�,.ya ,�R '__ `:'-�.. � y`J.'�y� the performance of the work for which thia permit Is iuued��� P.L � � � � � `� � .. � . ' l .ZSet.3097,Civ.C.). . ., . .. . . � SioE . .. � . . . . �. _ . . . . . .. , . . . ' � .. ., _ . . . .. ..P.L . �$ Lendere Name . . � . ./ � .... .� F �-� ..` ' . .. � . . ... . .,_. P.C.feeS .... . ,. .. . . PermllFee -� .! S'�. � . . . . . .. ; � . . . , '..t � ►ender't Addross - � �� . � Y 1 certify that I�have read Ihia applimtion end state fhdt�he �� � - . hsuancs F�a�� .I6.��� . .� .. . .. . .. . .. .. �.... � ..:-i� � ' � obove lnforrtwtion is�torrec�.1 ogrce ta Somply wkk.all Counh Invas�iqotion Fee . �. �� .� � .. �."���.�.. � i, g �..qrdimnces and$tafe lowa mloting Io bWlding tonatruCtion, . - - . .��Towl Fee � �. .. .. . . . . . ... I. . Y. ond hereby authorize ropresenfativ of�his Cavnty lo eNer � - � � . ���� � .up ove-mentioned propar for�lnspeciion purposms. .....� � . _. -. ., � ..: .. . . . .. � .... . - . ..-.. "�� � :. � �p ' ��. t .:;,Y!.�� I p � -. . �� (.�,/. f�{' bEE REVERSE fOR EXPLANATORY UINGUAGE .. . ... � �... � .:�s _ ' . _.�'�--..._s . - . . . . i furs o Applicam o � pafe . . �. . . . . � . + _� .. ._,. ,:.. _ ... , . ,. ._ .___.: :._..-.�.�: -,_. . .._. . . .. . . , . . .. . -�3Q N::�Snl� �0"1..,_" ._±� .� " 1 ^. ,y,;� �_ Y {. <:._ ' -- � , ,,,�P � .:e� f ��'pV����.�`�DL"��.�A�1��....��,.�...�9 I • - ... p .. . � _.,.�,herebyr,iHmA 1,. �m�B�MTP��.'a�+11he:CenlroftPrs � To: , ... .. •.,� R vrrted � .. .�... . . • .� ._. ,� Litense Law��tor I thC�,:foBouyi^8��nebsp�,, c1�a6t,,7D�1�5) � ... _„ . ._y' �� ^P, .._. " .. s , _.. _ ������ Approwd "� '� "—+-- "` ' Busixess end P ofe.ssons Code:An9 c�tv or cr�unty whtcb j Nb�: ---'.�Dafo.-."�'�'._ ..�Daf• ,: ; -"`�� " '" . ��= �: .. . . .—._rtquirrs�ap�ernr a��utru-t���it,d�ls--irraprovr;`�enio?isbi ' _ �, f ,.. 'r �'�� :.,�� -�.. arr¢pairanystr�uc�tttre'.'pivbrta�i � ludnle�dlstii4 tiiret ; .. _— .. _�--'...-- .--._... t �....: -. .. — -- ... .. [� �y { H � 1t -fs i! .B � � . �..,.5lre n P tcs t�r.r uc :p,rrK ta '1e;+pm tat ..i , _.�_� �_...__ �� ._ ... 4'^..:.... . ._ . _..� _., � �.. � r ebat he is licerssedpecrsuant to Lbe¢fou£N�4N.'s�Q�YAe GotF ._ __._� ...__ . .. t: 7 � � e:t `sh tar's Lieensa Le�e�Cbuf�Eer 9J(c�ommen�een cth�� � __ _ _ _. .__ _. � , ` s —::e��7000)of �=3"n7�abd�„i:�' ,� - I ,� ; _ ��.� `:�� ,:.� �`� ,�--.,. ( Cade)ar�tTidtbels�e.�eh3pEt6erbfrr�ia'aln8ldeE¢kisjorebe��' .;�.. � '_r - , „ >,' . . „ . �� - --i � �� � � --��--- -� ¢ll d e em aon fln ��olu�to�n�o�.�ettiox 7031 S b � ��-',`�R'equlrod ry��Racu�vud �l „ , :-.�:s»ys�pl:iar•f+'¢per»iitsrtb�crtstfi�applicPnEtdali! �`_—Rppvovala-� `._. � pr'/���roved '-. � ,... _._ .-.. � -C . pena ty of nnt nxore Ebs���ftt¢but!(Ired do.lars�as6�l:l Yo. Nq t t ��-. � . ... . .. .�.��f..`_.... .L..,.. �1.;.- . _ ed; 1�1 6as;o`ttnerofl4��.ProPeriY.�.or:�lYAm�PYOAt,witb , _. ,r n., ...�,��.:� '' , . .- �ateiCeruficate .33,�t ;�-:.. ,I � ��....,; � � � .,..�� � , : . r+v�gasvsdheir.c%Iecor�qiensotion.Ilw�Iide�.9he:vrAak>,and . .� . . , . . _._.__. _____._..._ __._.___.. . .�.d...�.,.�.�._.��._ _. -,�� .v;rHestructura'tarwhrm�nd'edorvsfared�foF-sets{6e2t�Ot4) .�.� H �$vAepat[. _ r � .�' .� �_� .. _.v..^ � .,,�,�. Business and Projessiuns Code:TFie Contractor's Licente .� .•..+rn r-n . �-: .-�;e,• _'..._.._.' "_,_ ....._ '_._" .�_ 1.. - _yau.d es no.E. ply.fa.cfs o er�JPr rty mbo.boii&ls - ,� Fire Deparime t 7 1 i, C '." O , .. {}�_�..� J-..' .."'.. _ �tJ�r A hrs� �,r.�Co3 s reuid d Cbut-a���r � �.. '.. . .._� ` ,i ..,,•( `. :,... 4 _._..�; . , ouLever,�[h"ebeil�ng�lnte�4�roven�'ex �ssotdweueb@Yn- . . . . ... _ ., . ._ ... �. ,.� . �,.. .��� � ,., �4��� , h � � rr tmpr6�es2beN¢o!�'�tri�wl o dodseacb7obrb b6 .� _ _ .._'-.'..,. .-...._..-- -._:.::. �.. ..,...�.�.�. .'...., _....� - �. . . . . Grading .� ke .�. . .-... ...,� � ` .� _.. - ;..�.� � '.hur n ti 4 �r4 i�'b�Jr' � tula If, fb�x ofle Geologic�l ^� � _,�,,.� �- �` year of coniplettott 1d�CTauxer builfler wslr bave Sbe - �� � ro>>n Zk E ki or[m r4ve or I � � " t� � a.G P�� � �y'- S r,�' A. .I ,. �.. : , * . , ' PedeslrianProtection ' ', >�� .:�. ,,i, � \ b�n=hQ�u�Q�,e�.o�salel,�.;+a( , r�.�.r� .,.�„' rr�c:f �� (Fence)(ConopY) '' "��'> � . .2 t '+ ) ��'� +; .t:.s❑ t,asov3dor'�f ihe�pro�ertyqnm�.ezdusively rnnirat- ' ,� ..., ...,,..�... . .,� �_ . ,J . _.. , _ � ,,. �.^ � �, , i rrc w ih licensc I .;nhactors tc� onsktr ci the ro�ect(Sec. Speciol'InspeEtion �� i �� �....,_..._.__.__ __.:...._. _ :�_.'. � ._._.. x;� _.,:ZS��,<b„�,.asin4sc�-n,1.Ynf�ssir'iis�Ga r�.T6e:6vr�tracMr.a (Conc.)(Masonry)(Welding) * ` �'�`^, � _. ,,., "� ��f.iccrtse Lau�doea nnt aQQly�to an oumer ofproperty m6o . . o a =, ;. i �� ... ,. . __. �_. ...._ buld orir.r,proiR5f6..renx np`��..{'onflyc#�auCb . Lot Dranoge .. r �"� '':'" .��: �' � � . .� . u, � ' ��pm�ect uitb o n�ract r(J l nee �ursuant,tq( � '�... .. i ' 'i . ...."..� .4l :"i , ;,,. l_. _ ___�+_ .�...l.t_ .. .. _�. _..,: �....� ""tbfltPaatzrr:c�'.zceu:cta[v�. �••�:`r� ' "��u 7J � ` � . ..: � � ' �� 'C�Fo � Parkin9 �:�: .. �. � r..__., ' _ �...':_. . . . . .._,__ __,:......___._. � ----' -- . .. .. .. ' . .._.�. .p____. . �...,r. .�. --t- � +' ,__._.__...._......._..___.. _, �� lameze Iuntlor5ec. B.6P. . rthia � . . o�� . - �_-. -, .. �` a�, ... - : .. .. " „ „ . i'� k � ' _ ..._.,.�._...... ."... _.�.,�_�_ .._.." ' _'_..�. ;�. ,'" 1 �.;.1 ��.; � �. ....� fN .-..�__. . ..,i��i._ _.'`.'_. [ �,l:nq �?' reason ._ . d:. ___ ! ._.._._ .___ �. . ,, . �-- -' .. ., . _ . .. __`"..' .' ���. ��",. � _ Date i_ i Owne � _ J � � . \ �� �i � t � � I � ��+ � ��5 \ 1 � 1� , � ��.i�L '` k ��� t.�.n��z_ i�.�E ,d.i 0 � ",1 i =�i�� R.. ���.i i v � � , � . r , Ap�rovats _I Dale `Isp�ac�or �SgnaCuee � ���t'� ..�... �� , ...:��.� . .�.`;; , ..�.;.-'—' �� � ._.. . -- --�-� � _ ---�-=-��� ` � k�,:.�.c��xs wop�s -�� ���,�__ _ ��� Location— � - ...___._.. _._--._._.-----.—._._.._..__._.___._.--..._. ��, . . � , „„,, (Setback&Yards) ' � t ..�si�.., �,."� o ro��� �c ,- � :. .. . , .. :. Foundations l ., .j j r _ � !.:: ,. , . f r �:�'. r � , `, ,.., . ` p t.... � i r-; � Slab ...,, . . ,:..:.r� .; ;�,� .,,, .. __" c.. ,. . � � , .,. � .;:�� �.�; t . n,..,,, . . . � . _,,,. „�?, i. ��.�..,rt,. �f,.�.. :�c��� i �` � ._��"-, - .I_ _Z 9 � . r , � ;� ,_ . • ._ . _ . .._ _,_.. ._ ...__. , „�.,.. �i- ,;t ,. „ Energy Insulation � '�_.__ � . "'' � � -�� ' , �, � t�-��c v t ,...,: ,�n � f � ....:} � . ' .� ....___.._.. . _..._.._._ .,_.i... ._1,..._., ..: �� ': . { J.-.ti�:,C .,..1 . Lath/Drywall-- i ' �; �� � u: Interior � .:.'...-..,;._,.._ » �...-.. . ,....:, . ., . .._, <.. _. ernc�l r'i��bnsJ : , _.___ .. ____._...___. _ _..._. �� `i I Lafh—Ezterior , ...____�._.'-�.___..._;�....:.:_...�'..._—_.__.._._ _...,_.' . .-I:� `_ .,�.4�.r �'�..".,,,,i r_. , �Y.. - ��. . ; �� �.-,r i .�... . , i �.�� �. �: . House Number— . ��. �-� � I Correct 8 Poated �.___..�_.___._.. _. ._.:._.._'. _"'_ .r.'.,___._. �� .,��,.,r.�If. � . .. .. ���n „ t.. .�n Finol— � ',;�z .. � i e�.n io ��,'.-o� ,�������.,�.r!6•,0 �- . . ,,..,,7� r. .r. Enter an Front . ..��,:� . �:��.. �,. -..' � �� '. �� � � ' . ;� , .. ' .... ,, .. _ . ..:��. �,. .. x � �:� � �"� -�„ � ti l._ � �;_,4. .- ..,.,. ;, m , , r . '�. � .: .-1.--�.— .�-- - .