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HomeMy WebLinkAbout1220A 1221A (6) WORKERS'COMPENSATION OECIARATION � - I hereby of(irm thor I have.7 cei��ficote a�conseni lo self APPLICATION FOR BUILDING PERMIT � insure,or a cerlificq+e of Workers'Compensation Insuronce, or o certified copy thereaf(S�c�„3800,Lab.C.) � � PolicyNo.IGo4 74 k Comp�y �-�-u� J=..,,/ COUNTY Of LOS ANGELfS BUILDING AND SAFETY � Cert�f�ed copy is hereby furnished. FOR APPUCANT TO FILL IN qppREu 2 � � Certified mpy is filed with Ihe covnty building inspec- BUitDiNG n N � Hon deportment. ADDRE55 2 3 6 C7 e N�p CGC �(. U Dale �! �- 8 9 Applicant � �1� C�i �rt/ Zic �p�q��7y CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF BL�GS. r�E.4aE57 / COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T CROSS ST. �This saction need not be campleted if the permit is for one TRqR 3 S B�OCc t07 NO. � �ESSOR �. . hundrod dollan(5700)or less.) . hwP BOOK OAGE PARCFI Tei. u orve o I cenify thm In tha performance of the work for whicb�his �NER �. �f�S I NO. NO. � � permii is Iswed,I shal�no�employ any persod�n any manner ADDRE55 � M � SPECIAI . � eo as to become subjec�to the Workers'Compenaation Laws. � 000 C7 �ON�ITIONS p U Date � Applicanl . . Ci7V 217 � ARCHITECi OR lEL. NOTICE TO APPLICANT: If, after making�fhls Certifimte of NGiNEER NO. DISTRIQ GROUP �NST. ZONE ��SSEDBY � Exemprlon, you ahould become svb�ea to 1he Workera' Compenaolion provlsiona of the Labor Code,you muat fo�th• qDDRE55 � �� � �/'a' W with comply with such provisione or this permit ahall be n. deemed revoked. TE�• 5inii57iCAt CtnS51Fl TION APT. CONDp. (A COMRAROR GI/C-�Q�- �•-{�-- NO. Z LICENSED CONTRACTORS DECIARATION � /� ' uC.- Ctn55 NO.�OWEIL UNrtS I hareby affirm thot I am licensed undsr provisions of Choptar 9 ADDaESS 1 1 fl ��lC� NO. (tommencing wiih Secrion 7000)of Divlsian 3 of�he Bosiness end ,. ��� ��R�P Professions Code,and my license Is In lull force and eHett. CITY C-✓q�n u CUSS VALIDATION 50.FT. NO.OF NO.OF CHECK BK. PG. Li[enee N�mbar � (�_Lic.Clasi,_,�_ SiZE STORiES FAMILIES- ONE � vawanoN ConlroCfor W�C^f'— � T,��f�"Dcie —3� DESCRIPTION OF WORK : NEW ❑ S 1�^n•� , ADD � (f/ ��am exempt under Sec. - Q �� ��^"� �� 2 2.Q A x�� 6 AUER � B.BF.C.for this reason � y Z � � REPAIR S - � �{•• • •2 3 _ Dafe:� �SE OF pEMOL EXISTING BLOG. I • •2�O O S'9nafufB �. APPLICANT . TEL FINAL L n;�NER-BUILDER DECLARX71 1'd 7RINT �v NO.� — DATE ,� " •.�Z J��Q O� I heraby aifirm that I am exempt from the Controcior's Litense � � Low for the following�eoson(Section 7031.5, Business end AODaEss } p�Np� ✓ 0 g Z q_g 8 Profeesions Code)� By - � I, as owner of the property, or my employees wifh A�DRE55 � , �,',/ � ages as Iheir sole compensation,will do the work and /Y� the structure is nat intended or offered for sale(Section ���`��TY ��� A 7044,Business and Professio�s Code). - MOVING 7EL � � I,as owner of the ro erf am ezClusive� cOntroctin CONTRACTOR NO. P P Y. Y 9 2�� �� z� 2 2,� A wirh licensed coniraciars to construct the project(Seo- - d �ion 7044,Business and Proiessions Code). nooRess �� , � ` • , � CONSTRUCTION LENDING AGENCY SET�BAIX YARD HWY T�TAp OtP.UNE WiDiH ppp I hereby affirm Ihat there is o mnstruction lendinq agenty for iRONi � � • �3 Q 7 5 Ihe performance of the work for whith ihis permit is issued P.l. �Se[.3097.Civ.C.). SIDE � • o •�6,7,�j� P.l. tenda�'s Name ��'2 9_�y 8 z� . �o�,Re,.. m lendei s Address �� F.C.Fee S .lrl� Pe.mii Fae ' � 1 ttrtify Ihol 1 have�ead this applicafion ond state that the luuan<e Fee �� ��� LDMA P/C N a6ove informotion is corrett.1 agree to tomply with all County Invevlga�ion Fee ! $ ordinances ond Stata laws relating to 6uilding construction, Towl Fee �y`7 LDMq perm.M � and here6y outhorize represen�atives of Ihis County to enler � �pon th�bave-menlianfd properfy for Inspe[tion purposes. _�/ __J,'��'-�7 �'�' SEE REYERSE FOR E%►IANATORY IANGUAGF Signarure of Applimm or Agem po ej �� � PlANS TO APPIKANT - . . INSPECTOR'S NOTES � O�VtiIiK-i3U11.UliR DC:CI.ARA7�IDV ' � ' I 6ercby offirm thot I am exempt fro��Ihe Conrr�no�'s . To: �. � � - . . Refu�ned � . � �. , . � � . � � L�cense,lnw -for'�he'foliowing reason.� �Se�.�703L5; � Approved . ... � ...Bnsiness<mJPrr�es�ionsCrHle:AnvcitYnr:nuntvu•licl No. Datc No. '�Dafe � � . . ' . . . . ..- rcyvim:u frrmit fn cnnsfru�f.aftrr.imf�rur��.drmnliclr. , . •, i�r ri fnirnn��ciructurr./�r r tn it.s i�c� �r,�alsn rryr.irvs 'y` . -.�' 1.'. ' . . • . . - � � I!r�ppli.�nt fnr aod,p�.r it ro Jrle a�n�nrJswternrni �� .. ..r � � ..� -. . ' . . "_� � .�. ....... .. ... .__._. _ __. _ J (' d 1 , . _ - 1!a! x�ia �,.rnsr pursuant ta I r��prnrisrort3 n/d (o - - ��.�• � .. :,�� • �• ','• !'�_�� .. � t.aan.t�t.reensel.,i<•rCtvpre�'11A,�m,n�na,n.eurrr�scn _ . _ . . .= . __ _ _. .. ._ .. .' ._ .. . ` . '.. ""_ , tinn?000/of Uu•isiun 3 o/the!)usrnccs and Pru/cx.vinns . .. .. .� . . . ,. _ ._ . . _ . -. � . . ... .._ . _ .:. ��. �. :� ... .... . . .CuJc/nrthutL�eaexempflberafrumanJtl�eFn�i�fnr�he . . nffc,erd exen+ptinn.An4'�,�•+lutron�/.Srr�inn'7U3f.i h�. � .. ._ _ .. .. - ' Raquired-' ... DateReceiv¢d.:� .-._._. .... ..� ...... ... . . �-� " an�'upf�liran!/oraprmritsuhjr�lfrLrapJ�licnn7tna.iril 1 APProvnls .ar Approved � - ., . �.. .,.. .. �. ��pP��Ly n�nnf n�nrc IfiJn firc L�undrrd dn!lars(S5f101.J: � .. Yes No . _:. .. . .. � �� �� � � _ .... . .. ... .. . �_ 1.as owne.of the propwiy.�o��my employoes with Wp+r;r Cerl�licc�e ` '" � � . - � -�---� - � - � . . . . . - .-_.___. .�+�ges as iheir sole rompensanan,will do the wo�k,ond � � � -� � � � �.��the sGuctu�e is nm intended or offered for s�le(Sec.70ddJ Healih DePo.imeni... � .. �...'�'`�.:�. -.- . ..-.. . . --, , � .� _` -.- . . I)usiriest und Prn/estior�s CoJe:7%>c-Cmitrdclor's Licente ....._.. .. _ ... _ � l.�in Jnrs not afJ�lv�ln an r�u•ncr r f rrnp�rll'u�Lo GurlJs �� nr irn •nres tl,errnn.and ud��d�,es surb u�or,F.b'nrs��! - Pke OePar�ment . -. . . .. . . _ r � i /ur ' . � llrrou,qlr-bis ou•n rrn/�lqpres.�pror•icjcJ�tGut surh irn. Grad�ng ' . , � J�mnemenh are nn! infendeJ or u//�rrd/nr Salr. f/, . � �bnmrvrr,lbrbr�iGiirs,qnrirnprnvemen�i.csuld�rit/rnnnc . . ._ ' ' .'__ ... ..... __ .. �..: . Geologiml . . . . � .. i �� l�ear nI enmplefinn, ile nu�nrrv6eeiJJrr u•il!lare tbr __ _. . . . . . _ . . -. . ._ . . hurdcn q/frm irr,�fLa7 he did nnt hur1J nr impmrr fnr , ... . . , . .., Fence Cono �' .. .. . !he rurfose oI*afeJ. . . . � Pedestr�an Proiec�ion ' .��••�• : '� �� �1 :� � .. �J 1,'as owner of Ihe oPerl� y 6on .. t 1( PY) : -.. . .-.. . " ... . . . � . _. . .. . _ . P� Y,am eKclusivel rrod . . _ , . iing wnh I�cemed tantroctors io consiruct ihe project(Sec. Speciol Inspection , . .. . . . , - . . . . . ..- � . .. .:. 7044)Uusinrrs and Pr.��e.vsians CuJrr 7/u Cnntr�rtnr's tConc.)�M11�sonrY)IWeldin9) .. . ._ . . . _ . .. . . .. f,icersiq l�md�es nnl aypll'fo art puner rjprnperrti'u•Gn . . . ........ .... .huilJs o:.irnprures�/1 cre�ia;.+ni1 i��bn runtruc(s Jur su<h '.;. �.' i .: -' _.. _ ._ . . . _ . ._ . ':-�pr�jccu a�ith a runtructnr(t)limnqcJ.pr�rSuunl 1n flc Lot Drainage ., � . ' ' . , � Contra<(nr's l.icenrr l.ad�j. � � -� Po.kmg . . ... . . _ . . _ _ ._. . . _ _ , i . . . _ '�, l . �, . . . _ (] 1 om exempt under Sec. ,8.8P.0}o%th-�s .. . � _ ... __.__.._._ . _ ... _ .. . . . , ' � `�rcoson . . .. .. �Dole � Owner . . � ' . j 1� - .. __. _.. , . -_ '_'�. .- ,. . Approrals'� Dolo . Inzpedor'sSignafure . . - � , . �� • �- � � -� � INSPECTOR'S NOTES Lomtion— . . .._. . (Seiback 8 Ycrds) � � �� - � ��� Found�Gons _. . . . . .. _ . _. . . . ��. .� . . , .. . � . . Slo� � ' . . � ... ., � - ._ . . � . ' . _ _ .. � �:: „, . � . .. : '- Frame � . . .. . . . . _ . . .. ._ . i . . . Encrgy Insulanon i . � . . . . .. <� _._.' _ _._ , .. _ . . . . . . . _ ..,. .� . ' . . . . . , . . � la�h;Drywoll-- . � � -- . . _. _. .. _ .. ,.... . - , . Inrerior .. . .. . -. . . . lath-Eatericr -� � . . . . . , . . ___... . . _ . � . . . . ..._ .. . ._ ,. Hoose Numbe.— . . .. . � _ . _ .�.. ._. . . � . . . . Cor.ecf 8 Pos�ed - . .. ... ... ... . .. .. . . � . ' F�mai_ . . . . . _ ., ., . _. . .. .. . , . .. , � . . Emer on Front - �� � � -