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HomeMy WebLinkAbout1730A 1731A (10) WORKERS'COMPENSATION DECLARATION � � I hereby affirm that 1 have a ceriifimte of�o�,e�,,o=e�f - � APPLICAT{ON FOR BUILDING P.ERMIT � 4nsore;ora cerlificote of Workcrs'Compensafion Insumnce, or a certified copy�hereof(Sec.3800,La6.�C.) � � � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.��Company�f�7 17`.�' � Certified copy�s hereby lu���shed. . . � FOR APPLICANT TO FILL IN euuowc. � �� Np��E lY AD�RE55 /"C. � Certified wpy is filed wifh�he munty building inspec- BURDiNG � � fion depanmenL ADORESS 9 c��-���« Dafe � 0 Applicant . CITV �D�� � � Zlv �J , tOCAlI7Y �C/l�.�YIQ�� CERTIFICATE OF EXEMPTION FROM RKERS'� S4E OF LOT �/�-ic . NOW ON IOTS � CRO55557. IUd1MO1Ld�iJA?'�r �ELSIf - COMPENSATION INSURANCE (This section n¢ed not be complered if the permit is for one ASSESSOR h�ndred dollors(5100)or less.) TRACT BLOCK LOT NO. �,�qp BOOK PAGE PARCEL _7� ^��l�A_] TEL / USE ZONE NUP I tertify thot�in the performance of the work for which fhis OWNER V. �d Y- '� NO.' H , NO. permil ii issued,I sholl not emplay any person in ony mpnner qD�RE55 � SPECIAL � so as to become subject to ihe Workers'Compenso�ion laws. � CONDITIONS � CITY ZIP V �ofe Applicant � ARCHITECi OR �+ iElo7 � NOTICE TO APPIICANi: If, afier making ih�z Cer�ificate af ENGiNEER C NO. �.-/ DISTRICT- GROUP iYPE FIRE PRp�SSED 9Y � Eaemptian, you should betome sublect m �ha Workers' 0 ^ CC�S�t�\�� ZOtaE \\ —W Compensafion provisions of the Labor Code,you must forth- qODRE55 (7� %�E / . � K "'- �7� wi�h comply wilh such provisions or Ihis permit shall be I n- deemed revoked. _ � N�� .._ _ STATISTICAI CVSSIFI TION APT. CONDO. N CONiRACTOR Z IICENSED CONTRACTORS DECLARATION �� � ) ���, a C�A55 NO. OWELL UN�TS I hereby a((irm fhoi I am licensed onder provisions of Chopler 9 n0�RE55 3Q/�C/[�U6Nr9ti/ NO.aJ�/� (commencing with Secfion 7000)of Division 3 oF the Businessand ��� ^ SFWER/MP � Professions Code,and my license is in fuli force and eHecl. CITY-� �/�t/� ClASS 4"�� BK � VALIDATION S�.F NO.OF NO.OF / CNECK LiCenSe Numbet����/ llC.C�OSS�L $IZE $TORIE$ � FAMIllFS r ONE yALUATION � � Con�r��fOflJ��2�'iJ .4-(�n� pp�g - OESCRIPTIO OF WORK� O � O � ADD � S /�(�O.O� � ` ,�"J �� C'oJF,Y , I om ezempr under Sec. � o AITER B.BP.C.for Ihis reason � a��u � REPAIR s � USE OF ��+^ Da�e: EXISTING BLDG. l L OEMOI Signofure APPLICANT 7E� FINAI �1 7'a 0 A OWNER-BUILDER DECtARATION 7RINT �Cyit�-(l C-�/9.J NO�.SS.��� DATE 1 hereby oflirm thot I om exempt Iram 7he CoNroctor's Licenae qDDRESS /ct,�.=/C.0 J.S/WA�L✓ ��� � ��� law lor the tollowing reason(Section 7031.5, Business nnd � FINAL Proiessions Code): By C I • •2�J.Q Q ❑ BUILDING U . I, os owner of the properly, or my employees wilh ADDRESS wcges ez their sole compensotion,will do�he work and � •°2 5.�l�c=i Ihe structure is na1 iNended or offered for sale($ection ��`��TY , - 7044,Business and Professions Code). MOVING - iEL. . Q 9.2�—8 8 � I,os owner of the property,am exclusively conlroding COMRACTOR NO. with licensed controctors to wnstruct the project(Ser qooeess � `� 7 3•� A �ion 70da,Business and Protessions Code). - CONSTRUCTION IENDWG AGENCY SET Ba[K YaRD HwV T�TApROP.LWE WiDiii � t���� � � � � I hereby affirm ihat there is a construction lending agency for FRONi � •.3 6 7 5 the performonce ol�he work for which�his parmi�is issued v.�. (Sec.3097,Civ.C.). SIDE P.�. • • •3G75� Lender's Name /�� LDMA Ref.N 0 9,c 0—8 S m Landei s Address - - P.0 Fee S .VU Permi�Fee . ' � I tertify that I have read this application and stale ihat ihe , Issuanro Fee ��•., 0 LDnM P/C N above information ia mrrect.I agree ro tomply wifh oll Counry investigation Fee � $ ordinances and Sto�e laws relating to boilding tonstroction, Totol Fee � lDhtH pe�m.M R and hereby aufhorize rapresentatives oF Ihis County to enter t upon tha obove•men�ioned proparty for Inspection purposes. m ��G� ,�� �� SEE REVERSE FOR FX�LANATORY LANGUAGE Signaiure of Appl' nl or Agem Oo1e . � .. PIANS TO APPLICANT INSPECTOR'S NOTES , 011'NIiK-llU1LDF.H UG('.I.ARAllO` , I hnmby a?fvm Ihol I om cxcmpt�rom thr.CoNronor's' . 70: Refurned '� �.y��n-� ,. � , � , Li<E se ,ln�rv� for �he �ollowing rrneon (SeG. 7031.5; ApProvod " " � !iu n�ccanJl'rnJi�cinnsGuheAnycitP��r.nunt�'u�l�id� � re u'rrq rrn�rt t �nnvlrua�t.�her..in��r„I�q Joinr�li.dr. No. Date No. Oute � y � uh ..4. . ,,1„ , —, --' . .. . - -�rrrc•fairrinl\3fruCtr(r�•,hr(��rl��ifci:���I�r�rC;ullr�rCyuirr3 --�a , . . . . . L � �'. -- - tGc�epplirunt Jnr surh(���rmi!fn/i1r n a�,qr:ed statrment . , ., . �, . ,.. ... . .. . . ; . .. .�- : . .,.;.- � . , ' . �. _ d��f Lr is li�rnsedpursu,�nt 7n t!r prnriaiuns f!hr C.no- � , .` . .i��f,... .,\�.,.,.�� `�� , � 7rarturk,.;���n,��r.u�<��cr,��f�•>»r<<,��.,��-,��rns,,,�,���JLi�' . � . . „ „ . _.. ( 1 ! ' d �`\, �.,11 '_ � .., 1 r ,, tiun?1001 n/�)iri�iun 3 nf f,e lus�nrs.�wn Rcu/rscrnns ...i '... '�.�'•.:'",��.•�. . ' ` �`,' �_ ��� . �!-`.�. .._CnJrinrib3l�%�risc'xcnip[d�errlrumundtlrk:}sis/ord+e � ..� .. . . � � . . . � � • ... . ulle,yrJ exenrftinn.Any nin[atrnn i�S�rtinn :(131.5 1 r "..� .• . ,liequiied .. .��_. . , .. . - � .•., ' � � ant�appli.artt Jnr a pernrit suhjrc�e'the app6rnnr a�a ciiv! A rovals .. ,�,.` : �Dafe Receirad �. . �. �P or Approved �fenultY�/nn!nrnrr Ihors/ir�c GandrcJ dnllurs($500/J' Yos No - . ._ _ _ __. :� . __ . \ i -� ..,�} [J I,as owner of the property.br my nmpioyees with Wa�er Cerbficme. . � - -- -' � - - � - � - . , wages os iheir sole mmpensonon,will do the work,and :t �. .the siructure is not intended or offered for sale�Sec.7044) Hcohh Depor.mrn� - - -. - .._.- - .. . . . . . . Ui�rirtrss anJ Profrssrnrrc Cnde:77oe Cnntra�rori f.i.rnse . l.u:r drie.�na�t upph•fn�n oivnrr�J prnperh�irL��l�ur(d.e F�re Depanment - . � - _ or nr�prnrrs thcr��un,and�obn dort rr«i�irork:l�inear.f/or � •.�.'�, . � , _�y'� ' � Jl rnu�L.L�it nu•n ernpfq�'err, proridcA�tbur suib iurv . G�oding�,' � j� .. � � . , '�� prn:rmrntr ure noe rrs�ended or�u{/rrrd fur sale. !J, . � 1.-'� 1'.�.;'.-'":'i � . � � �"bnurrer.tbrbuildi»,qorimpronrmrn�issulJi<it/innnr Geclogicai . .. ` . � `,`,� 1'�Jr n/mrnple�inn, fbe ou�nrr-huild�r �oilf hnrr the . �-� - • .. .. .'��' _ • ,,_ . 5unlcn r�/frorin,�fhnt(�r JiJ rtot hriifJ or rr�r/�rurv f�r Pedes.�an P�oieo�on , : : -..,� � .; . �be purporc n/snlr). � t�er.<e�(Cnnopy) ' ` � � - - � � -� � - .L.)„ �.asowneroflheproperly,amecdusWelyconiwc�- , �„ ��img wnh Lcensed controuors to conso-uU Ihe pro�ect(Sec. SPeual InsAc:llon - .. . . � � . � .\ � � � � 70n4�j1��iina�s iend Prn/cssinr<s Cn�lr:7�bc Cnntrurtnrk �Conc.)lh5osonrY)(Wcidmg) � � . . - . - - _ ._ . •..��� ��LitrxscYa�vJnnsnnta/rff,1'�tnunoa�nernf/��uf�ertp¢�Go . ' -, ..� � huiLls nr improres 1Lerenn,und ud�n rnntrac[s Jur sui! Loi Droinage '.C;;"•".��, . � . .._ . ... . , 'pri�ectru�it!p tnnfr�ctnr(s),%i<'enard.piuiu.:nt [o IGe ' � Cnntr��ceur's l,icrnie l.auf. , . . 9 �', , ' ' Forkin � [,' I om exempt under Sec ,6.8P.C.fa Ihls .. ,'1- . -� . reoson . . . . ' � ' , � ' . _,. ... ..--� .� . .... . . .Dole_ . . __. . . _ . Owner Approrals ' Oafo In:pocfor's Signafuro ' . -"' ... , : L:��`.. . . � . , . . � INSPECTOR'S NOTES Lomfion._ _ _ . . . _. - _ ISstbac4 8 Yordsl � - . - . . - . .- . . . . .. . . . . � ..' . . Fouodations . . . . .. _ . . , . . . . � � . � Slab .. ' - - -- - _. . . � . . . . . Frame - � , . . . . � ,. � . . � � Energy Insalation . �. ._ _._ ._.... ... ._ _ -_. .; . __..:. _.. _ - , . . , � . . . . . . . .. .. laih;Drywoll._ __ . . . _ . _. � .. . . . . � "Inierior " . , ' . � ' ` 1a�6-E.renor . . :,� __.____ _. ._ _ .. . . ._.__.___ . ' Hcuse Numbe.__ , . . . _ ._.. . � . _ _ _ . : . . Co�reu 8 Pos�ed . . ����-'��� �—�-� ���- � �� ' ,� . F�nal_ . . , , . ._ . . . . . � EnIA�Un Fronl - ' ' '� ' . . . . � . . ,��- ;.�- . ._ . .'�• i