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HomeMy WebLinkAbout0860A 1464A I �. . . . , . . � . . .�. ,. . _ . . . . , .. . '�. . .. . . . ,. . . . . . . .; . i . ., , Y WORKERS'COMPENSATION DECLARATION . . . . : . . !. APPLI�ATIOIV � ��e,ara certlfimte of Waec. L b.�, 10 ae�f - - - I��R BUI�DING PERMIT � � aeb offirm�ho�I Nove a certifleafe af aonssm rkars'Co�nsa�nsumnct� .._,.. . , . _ ., _. .:, �.,.. , I � or a e rr�fr co e of(5 ) COUNTY OF t05 ANGELES BUtLDING AND SAFETY _ �.�s..i� ��3q�� Pqli yNo.� mpony . . . . BUILDING �]/ � LJ �Eertiflvd tapy i�hereby furpnhed.-� �FOR APPUCAAET 7O FI L IN ' ADDRE55 ..z � � �-Cntifled'topy is filed wifh th unry�6ult 'i ec ' '".�; BUILDING �� � � , � 11on depaH/m�e�snt.`,.., ,. ,... � ADDRESS � . • �• �ate��F�r`�"� Appllcant� � , .,.. CITY 1 . ..� , b�tr ZIP . . �.� IOCAUTY .. . �� � ���CERTIFICAIE OF EXEMPTION F OM�WOR RS' .;,. �..:_ .. . . ,. .... .�..MO.OcffiDQS .-. ' NEAREST . . �_ t1 Q� �. � ' ���� ' --�����COMPENSATION INSURANCE� - . . � SIZE OF l0T � NOW N LOT �� CROSS ST. V c I terlif�.Yhat In Yh�� erfo�mcnce ted if Ihe. ormff b for one .- . � .... „��...: NO. �� � u��E . �.,: .-� �� �-" `. � (Thlc fectlon need eot be sompl P � iRACT -. . 6tOCK � t0T NO. _ - MpP 6001C��- ��PAGE PARGEL I� herm le n i�ulue d,s hOa 1 no tl e m l o f ) 1 �y p " of t �work for ch.ihia �.��. ��R � . . �. � ' � p ' p y rin p rson in b an � .. , . SPECVAt . ... .... . . � w os't ecome fub ect to fha Worke ' ompero � t "��� ��RE55 -�e..----- - � ��� CANDiti0N5 I Q ., , .�..�. :� �. , �::. .. CI�Y . 21P � . . , .... . ._ ..:; . Ca Oots ..'�Z���AppUcont� . - .._.... . . �. ..... . . , . ' . � NOTICE 70 APPLiCANT;Jf;�ofPer Makin ��thil- rHfie6te of - ARCHITECT OR �' � ��� ! DISTRICT 6ROUP ttPE IRE $SED BY . � fl ' ENGINEER O N0. � ' " ��� ZIXJE � � Exe rlon; ou should become aub�ea to' e Worken' --� J �y 1(� � � Co pnaafion�provhlon�ofihedoborCoda,Yo���.muitfar�h- � pppQEu � � �n � - .. .{.v.... /�`c3. '.�L� .� � �� wifh mmply wHh sueh provlsions or thia permil shall be --....._ . ... . ...... . ... .... .�l-G+�7I fI���� STAT15fIGL CU55 ICATION ... .� APf. C'ONDOi.. N deemed revoked. ..: ., .-.. � . .,.. .. : �prytRACTOR ST-pq.7 CiMypvp', � � . ... .._. i. . -Z � LICENSE�CONTRACTORS OECLARATION ._. .... . ._,._._ � ... .�... L�. CLA55 ND:�DWFLL.UNITS., _ 1 hero6y affirm�hat t am licenaed under provinioro of Chapier 9 . AODRE NO. ��R�P � f Civlsion 3 of�he Boainess ond ..._.,._ . : _... . . . .:,.-1tC. ,'� � ��..� . Profeuions Gode,�and m Ncenae Is in fuil force a�d trffect CiTV � . ... Cu55 "'�� . . .:eK :. .p�... -..`.. .� '. ..` .. .VALIDATION �� �. . .. t� -..�., . E� . U�cen eeNumberrh *�D5 ro �Lta Clau��� '. --...... SIZE .."STDRIES � FAMRtES "= ONE' �. . � . � ���j�,Q A �� Y ' . ... . t . �. ,VAlUAiION . . . � . coerraeror Daie � ., ueu ivri oF wo(a�K oF . tao.oF . A o' : 7 ^Q #••• •2';3 .I am exempf under SO. � . . . -� ....:.... � l OQ�. /...4'��^ AITER� . � ,. .... � •.��J Q�i9 . 8.8P.C.forfhisrenson .�, . ;.,_. �,�� � . ..... �� L REPAIR. �. s .. ._.. . . .� �'. . • .ti54.1.i9c=.> - , ' � Signofuro� ... .. . .. �ro-� ��VR M tD6.� $ � No DEk1ql FINAL.�.._ .... , . ��8,1�`$''8 .. '��. OWNER BUILDER DECL4RATION ��i.DATE . . -� � ��1 hmeby oNum that 1 am exempt from the.Comractor s�cense � qooRE55 � ' � � � PINAL'� � � ' - � � Law for the fol�owing reawn�(Section 7031.5,Business ond � ' � � � � ` Professionstode�:.. ..__.. . . .. , _ .._ _., ,�. ak N � , �..EY n..--..,,. �` . ., _ . . . i . .❑... BUII�INC . .. . . ,4 ' .,.� , . . . � . .i � . I, aa owner of 1he property, or my employees wi�h ApDRE55 p � . , � , - . wapeaoalheirsolecompenwtion;"willdotheworkand "�"�� � � � . ',�� '"�� •,�u -�; -. � ths strudure Is eot inlended or offered for sale(Section . ��'��TY � � v - :- � i� J .....7044.Boainesa and��Profesaiona Eode1• .� .. ... . MOviNG .. .. .... TE4 .. ..� . .. .� .. . . � ; . C .�-.l. tONTRAROR .._. . Np . _ ... . . .. _ _ . . .. . � . . . I,aa owner of the property,am exclusive�y comwcfing � I .. ,. ...:., � . ..: . ... . . ,, ....wf1I1 IitOnied[onh'OCtoA�tO�CODbfrUC11F19 p'O�BCt(�C- �.. . RE IRED TOTAL SEiBACK . .... . . �t ��41A � � '� fion 7041,Business and Profesaions Code). ADDRE55 ' _ . _. . � � .._. .... _.:. .. . _..._ . ., .. . � . .. .� . : I hereby affirm�has the�a�a coro�tr eG nGendlnq agency for �RQ�CK �YaRo hIWV ..;pgOP.LINE � �WIOTH: . � �. ���• • •1� �, -dhe-performance of�the wwk for whicb�tbis�ps�mit is iuuod ..� P.L.,.•. .. , . - - .. .. . . . '..� �seo.so�-r.c�.c,�. s�ce ' I + •7 4 2 i5 v.�. , Lsnder's Nome_ . ._ . . . . . :_. _ . ._�,. , . � - � � ..fO���7 . ... .... . ., .__. . _. . . � ..•7/J,��c2i . LDMA Ref.M 8 . _. , . .. . .. ..._. . .._. .. � ..._ G.GFesS . . .. ...PermNF�e .. .. l. . . . . .��. � ��ae�•.ndd�e.n _ _ �--yf tl 9,0 6-8 8 � I cenify.ihat l have r a thia applimtion and.state that ibe .�.._ ._. ..... .,..�..�, _. . ..luuonn P.e d�.U " �DnM P!C k � . �,.. :.. i :.. g pbove formrnion le ct.1 opree to comply wNh all Co�nty Inwsupouon F�r � . . . . . I � . $ _ardt n es ond Stot ia a IaNng ro 6ulldir�g conatrucllon, �.. ..: . � ., to�ol Fn- !�� � IDMA Perm.N .._ _ . .. . . ..� _ . � , . R � and e 6y auMoriz r pr entatives of thia Coumy�ro enter . �� �� -� � .u�o t e above-me � ne property for inspection purpoies. � _ : �, � � � f � � $ ... . ... .. .... . .-.. �.�.. .. .. . .. .. . ,. . , n r Z fEF REYERSE FOR,EXPLANATOR�LANGUAGE � � � . � I _ .._.. Siprwtun of. PBmnr or. n� __. ... ..Dote ._ ._. . .... ... . .. . .. . .. _. . . .,.. ... .. . , . . � � � � � � PLANS TO APPLICANT � � � - �IKSPECTOR'S NOTES � � QLV�'�'K BUIF.DFK UECI.�RA1'�C11V:' �. : . , .. .. . ,.: � . °. � 4 �..' : .:� , r k;' , ', .eLiiense�lhwf;`for1rh��',F Iow�7i�reasoilhfSetn'70a'.�b) . . To: � .. �..:;, . v'i... � Roturned ,..' ,. •. ..... -.. . a:. . , . � . � .. :., . . .:r . . .. �. . k `,... �. ppprovad �R�uinpsx anJ�Pr iJ'esMnnt Gp{I t'1Ky nty�irrouniv u•hid�, No. . -. Doto � -, .No. �',''.'�'Data.. -,0-�-i' '�,-; "•.�'..( • �"�t=' ✓:-' � , n rc4�r}°�°.!':ernrtt! s_neA{fru t�..qku,�emprrniti'.'�leYn��Ji.sA� � . �' . . _.. . . . . .r:Cerr�e/��+iruayxtruc�ure':;�tire�irYo��tsissuance,�akri"Feyai�.�'- � � . . -.; i ._�'...�� S 1 , . �T,� ."�'.. i'.' �.� .i. -- � � tbe�epplecu�t for'sacfi'parntlt te:Jife�aat,qnadstaternen(j . � � _ .::. _ _ �p . ��- -... - .- .. —�.�.. " {bat J�¢ts(mnrysrrLpuraa tn 1 e Erroi�cr�ns pJ the(e n-.. ' � ' . _,.... t�� _..i} � r�..:.�d_J._..�., - 1��eFactrxi�Li�crixi Inei!(Ch pter9l(��ramPncinR�,w�t<.^kec'•,.` _._ ____ . ..., .i.�.. ... �_.'- ..- .. ...._ . ._ _ .'��� � � ' . .<r e���� '�s�fX rti iberefmm�nJ�e�pri:���tbe . � } ,, t'- u/4'/��r�x _ �, O�n/D .�� .i -^� � . ..�t . ...._._ . , ..._ .. . f7egr rem PR r . �� R°qyi�.._v DnfoRacrtv� �.. . . ^.' � � `� r „An yirilatin,qafSectrnn;7t1,�1,5"hy �"' ':'�- 'y�� -� rti!- . . _ a�' ed'. . .--��-- -�:�� : '�-.. - ..-..- ... —..=.. �.uny u/�/i ecah�nr a flern�la a�IhJaars ilbe ap'plicant t�>a rr��r! PP ..� .� , �oi ..ko or,Approved,,: +`_` ,: �.�+ .` � �ji" � he�r sole�c tme ensahon wril do ha wo k,a�' rovali -.. rrrehY�+{.rnt mnre dbud rem huadred�dnllars/5500) .�.:.� ._.." .._..__._ .. �_ __._ __,�:I.,� . 3�-�Bµ�e aCFa+ndY�rnlession.+�Cede•{T�?eContrra�lqrSsJ.iaatrk �. . . Wo�er,Ce pf,tate _. _ �"`- ' �r'' r 704 j� �. ' Health�Daparrment . ...-_. .. . ..:.:.._ ���:._.__._,_. _..... ___ _.. .�_... . , . nsr , .. . . . . ��Y.aw dhex no+apply cn_�n uu�ner aJ,�+rnper`ly u�br�builds � . ' Fire�Deporiment-:-. .- � °: ..... ��: - ., ��� -`' p�++�* ..,sYberarin.A d toi�p oes tu� rtr��$itl� ff or � ._ .. __ �' `�S o� . . e ,d bu Sn � ,.. � .,, �'. . � . �,iu (h.r�KRA�dia-nu,n.�.emplo,yec.c.r!'mnided ehui�xvc6�im� � ' �'.� � _ �� ��� �.a\,�i t � . � . � Grad�in� ! r� . . � .. � ` � � r��roiMma'wls�.wrr.aot�iat�xda��d br.�mf/er�+d J�r�ole�.IJ„ � . f,��'.���f f�� � � ��'. V_,-.',. :', 1 '''bHiae�r,Yhc burGiin,Q nr unpio+�amewt ie sald udthra one ` .:_._. _..._. _._..._..�,.. " � ._._. '._ .... . ... __.. .-- ' . "rar d enm fediai �ibe��' "xar6uildar�u�!l�hane'' � � g' .• . . ', � :".�.i � . Geolo Kat :��� � '.. �, �.,� I 7 y' - �,�'} � � f ...., ��'�burde�of prn�enR tGut he d d not barFtl nr'rmQi»i•e�;(nr � ��. .__.... . . �,�.��. ���; ... . ;.�.�i 1 0 r '_�.'_, r :.[: ,Ltf�<:: � th�urf�ose��ef ral�/ : ':. _i .:� . . _ r �sdeSYrirtn:Protedion . :- , "� 'a � ��., ' Fence Cano ����� ' ` � �-- :7, Cosowaeroiihe�propeny bmeKtlusvelyconfiac, ( )I PY) - � � o `FtiI � �f h , � .'�.:.. � . .. .i . .. .___ ._Y./' + � xC ucT � n ar . .. SPecial Inspection � � � ' ". ...... .. 1 . � , nn�� � : (Conf.l.lMosonry.)(Welding� ",,..�.' .. '.�- . .,-. —"-_.... .. _ ,�._.._ . �.. . ,.. . ;:� ... _ �'�fC�JP�?p rlYf§e �yaa�vai ti cense�l on�ro�ors n s.'. . ... . ,_.` . . , ' ��n�3�Q.�m d�+e Cwrl�e oK��d wh�il/�cnnfracfr'Jnr sss b '* . ,. LofDrmnaq'e." '• `, , .. .,.y"-. �. ;. ,r'-�: j ..... �__ ... _.. . -.�... ,. - i (s Ewetb o contnctor/s/�1�ccros7��uAsa+3nt M tbe � • ... .., , a . �"M �e ..,,. . . L.;.. ,. +.� �.�,_ r 1.r� �-t.;..,.. � n nrs innsc - s . . . i . r ��'. 'C nka t ,..I I:auJ � ' . ,r ' ', _ � „�..,.,�� ; ... _ _ _. .. ... . . ..._ ..._ � Porking � . . ..�'.' � ` f`_:.} r �.',£":s. r :s:_. `t.., 1' � � ,�.t .. . l�l i am exempt under Sec � 8 87.0 for tfiisl . .�.^ .1 _"__ ' '._.._.. —._._...... ... ,. . ' . ,�. ... .. , �� . , ,... . . . � , `,. , r y f }; _reoson . ... .. _ _ . _ �.. . ...,. . .,, ,. _ _. �f .:.._._ �_. ..,,y� . . � .__._ ..._. ...;.,_..__ ._. ._.. .._ . . _..—_. .._ .. ' .. ;�:. :� , . , }__ .�, 1 �. � Dale � . � ` .� . i " ' , _.�__ _._ . ..... ., . �_ . �� r .. .- - ; , � a _ __ Ow er _. , - .... ...__.1...�. `':. 7 ..�-:r _._�_1 ,.�_.,F _� . � i.;:l rr �, i-� �.; •., . .._... .._._.___._.. . ._..... - �`� ... � ' . , �.-.-.... .�- _ . t, n,.. . .. -.�Approvals - Dofo I z dor's S{gnqfure� ' � ,l ��] 1 � . .. . 2.t.^ INSpECTOR'S NOTES � LotaYion— �.�.__,_, .. . _ .._....._._ . , . .� . . .. ....- . .. . (Serback 8 Yords} � � -- .� `�� � ' � - n v�,. i , _ .,. . .... . . ' _'___".__..... _ ..... ..__.".._. _._. :' :.� .-.. . . t��.. . ... , � Poundalions ,'- � � '� � �.., - . . .. �� �� , .' ,. ,.-.r . . i. � SIo6. . . . „ ,., , ..„ , - . . .___..__. '.__ .r___....._ ......_.__..._'__. '.: §; C�`����,:�r . .���.� .,,,,,.v: �..q� , . �.. _ _ I � : . . , _>,.' � . .. .. ' � .:, Prame, � . . . . .. . . � .�,..,,.,-y. , ,r.�i i. ..� ,�.. . � EnergylnsuYa4ion �� � .'.. , .:__.. ___._I .. ;. ,. `. _ .. � . , , . ... . . ,...,f ' . .'._. _._...� ... ...... ,. ,,.. .,. ,.. I � -.I •rr... �i t LathF.Davwall-- . -� ._......-.-.__....._..... .:.__.,._.__.._..i._ �,i_.._.. . . . . . .. ,_ . . _ .� . � � _ ;.' �..i.. ._.. . ...._..._ ......_. ..__. ... _.._. � . . 1mpYi0� � � � f � �. ,. ., . . .-� ' ... ,�'.�.: . -. .. .�;� . . ...._ . .._. ...... .�. .... , . _...___..._...,... -.' 9-' ' i �.. . . � ,�,,,.. i ,., -. ,. ti. � ... .: ... ..... Ldlh—Exlerio�`'.. . • .. -.._..._..._ ,.._...., � . . .,� . . �..t .., . 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