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HomeMy WebLinkAbout1028A (5) �� WORKERS'COMPENSATION DECLARA710N � �7 ',�ere6o�a`�e�;f�a�eofwokes"�omPa�sa,o�°��S��o��e,` APPLICATION FOR BUILDING PERMIT �s or a cert�fied copy ihe�eof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olicyNo. Compony BUIIDING Certified copy is here6y furnished. FOR APPLICANT TO FILL IN ADORESS ��'�� � Certified copy fs filed with ihe county building inspec- � BUILDiNG /� � tion departmenf. AD�RE55 `�'� 1 IOCALITY N'� p NEAREST Dcfe Applicont CI7Y � c� Z�F [RO55 S7. � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.oF B�o�S. AS5E55oR COMPENSATION INSURANCE. SIZE OF LOT NOW ON LOt MAP BOOK PAGE PARCEI (This section need nor be completed if�he permir is for one use zON hwv _ l hundred dollors(5100)or less.) TRAC1 BLDCK l0T NO. �l�� NO. � � '1 1 cerfify 7hat in the performance of the work for whith ihis OVJNER �� L N �l� SZ. +�'��� CONDITIONS L permit is issued,I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY u so as fo become subjed lo ihe Wor�,eri Compenso� n Laws. ADORE55 Z. C���L1� 1 �� CONS� ZONE � Q , CI Date �+��`�� Applican�..r� ���Y M � Z�v STATISTICALClA55iFi iOnl AFT. CONDO. p NO710E TO APPLICANT: If, after'mdking �his Ce i�cate of ARCHITECTOR � TEI. � V �Exemption, you should become subject to the Worken' ENGINEER NO. CLA$$NO. �WELI.UNITS �! Compensation provisions of ihe Labor Code,you must forih- . ADDRE55 SEWER hV+P � � wHh comply with such provisions or this permit.shall be � E- iEL.2S1 deemed revoked. � . COMRnCtOR �. QF. O. ^ '?i2.� BK� �. VAIIDATION LICENSED CONTRACTORS DECUIRATION � �i�. I hereby a$irm rhot I am licensed under provisions of Chaprer 9 AooaE553�1� � No. �3� � yAIUATION .s-'� �2 8 a (commencing wi�h Section 7000)of Division 3 af the Busineu and . _ UC. �± Professions Code,and my license is in full force and effect. [iiY '1 '. CLn55 �] S a� ��� ��• • • • •� SQ.FT. NO.OF NO.OF CHECK License Num6er �3)�oo� u�.eiass � srze 3� sTORies Fa.rvues orve 1 • •3�.7 5 CoMraCfoR'�U ��r'�I1C0�1 lCfl�il'—Date- �Z���� DESCRIPTION OF WORK C, N� ❑ S '• • •3 5 7 5 c=i a I om exampl under Sac. ��L,�O G' (.��� �'�, AL�TER � FINAL 0 6 2 8—8 5 B.BP.C.for fhis reason �R�c- ' L��i'<7.A, � REPAIR � DATE � � , Dote: E%ST�ING BLDGS �\� C.�t O�L ❑ BY Al � Signature APPIICANT TELa . OWNER-BUILDER DECLARATION PHIM �NO. �-� I hareby affirm that I am exemp�from Ihe Contractor i license , � Law for Ihe following reason(Section 7031.5,Business and NDDRE55.� MQ •�� � . ' � Professtons Code): _ a ❑ BUILDING ' I, as owner of tha properfy, or my employees with ADDRE55 woga�as Iheir sole compansation,will do the work and `��TY tha structure is no1 inrended or affered for sale(Sectlon . 7044,Business and Professions Code). MOVING tEl. � I,as owner of Ihe property,am exclusively controcting CON7RnC70R NO. with licensed contractors to construcl Ihe pro�ect(Sec- qDORE55 tion 7044,Business and Professions Code�. � REQUIRED TOTAL SE78AIX FROM E%IST. � CONSTRUCTION LENDING AGENCY 5ET gqCK YAR� HWY CROP.UNE WiDTH ► �. I hereby oNirm Ihal lhere Is a consfroction lending agency for FRONT � - �� �ha performonce of the work(or which�his permit is issued a.�. i5ec.3097,Civ,C.). . . . SIDE _ P.l. � Lenders Nome � r a � P.G Fae 5 Permit Fea ��zv Lender's Addresn I certify that I hove read this opplication and atata that the issoanro�ee- l� '�� � - � abova information ia mrrect I agree to comply wirh all Counry �n�esuga�ion Fee . q � w�� ordinances ond Srota laws reiating ro buitd7ng consvuction, To�at Fe< � Y and hereby authorize represd�latives of Ihis County to enter � uponRha have-men�i d 'r perty for Inspeclion purposes. � � � � � ) � � (mZ��j� �� SEE REVERSE fOR E7(PIANATORY UNCUAGE . ig Nre of Appiicont or g nl pote � m� ' ' FLA7l.SG Al`�11U.FiT . . . —�) ; . , . � . � ..-p' . c i;:i:i: i, : ,. OlC\ I UlI i?�i ]7('f A 4710N _ ,.� . �. I hc;ro;u.i r 7 .1 c i n pi f om�n Conlrcctoi s To: ��, Ccttrnod-' � _'__�,___�� Lic. ..^ Lar f Irc. ol o � aso. (Sea 7031.5) . ` .. _..,., . ' � _.rcr.�! �—� ' linrrne•r�.'dlr / � C 1r}crti'vrroaetyu�hicb do. --_. .Cat¢.__ __ S:a �0^.la . _ .. - ._i . I . ... . �.. . . . � . � , . .'r:�::ir,s'a�^:,r.r 1nr..r,t' .t� r••r�i.rprore,darnulisb, .-._�____ � ' . � . . --.�__� —__- , .. . ... . .. .._ . _ _. . _ . . .. ,_. ._ . _ � i orr�;niru�i�strr<:..rppr�rt r:r�ssartarr,alsarc?vrres :�.tho cfpJi�_�t J r s„dr p�. t Jr7c a si,qneJ ststcnicnf � -�" .' ,. � ---� , . _... _._ — tbe!he is licnued pursun t J tf r fronisior.t af t!c Con- .-._._. _ _ .__.. _. _._. '__ _. _ . , __._..._ _. .._... . .. _ _.._ • _ I , tructor's I.fCft6C Lt[fP�CLc:pter 9J(cnn:nrencing u�it!Sec- . .,. —I . . -- fi.u�y^OOpJ/Di��:�i.�n i J il c 1;us�nesc and Pmfeasioks i Codc7 ni�.11•�.t h��ie e��rmnt Iher��rnn:and tGe basis Jor tfic nll.;qeJ cr<•r,r;+fioi•.Ar. irfaiioir-oJSecNnn 7031.5 by � ' ' . F.c;vi•�d I , �..� . . - ._ c. 1 ,•�J ..S l.ct tJ.�a,^ licur.ttoatiri! I '' . '. . .. Dc.l:Roccivsc _._ r r ' '.,., I�-- r-r�*�:=!-_ _� _ -- I Yes �.o cr Appra�c:: � ' ._. _ �., � � p It� /.ut- r tl J� !r lrrl dnlfJrs(SSODf.J: ' ---- -- -'- - ---__-- .--- . .. .-. -�... � ._- .. , . „ . ;..1 I,cs oy.r�r cf tl,e nrnpa,�Y,or my emp!oyot�s wlth Wa7cr Corhiicate� � �I�T ��r_�L� � _ _ ' _ _ _ _ ' ncc�Rs cs Il�i• � :c r c o�on:wiil do ihc work,and I ' � �, � ' ' � � � � :;h,�s�n,cr.rc i., �_t�n�ri.d c�c�Fcrrd fc�cola(Sec.7044) HeolthDepertment.� � ' � � � , . . , Gr..ei;;o�scr;dPr���, nc,. Z•rCnntrac�or_'sl,icense .._ __ . . ... -- ..--."----_ . ...', . . S�r�:r�C '..7 � --- �- --�--- - - - �- � I.:c:.'..rs';�, i,i:l��t� _ :-ro/prnpertvu.•loburlds ., FireDepartmenf � . . `� . . , : �.— .` - _ , .1.�'t�r ' crfo'r ' �. � ' �.r �. r�� ! r . �eF�7r/enarl+hini � ..._ .. . . '.' _ . ...._ '_ _ _ ' U�rm�,h /.i< �e . r.. . ..f•ro. deJ-tf•at rerfi ini- � Grading .. .._.. _. . . _. . _ -. - . . - �F'n4C�rn.crih are,r.i�t`ict:.vAed'nr afcred jY.56Ic..YI ' _ . .. . ......... I r � �. .. . � �i.r.l'. • , . . l�h::���rrr..hr/.,,�:..:..,;n,-.•n,•r,•r,..:�.�::!ic sold eritLix onc Geolog cal - � � _ ,___ __ . — ' --. '-'-_ , , . .. i . ! r ( ir. , .��:�1<,r uill hare�fhc � ^ � 71 �'i _ r.r1•l:.i!.!ori�r.,n �rJnr Pede:lrian Profection � �. .. . .' , . t1 f�rf�,s,.� r�.. ...l , . .� ... (Fence)(CanapY) . � . . , � J- L r.s or��r. , �.r,-.,r.�rry,or ezdud.velycoMrac . . ----"---_,----- . :-"-T- . ,_— iim.,. .i!�� ,...� :cicrc;� ;U Ihc project(Sec. $petial Inspet�ion' � . '-�'-'.- �- - . ' . � -'�. ... .. _ 7C ) �sr • 1 . �� - � .C..:::•.7�1e Corttractor's (Ccne.)(Masonry)(Welding) ; i . "�. _ , . . . --...1 r r ! 1 -.t !y 1 no<er of pro/�rrf}�ubo �. ._- . ' -- . ..-. .. � 1�viLls rr r., i . �. ^ .v,��rnl�rJ�n cor•trnc:rfnrrrrcb 1 � . � '-� ---'� " - (, . . , .�.., j . .:;ir tn�eGr Lot Drainoge � � , : , , - ,.. ..�- , .; : . � �� � ... I ... . ..� , ._ _ ' _ .: _ _. . . . __ �.. . , . � .. -- r,.r,...�:.. . .,._�.�.:..). -. Parking _. _ . � .�. , . .. . �. . _. . . .. ._-__ (_ -I a�n-c c-.,-.,�un::.�S,c."�.� � ,E.4P.C.forthis _ � ' � � ' � " -� -___ .,t�::------..-_"-_---�- _�.��-----_----- __-- �-- ._ ._ __. -_--------- ' . " ,. :-... __._.._.. ... _..... _.i .� . . _ fn4.:�—_— _— . i __ . _ '__....._._ ."._ .� .. , , . . " . . . .—_70tC _" __ - — - OV/IICI . �__. - . � . .. . -. . . .. ' t hFprovd: i �a�. ( Ins�.c�"ar'e',;�:.•�� � � ._ . r_ __-..__-_ . . ' � ;_ . .` ' -_ � I. �—__ �—____' —-'- ' _ _ _ ... LOcotion- I I �_'.'_._.__ ."__ __.'_ __' _ _.. ._. .._ ._._. . — ''.. - . ., . '_ (Sel6ack€Yard,} � �� � � ' � Faundations � � . . . . ' . . ' ' . " ' __, Slab �I . . . , - � � . , . . . -- , _ . , ( . „ ��.. i � - Frame . _ .. �. . . .,. ..,. . .. ,i � . _ . ...._-'. .. . ._ . .. . , - Energy Insulction � � ' ' ' :...-� ,-' . . , �` .. ,' .'., ,^- � Lath/Orywal;- ...._, . . ' � '- Interior . . . . -- � ' - --. �� •'-.'-" • �i - ' �' . _._ _..___�.�_'_"' '_"_— ' .... Lath-Exterior . ._._._� .� _ '�' � '� �'..�� , . House Nurnbcr- '�I ' �� � ' � � � ' -� � � ���- � ���� • • . . .,..�. � . .. .,. .. " __ .__ '. ' . _ _ __ " 1_ I', . . . .,, . . _ . Correct&Foefe<I i ._.._ __. . ._ ., . . , . . ._,.... ,.�:.. ,�: ' Final.- � . � . . _ . _ �._ ' - . Enter on From .. .. . '. . . �' .' � � � . .' ` . . I __..__ , ' ' .