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HomeMy WebLinkAbout1241A WORKERS'COMPENSATION DECIARATION � I hereby afF�.m Ihat I have o certificale of consent to salf APPLICATION�� FOR -BUILDING PERMIT insure,or o certificara of Workers'Compensaiion Insuranca, or o ceriified copy thereof(Sec.3800,lob.C.� COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑olity No. Company - f. Cerrif�ed copy is hereby furniehed. FOR APPLICANT TO FILL IN ADDRE55 ��l/Q � e� .�7. � Certlfied copy is fiied wflh Ihe county building inspeo- BUILDING �� � � �/ / � fion deporfinent. ADDRE55 � / r {1P LOCALITY �x./�e.�c. !3!.[/ NEAREST 4s Dota Applicant CITV ( 21F �l CROSS ST. �� CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF LOT �G�X �PO NOW ON l0T � Mna e00RK PAGE PAR�L COMPENSATION INSURANCE (This aection naed not be completed if the permit is for one ^ �J uSE zONe /a.na hondred dollors(E10D)or less.) TRACT aJT�y I eiocK ior No. ,�e( No. �l j4� I TEL. /�7(� p� SPECIAI } I tertify ihal in the performonta of the work for which ihis OWNER n �O(l, 1� NO. �I� �r/� O � CONDIT�ONS 0. permit is issued,I sholl no�employ any person in any manner �ISiRICT GROUP iYPE FIRE PR ESSED 9Y 0 so as to become subject to Ihe Workeri Compen tion Laws. ' AODQE55 C�is�lmT�e-�� Q(�V�i CONSi.�' 1NE V / C atr fll0.�m nc�. �n.r i�vQl76.i /D x3 �S /// ""`J O ��Ofe—�—"�s o�Applicant J � � STATISTICAL QASSIfICATION APT. CONDO. u NOTICE TO APPLICAN7: If,.ait making this Cerfifica�e.of � /+RCHfTEttOR� � � , �.TEL, � ..�.� . � �Exemption,�you should�become subjact�to�the Workers' ENGiNEER' NO. . �CtA55NO.�OWELL.UNITS � Compensafion provisions of fhe Labor Code,you must forth• . qppRE55�� ' � �. � � ' SEWER MnP � with comply wdh such provisions or this permi�shall ba '� deemed revoked. � TE�' . eK. p�,, VALIDATiON CONTRACIOk 1')�/�� NO. LICENSED CONTRACTORS OECLARATION ���, , ' I hereby affirm ihat I am licenaed under provisions of Chopfer 9 A��RESS NO. VALUATION ' (commencing with Section 7000)of Division 3 of�he 8vsiness and i�C. �7 Professions Code,and my licensa is in fuil force and effecl. CITY CLA55 S �c�� . ' - , SQ.FT !a NO.Of / NO.OF CHECK , . ' Lltanse Numbar lia Closs SIZE •7 5TORIES ! FAMIUES ONE � N�, mS 5 Con1f0[�0� Dafe DESCRIPTION OF WORK IJ ' ❑I am exempt onder Sec. qDDg � FINAL � n I\ 8.8P.C.for this reason REPAIR ❑ �AT �� ' � � Date: USE OF � E%ISTING BI�G. (,� DEh10l ❑ 8 A� c� 2 4.� A Si nOtufe APPLICAM �' TEL. p ' , 9 OWNER-BUIIDERDECtARATION PRIM 70CL� N0.3GI—�i�17� �� -- � �r•• • • •� � � I hereby aflirm thof I am ezempt from ihe Confracfor i Litanse qpDRE55 S CC(1 i � . ' � • ��l J�.�Q law tor the following reazon(Sedion 703I.5,Businass and � , Professions Code): , � . 1' � = i euuoiN� ... • • •4 3.0 0� � I, as owner of Ihe property, or my employees�wilh ADORE55 � � i wages as iheir sole compensatian,will do the work and ��TY . . •.0�,'�5:•8[i the structure is not Imended or offerad for sale(Section , 7044,Business and Prafessions Code�. MOVING tEL . , .� �, � � � I,os owner of the propeny,am exdusively cantracting C NTRACfOR n10. , . � wilh licensed mniraaors fo construct�he project(Sec• qDDeE55 � � tion 7044,Bwiness and Professians Code). . � . REQUIRED TOTAI SETBACK FROM EX15T. CONSTRUCiION LENDING AGENCY SET BACK YARD Hwv pROP.LME wi�iH , - � I hereby affirm Ihat Ihere Is a construction lending agency for FROM � � tMe performanta of tha work for which Ihis permit Is issued P.�. � , �5ec.3097,Civ.C.). SIDE _ P.l. Lender's Name � / P.C.Fee S Permif Fee �� 3 D LandePs Address I cartify Ihat I hava read this applimtian and stata Ihaf Ihe Issuance Fee ��•s� . above fnformation is torrect.I agree to comply wifh all County Invesiigotlon Fee ordinancea and Stare laws ralating to building construction, To�ai Fea �3 �� � dnd hereby authorize represenfa�ives of this Caunty to enrer . upon the above-menrloned propeny for inspetlion purpoaes. � � '`,/j1/ � SEE REVERSE FOR El(PLANAiORY UNGWGE _ . m� ignmura af Appllcont or Agent pote . . ._.. ._.. ___ _ _ _ ..�__.__._ _ _ , i , . 'flAt;S Tp AFi'LICi.f1T � ' 1:7L�ECTO�iS f17iC� � . � OlC`f.IL•I.iL1JI.D.E.D`CI.AP.A7'iOti , I hcrc6v oilirr.�ILct I cc�e:cr•�.1 f+om Ihe,CoNroctor's To: . . ,Rct�rnad . , .,,,. Licrns Lavi ( r 1Fd 1�Iloving recso�.,�Seq 7031.5) ���PFrov�d �— 1' t: 'I {r. � Co.4:An.citl ormr.nt�u•hicL No. � � Ocf -��- �� P10 .,'. .Datc .. '. ... - .- . . . . . . . "�-r gruns«/r .��i:.c�,strr.ol,.:lf.r,ii•t(,rori�,dcrr�o(i�sl,, -- -- - repar arrti�strrk:�irr,jriortoilsrst�icncqnlsorcgdires ____ �- ��_ '__..__ . _._ . . .. .� . . . _•.. _ .._ . . . .___ ... _ _'. _ �_�I, � • - i/o�fplirar.f Jnr sveh ferrrri:to file a srgned statenecrst � .. _.__._. _...,- �� � . : ._ _�_ . _ ,.�. . � .. � _�._ .. . tlatLceslicer:serlp�ersuaritmtleproririonsoJlheCon- i ' ..' - .t-{� . . � .. . lYc:lnY3(.(Ci'nSr I..l:t`(C�/rS/>lCT 9�(COnir,ICIICinq u'fil$C[- � --�inn i00DJ JDiniiiorn 3 oJtGr7LrcinessnndProfessrans . . �. , � , �' Cort.-Jortl,athriac.rruipttF-rrifrnmattdlLeLasisforibc � -- - �1lrqed rrrnr t.� A v i frfi r of Srction 7031.5 by i �:�-.'i�- RcSvlrcd . DataRocebed � � � " � � - �':i�ii��::•';f �: r� � t�t1:cj+f�lr:cnttoociii! � P,p^rovct; � or,Approvod � � , . . prr.ul(�q(s�t . r, tl a J � !ur:.lrcd daticrs(S500J.J: � Yns Ido. , - � . . - .- - �� � - ... �.... �.es ow,cr ct liic prop�+r;y,o•my employoos with Water Cerlific�c � � - , ,� �� . , , � wc��^:s os the� s � nacn�o'oni will dc fhc work;and �-il c s!u<iur� s i_l n�.ndcd o oifar�d For sale(Sec.7044) HcalthDepo%imc�t . '.���=. . . � ' �� �' .. � ., � . IJusi�n�ced 1 r /. Codo:T'1 r Contracior's Lireasc . z._._� ._ _. _ _. _ � . . � , .. . . .- . . ' -.. . . . ,..I . .l . :.p�,l�.�.n irn o»r.cr nf prnper2y u;Gir builJs _ FireDepnrtmrnt � '.. � '� . , �� ��YIp1�Thf'('^'7. l�rl•.,�FY.L�t✓'�•140?{SYCGI['OT�Iltf11SClfnr . ; ___. .. . :.� , . _ . ._ _ .. . _ .. . �_ � . ..._ ., . ' . ru;crv _ • t�,r�,�,,,, ,,,.� a,�,- �,.:r._ , h,„��:����r ua�,�,��, ;M. Groding . . . . . . . . - . _ . . ..- _ ..._ _. .. . _ ,�',�C'��:':�rrcntr��.ra r.nt ir.tcr.acd iir nfj:rrdJnrsalc.7f. - � , �' T•n:r.rrr,th.l�vil.l:r,�� .. r.i �r:tissalJu�i:J�innnr Geolo�icnl- - '-... � - ` ,, 01 cn�s�^.Jr.'ic^:, l:�:..e4�-cr-x:�ildcr wrfl bare OLe br� y��o�r;::�t': .. . :..t i: nr� nrni�r jnr Pedestrian Proteuian ' •. . � � tL•c f�:uposr of s:Jr1� .. ' . �,--_. .. � . i (Fente)(ConoPY) . �'�����-_ �'-..I,��e.oamnr of the property,am eadusively confroc- �. - . - -�,�.� - . t�n,�v.rf I�e.. .- �.trc'sr.1��cens�ruct ttie projen(Sec. � Special Inspetlion . . ' . - -.� .- � - -__70`��)t�:.sioi � vJ 1',-c/r%;ecs.Coa'r:7�hc Contracrors (Co�e.)(Masonry)(Wcldlne�) ' . . , , Liecn c Lcv�Jnrs r.n:c,nnl�•tn cr:o:r�irr nJ fr�crty u•1» s � � �-� haeildc m inrprorrs eb�rrns,er:+ufin rn.•Jrccts fnr surb ___.._- .� . . . . . lotDraincc;o � .. . . . � . . , .. ..-Jvojr�tr :� � . �o,:tr,:r:�..(.,1 li,:.,,,-:1 fv-sucn! toitl�• . . . . _ _ . ' . � Cn.::i✓�n;r'srf,i:,r.;:1.-ry._ . , ,. .'_ Parktng � � --� . � �.. . . . ._.-- -. .. --- ---�- . . . _ . .. �"--' ��-� �" ' � '- - - -� - - r IamFxe�mpiunn:+rSee ,B.LP.C.forihis . ._. _. .___. . . . rrasor. �� _ . ... - - • �.�. ��." � '' ' � _'_ _ '_._ ._ . _ .. _ .�-, .. � ' " " ' -� �� , Date Ov+ner . .. -,.i . . . . ,.. .. ., ��a-:., . �iJ - �_ ���ssia�m�« � i �r_cr�,e�:.;�es , � ., - � - - --. .. _ � Loct - / ..._.. . .--- _ ..--._ . _ _.—_.. . . . (Set ock'E'-rde)� ��, I � � ' � � ' . � Founda�i �� .._ . . ..: .. . �.. , . . --�- Sleb —"'_'---._..... _ . � . . . . _ , /� Prame � , � . ' . . . . . , .. ,- : . . �". . .. .. .. , Energy Insuloiion . ' ''. .. .� . , � ... . . `.. . .� .. -., � . Lath/Urywall- . . .. . � . Interior '. , . , Lclh-Exlcrlcr � � � ` ,� . � � � - House Numbcr- -� ' � " ' -�� ' � � �� - ' > ... . ... ,. , . Correct 8 Pasted _'. _ _._._'. __. .. .. ._. .____.. . ._.. ..�� � . Final- . . � .,�,. ��. Enfer on Frent , . . . , , - . � . ' . . � . - . .