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HomeMy WebLinkAbout1365A (7) , ,. _ _ _ . .. _ . - _ . __. .__. _ - - - .- WORKERS'COMPENSATION DECLARATION � � ' � -'� " �'� � '-� � � : " I�hereby affirm that I have o cerfificafe of conseM to self __ __ . . insure,oracertificateofWorkeriCompensafion��,��a��e, ���APPLICATION,.FC�R.BUILDING PERMIT �� or a cenified copy thereof(Sec.3800,Lab.C.) --' � - � � --� � �- - , . - COUNTY OF LOS ANGELES i BUILDING AND SAFETY , PoliqNo. '. �.. . . Company . ._ - � � CerHfied mpy is hereby furnished. FOR APPLICANT TO FILL IN nooRess ���9 .� �-a.�' Certified copy is iiled wi�h'Ihe c u ty�building inspeo - BUILDING / ' � ` � 'lion deparfinent. ' . ' �� AD�RE55 i 1 � � : � . .,'.. -.�1 . ,. . . � __... . . � . _._ . �oie �/^IG•b���Applicant l7 - CiTv ziP ipcqpiy . . . � 'CERTIFICATE OF EXEMPiION FROM WORKERS' �' �" - - -�NO:OF Bl�GS.� -- � NEAREST - - -. � � � " COMPENSATION INSURANCE � � SRE OF LOT n NOW Ot�i0i . � 1 � CRO55 ST. I (This section need not 6e completed if the permit is for one �-- - - � ---- �--- ASSESSOR . ---� . '- '� � hundred dollars(5100)or lezs.) TRA�T B�aK LOT NO. Nlqp gppK PAGE PARCEI �L. " 115E ZONE � � so as1fo be�comersubPetl torlhe WorkersaCw,ork far whi�h this owNEe� � . e�- r• o. -Z� L� N� � �( -�� - • ;} p ., shall not employ any person in ony manner � / . . SaECiAL�'-. _ . ...-- '- �0. ADDRE55 � vO tJ � �--Gr . � Y� � J1 � _. . .�� '"�-�- C ' ' ' CON�ITIONS . . .. � �, 0 � ompensafon lows. / /� � V ermrt is issue Date. '-, , ... APPIicaN ... . . ., . GTY._ f -� _. ..ZIP z�P G'� . . . . _ . . _._ . _ .._ _. . , '.O NOTICE TO APPLICANT: If, oiter making ihis Certificate o{ ARCHRECT TE�• OISTRICT GROUP TYPE. '... .-,_ ' FIRE_ . ._PROCESSEDBY ;F ENGINEER C f��' O. Z - � �ONST � 20NE . V Exemption, yod should 6ecome subject fa�Ihe'Workers' -� -� ��` , .W with mmply�with such pronsions or ihis permit shal� be AooRE55 p O tv n/. C.uN � ��-� -�� `-"'� �-�- -� - - �'y Com ensation rovisians of Iha Labar Code,�ov m�st forlh- � , deemed revoked. �� � - � coNlataCfOR ...7". ��1Q NQ NO. I./-Z' � STATISTICAL QASSIFICATION ; APT. CONDO. -�Z T t. . ., . _. �9�._ . ._. . � _.. _. .._ _ ... LICENSED COMRACTORS DECLARAT�ON� � � - � - �r-�-�- - � - pc.� - � MSS NO.�LDWE�L.UNiiS � I hereby affirm that I am licensed under provisions of Chapter9 ADDRE55�L U w/✓ � �jU.✓ NO.���.z ) , , .._. SEWER MAP , �, ' ' (tommencingwithSection7000)ofDivision3ofiheBosinessand - - _.- - .. . . "-_-.-'-_.. ..LIC. - - � .. .. . Professions Code,and my license is in full force and effecr. Ciiv QY4.v 'C cvaSs ' - BK "-�-���-- � "'-i"-'�'VALIDATION-�� : . . . .�. . � ,, Q ' - .... 5(].FT. NO.OF..._._.... NO.OF .. . CNECK : . . � ����1?� ' Lit.Claes '�t� SIZE� � STORIES fAMILIES � � ONE � � � � 'License Num er . '- � � ' ' � � ' . . . . . � ` . VAIUATION -.--. - . -.- -- , C0�1rc[tor �� Dole ��-��`�J - DES[RIPTION OF WORK ' '" " " '"" '-- �� ' N� S SOOr � � � / _ AOD � , �I am exempt under Sec. . _, �C-v�� .. .AUER ❑ .�.. .� ...�_ - 8.8P.C.for ihis reason __ � REPAIR S - . .. .. -. . .- -�-- -- ---� �� ._. ._ . . . .. �ate: '_..'_ USE OF DEMO� , exisTiNcaio�. , -._ —�1365A -- -- "-Signoture - '-.. _... .-- � -- --- ' - aaauCAwi r TEI. � FINAI . . . � OWNER-BUIIDER DECIARATION PRiNT P . s✓ � NO. l • � � . DATE � � � � �-�-��� �-� ��----� -I hereb afiirm ihat�am exem t from the Contraclar's ticense � 1 1 . low for the following reason(Section 7031.5,Business and ADDRE55 C'�/C /OW Il N C`�)�lalY .�d FMAL .' i � • •2 5.50 � . -Professions Code): ._ .. _.. .-- -. . .. - - aa N ., . Ey . ._ _. ..: .., . . ,. . - BUIL�ING ', � , Z.rJ.rJ Q�' _� I,as owner of fhe property,or my employees with ADDRESS ' ' _.'. - . �9 • P . ; ' — - --- 0716,-85_ we es as Iheu sole com ensation,w�ll do the work and � � the siructure is naf intended or offered for wle(Section ��'�m • . ' 704d,Business qnd Professions Coda). � �-� MOVING - ..-..... . - �� " TEL. .. - . - . .,� . . .... - �- . '-- '� �-�- -�-'-. . _ : � I,as owner oi�he property,am exclusively conhacting ��MRACTOR NO. ' � _= .. with'litensed contractors to�tonsiroct ihe projetl(Sec- - -�- -.. "� . . -. - ..._- . _ . . _ _ _. . _ _ . . - .- .' .-.. ..:........ . .� tion 7044,Business and Professions Code). ADDRESS � � � , REOUIRED . TOTAL SETBACK _ -_ _ - �-. -_ . ...__ . .._� . "" -"CONSTRUCTION LENDING AGENGY - ��'�� ' sei enCK YARD HWY- pROP.UNE WIDTH� � � � I hereby affirm that ihere is n construc�ian lending agenty for FZONT � ' ' ' '� ' � the performonce of the work for which Ihis permil is issued -. - P.L -. . _ . . . __ _ .. . . . .._ . ._..'_ . .__ _ ..._ . '_._ . . ___ (Set.3097,Civ.C.). SIDE � , ' '� . ._..... .. .. .. .. .. ., ..,_ . . P.l. ._ _. �,. : . _ � ..._._ ...__ . .. ._._ .__'._' � Lender's Name '� $ . /�+vU IDMA Ref.N __ '_: . _ ... ..._ . - - -�- -- � - - -- � - G.C.Fce S- � � � - Permn fee /V - - �= Lender's Address � �. ' ' ; � I certify that I have.read this applimtion and state thot the _-_. ._.. ._. .. . iss�aoca fee... �4 � IDMA P/C M- --.._ _ .._!_ . .' _. . a above informari rect.I agree to comply wilh all Couniy ' invesr�ga��o�Fea q f ' �' g __ordinances o S te ws relafing lo building construction, _ 7mal Fee �'C s•V� � lDhw perm.�M �-- 1 � � ..__...._ _.. .... .......... ....._._ ..: ii ond hereby ut oriz epresenlatives of Ihis Counfy lo enter ! . . � apan Ihe _Qv ioned prope (or inspection purposes. � ; � o - -� -- ._.. . _. _ --. :.:� ._ . . . - - - , - - -- --- -- .-_. .- . . -- � - - ---. . .. ` '7-lG-kS ^ , SEE REVERSE FOA E7IPLANATO0.Y LANGUAGE ' O ' - - -Signarore af Applimnt or Agenf��-- - - � Doie �-- . -. . - . . .-.� ..._.- _.. .- .. ' ___. r� , '_ __ . '_ ..' . . _ _' _.' ' ' ' PLANS TO APPLICANT INSPEttOR'S NOTES ,.OWNGR-I3UILDGR DECLARATION , I hereby affirm thol I om exempt from Ihe Canfrattor's To: � RHurnod ' � � . ' ' ' ' � . � License law��for�the�following reoson: (Sec.��7031.5) � �� � " - � � ' Approved " -UusinrrxartJProfcrsinnsCode:Anycieyorcoantyu.�Gich No. Date �� No. ' � �.�Dnfa- � '� . ., . - � . � . . seguires a pem+it to cortstruct,aJter,imfrove,den�olu/, i ._or repair an y slruclure,prior to rts issuance,also requirei , _ , ru�a��rr�anr/or sucb permi!to filc a signed statemen[ - lLat Ge is licensrd fiarsuant to tGe pmvisians nf t!e Con• � , , . " - t`. � Iratlor's Lirente Lam(Cbapter 9f(�ommrncing mitG Ser - tinn7000JojOit�isron3aJUcDusinessanJProfssinns � � � _ , , ' � • � CodeJ or d�at bc is excroJ�1 tGercfrom and tGe hosis/or tGe � � � . � a!leged exem/�tion.An,y violotion ojSeclinn 7031.5 by . .____ _ _ _ _.'_ _. ---_Requited _ -Date Racalved- . .. . �- .. �� . . . . .. .-. �nya/�flitanlforaJ�crnritsubjettstbecppliranttonoini! Apprarols Yes No ��APProvad , ��� renplly nJ nn1 nrore 1Gan five bunJred Jo!lart(SSOOJ.J: -��� -- �- �- ' - -- ' ❑ 1,os owner of the properfy,�or my employees with Woler Certificafe� � - ' � . _ . _ - , . . _ ,_ wages as�heir sole compensotion,will do the work,pnd ----�- �----- - �� �- -� �� ' . ihe slrvcture is no1 infended or offered for saie,(Sec.7044) Healih Department_ _._._._ .._� :. - � . . , �- �� � �-� ' - .. .. . _ _ Ousincas and Prnfcisions Code:7be C�rttrador's Licenle ���� - � , � Lafu does not a/�fly to an owxer of fnof,erty wi o builds Fire Deparlmen�_________. . � �- -� � - - �-� �- �. ar irnfrovrs tbereon,anJ u�bo Joes sutG work bin+seljor , .___._ ._.. .. _ . . . . ' - � �ebrougl Gu ou•n enaployers, proriJed,llat rrsol ine: _ Groding � ' �' . . , proneneen�s me noe inlended or of/ernd fnr aafe..lf, , . , - . � �bnu•ever,!bc burldrng or improvement is snld u�itbin one � Geological�:,j� i<,��-' - � ' . -_ , ; _ year nf cornpletion, 15c ownervbuilder udll Gace t5e . � � burJen oJ prnring tbat Ge diJ no!bvilJ m imprave fnr , . . . _. __. _ ._•._._ _-. .__ . Pedestrian PrUeaion-.��.'-� � , - � � tLe purpose JsuleJ. .� � � I (Fence)�CanoPY) -... ,. . � , '. � _.. -. .. � - ... . . . .--. � ❑ I,as owner of 1he property,am exclusively confrao- , , „ ting with licensed con�wctors 10 conslrocl the prolecl(Set. �"� ' � � � �- �-- � � - - - -� --� ---� � - 7044)Dusiness anJ Pr/essinns Gode:TGe Conlradar's. Speciol inspection �' � '.- . . .- , � � (Conc.)(Masonry)(Welding) � � � � � � � ;. . �• � . Licerssel.auJnesnnlapply[oanpmneroJprnprrtyu�bn ' � ��� " ' - � -� -- --� - -�-� � - " �� 6urfJs or imprriurs tGerrnn,and-u�bn rontr¢rts for sucl Lat Droinage ,' .�-- � �� �' � .• � .. ._ __ ._ _. ._ . .�.. .. .._ Qrojects wrt!n contratlnr(sf litensed Qursuant ro !he �' � � . , , --Cnnlractnr's Lirenso I.awJ. - � -�-�- " , Parking . . . . � --.. . _ -- .. . . ... . `.... .. "_ ❑ I am exempl under Sec. . .,�8.8P.C.fp' ' r ihis .....reoson.. .. . _ __. - � . . � � , . . .. __ ._ . ...__ . _ . _.� ._.'_ Da1e O ner Approvuls : '� Dafe Inspvclor�Signofura � . , _ . ,. . . � �. INSPECTOR'S NOTES��� localion— . '. . .._ _ ._ .. .. __ . (Setback 8 Yards) � ' i ; Foundalions � � � ' . � ��� ,, ,. � � , ' . ,.� ,, Slab ' . . . . . , Fraine . . . . . , . _. . . . . . . � .. . Energy Insula�ion � .:. . .:-.—-.' . ' . . �� , , , �. lath/Drywoll— .. . 1 .._ ._._ ._ . .. _ _ . .__. . . _ ._. IMerior _...-- ---� �- � - . , _ . , Laih-Exterior . �. . : .� .. . , .. House Number— ' . . -. �, _'_ . _ .. . _... .__." _-'_ , . Correct 8 Posted '• � . - -�-� � ---- .. . _-. : 1 � Finol— . . . . . �� .. , . .. . . ._._ _ - _ __ _.. . . .__.. . Ente.on Front � - --� � , - �� . . .. . . �. . � . ,.