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HomeMy WebLinkAbout0873A (4) WORKERS'COMPENSATION DECLARATION � I hereby affirm thot I have a mrfificate of consenr to self APPLICATION FOR BUILDING� PERMIT � insure,or a certificaie of Workers'Compeneation Insuronce, or o te�tified copy rhereof(Sec.3800,lab.C.� COUNTY OP LOS ANGELES BUILDING AND SAFETY Policy No. - ComPa^Y BUIL�ING � n ` � Cert�fied copy is hereby i�rnished. FOR APPLICANT TO FILL IN ADDRESS � � ����s�,..�.� � Cerlified copy i�iiled with the county building inspec- BUILDING � O ,/�' tian deparfinent. ADDRE55 /� ` 3M Z�P - Date � Applicant CiTv tOCAUiY CERTIFICATE OF E%EMPTION FROM WORKERS' NO.OF BLDGS. I CNEA�E55T . � COMPENSATION INSURANCE 512E OF lOT NOW ON LOi (This secfion need not be eompleted if Iha permit Is for one � ASSESSOR hundrad dollan($100)or Ie53.) TRACT BLOCK LOT NO. MqP 800K PAGE PARCE� TEI. f I certify thcf in 1he performonte of the work for which ihls OWNER � � NO. O•[o�� � �� OP 3^3 � permit Is issued,I nhall not employ any person In any monner noor�ss ',1. OZ tn.�l CONDITIONS p so os to become subjed to the Workers'Compensation laws. �„ 2�Q . ��,H�� . CRY �- [x�� ZIP � Dcfe� / �Applimnt ARCHITECTOR TEI. NOTICE TO APPLICANT: If, afler moking'thie Certificare of ENGINEER NO. 015TRICf GROUP TY7E FIRE OCESSED BY � Exemption, you sho�ld become e�bjecf to the Workers' I� CONST. 20NE W Compensa�ion provisions of the labor Code,you must farth• qpppE� � � with [omply with 6uGh provlsi0n5 O� Ihis permit Sholl bB 7EL. STATISTIfAL CLASSIFICATION AP7. CONDO. � deemed revoked. CONTRACTOR L NO.4�J3'Hj)H 7 ! Z LICENSED CONTRACTORS OECLARATION LiC. RA55 NO. �'"� DWELL.UNITS I hereby affirm that I am licensed under provlsions of Chopter 9 ADDRE55 Z, ri-k...+ NO. (�2 (commencing with Sec�ion 7000)of Division 3 of the Business end �i�. ��R�P Proiessions Code,and my litense is in full force ond effect. CIiY �l.�Gw QA55 BK � VALIDATION SQ.FT. NO.OF NO.OF CHE K License N�mber y 1��Z� lic.Closs� SRE � SiORlES FAMILIES ONE /��j/ VALUATION CoNroCror�/�.lilf��^-� -Dofe�—�2�Y 4- DESCRIPTION OF WORK � A D a s p2��(/� �I am axempt under Sec. �� AITER � � . 4:�$�•J A B.&P.C.for this reason . REPAIR � : �+ • • • • � USE OF D018: E%ISTING BLDG. DEMOL ❑ Signatura � APPLPRI TT NO. FINAI � • •4 3.0 0 OWNER-BUIIDER DECLARATION . DATE �—� . a c[�J.�Q� I hereby affirm that I am exempt from the Controctar's Licanse law for the following reason(Sec�ion 7031.5, Business and ADORESS FINAI Professions Code): - 6y ��.� 5—�'s aew�oiN� I, as owner of Ihe property, or my employees with nDORE55 wages as�hei�sole compensation,will do the work and , �ha s�ructure ia not intended or oifered for sale(Seuion ��`��TY 7044,Business and Professions Code). rotOviNG - TE�. � I,os owner of ihe property,om exclusively coniracting CONiRA[TOR NO. with licensed mmractors to construct the projen(Seo- nooRe55 tion 7044,Business and Professions Code�. CONSTRUCTION IENDING AGENCY " SEi BnCD YARD HWY T�tApROP.LINE WiDiii I herehy affirm thar�here is a consrr�ciion lending agency for FRONi Ihe performonce of�he work for which this permit is iasued v.�. (Sec.3097,Civ.C.). SIDE v.t. Lender's Nome 3z� ��R�,.« Lender's Address 7.C.fee f Permit Fee , � 1 certify�hot I hova read lhis applicotion nnd siale that the iseuance Fea �V � IDrM 7iC M � above information is mrrett.I agiee ro comply with oll Couny Invesiiqoron Fee $ ordinances and Stare laws relafing fo building construction, _ Tmal Fee �•U� t�Mn Perm.M R and herehy nuthorize representaiives of ihis County�o enfer upan�he anbava-men�ioned property for inspec�ion pvrpases. w �/ "`�'��_ �Z,—�� SEE REVERSE FOR EXPIANATORY IANGUAGF E S�gnolure of Applimni o�Agenr pofe . �i fLANS TO APPIICANT �NSPECTOE'S NOTES � U11'NfR-fS�qI,DF•:R 1)fiCLAKA'11C)\ I herr.by afh�m thnt I am cxcmpt Ircrn ihc CoNmcmr"s To: - . Returned . � .. ' . � . �. . �Lic«nse Lnw lor ihe (ollowing rca,onl (Sec. 7031�.5� APP�ov¢d � liu�rru-asundPrfevcinnrCndr:ilnvcit,ynr:nun(v.�irbiil� No. Data No.� �Date . . . . . ' . . rryuirec uhrrn+illn oo�istru�'!.uhrr,irnfrurr.Jrmulish. . - -- . . . --ur rrpnirun��slruoture,hriur b�iu isnaance.uLn rryurrrs . , � ' ' , . . - . ' � .. � �hr op/liiau�frir�sur/r rerrert m Jilr a sr,trtrd.rtatement - - " �"� - "- - �..tGo!be is li.enseJpursu�nt tn fl�rpnmisi,m.e n,/!hr Cnn- , . . � tru.tnr'sl.ieensel�+ir(Ct•.rpter'))(oorrrn�rn<in,qirrtE�Scc- . . . . ., _..,.- '...,.,. ' , , ,. , . tion 70(IOJ n/Diri�iun j nJ 1L.�(iu�rnr.a�md P���Jrsxinns . . _�.:.�- • . ,� . .. . .� _. _ .. _ .. . ._. . . . . _ _ . � .. . �-.,t.� ... C-ndeJnrthalbeicrxrniftlber�JrnrannJilrhnsi.c/nrlhr - .._ ._ _ _ . . ... _ . ... , nllrgrJ rxenrftion.Anv oinfatiart�JJcrNon�7(19f.s h�- . . . Ro9ulred.. .. , -. . . . � .__. __. . . � uri�'applicuntforaprrndrruhjcardrPA�fIIC(Irt(fOJCIPII ��-�- Dmo Rocelvod Approvalf . or Approvod , � , prnul(Y n/nnt mnrr fiun Jirv/�unJrrJJ��!lurs(SSDp1.J: - _ Yos _. No .... ... . , �' - ___..___ ���_ - -" � - -� � �,� - " I_I I,qs ownor of IFie prOpr.rly,or my ninployeeS wi�ti VJara�Crri�hca�e ' � , � . . - � - . - . __ .. _ . � . . � �wngos as�helr snle con�pensonon,wlll do ihr.wo�4,and - � - - � . ihe siruUure is noi inlended or oiforeJ for sale�Sec.7044} � �.. Heohh�eponmer+t - - .. - .. " . ' �- ... . .. .- ... . - _ ..flusinetc anJ PrnJrssionx Cudr:-T7�r G'unbdi'tnri l.icrn�e . _ - . .. � , 7.uie Jnrs nut af/+IV fn aq nu•ner i��.,����.��•„�����huiLL� iire Dr,partmem - --- - - � .. _ or i�nf+ravc.a[lcrrun',_ond u�l�n Joersurh u�nrk hiri�acl/ns ' .- � fl�roukb�bis nirn ernfli{yres.�/�rnriJed !1 ut tutb irn- � Grod�ng . . . �-�psntrrnenit arr nnt infrnded ur n//crrd fur sale. 1/, . . �. � � Li�i�rerrr.lbe6aifdin,�nri�nfronemrntissufJioitLinnnc _..., . ,�. . Geeloykal `. .. .. '. '. . �,P�'�r rr�mmfle•finn,4L��-uu�ner.hr�ilJer u�il7 lare tbc . . _. �. , . ..... •,_� - buidrn r f prorin,��lhul be diJ nr�t hutlJ nr inr�,rnrr(nr Pedestrian Protecrion �� � ,- � . thc purhuse o/mlel. . .. . (Fence)(ConoPY1 . �' ' .1, . . �.���... , . ,.. ' - , ❑ L m owner oF Ihe�proptnY,am ec:lusl�ely convao . )ing wnh hcensed eonirouo�s io construct Ihe projeU(Sec. Speciol InspeUion - - . .. . . � . . _ _ . . -'.. ..� ' ` -� 7044)�llusinesc�nd Pro%ssinna Cndei TLc Contr�rt��r's (Conc)(Mason•Y)(Weldmg) ' . . .. . . . ... _ . . . .. . -.. . '':f.rccn�r(a�rJoes nor appf��fr�uri.>u�ner nf/�rr�frrh�u�Ln - �Fuilds eir iurprn��es lbrrenn,�irJ u•bn`ronfrucls/ur ra�h lot Dra�naac �. �':� `- '=� . .. _ ' pr jrrJs u�Ttb a tonMactnr(sJ liocnsrr/p��rruanl tn fhe _ ....__ . . � . .. ... , , . - , _ . . . . Cnntratlnr's'Licease l.ate�l. — � � . _ � �. ..,. ., • . .. Porkin�j . ' ._ . . .. .__. ._ . _. ._ . . . _ . " " � � , ❑ I om exempi�under Sec. ,6.&P.C.fo��hrs . __ _._. _ .__. i . , . : ieoson ., . • � � . � �. Daie ._. �. ..� � �Owner .. Approvals Dnfe Inspalloi s Signotore � . . � � . � INSPECTOR'S NOTES v � � toco�ion- . . ' . ' ISetback 8 Yardsl - � � � Foundatrons � . . � � .� . . . Slob Frome - � � '' � Energy Insulabon � - - , � �- �� , . � lath;Drywafl.. . . --- . . . ..- . - - - , ..- . - . INerior .... . . .-- , ' lnih-Ea�enor � . . . - . . - -. - .. ._. ... ._ . , . House Numhe�_. . _- ..- -. . .. .. ... . ... . . . . Co�reci R Pos�rd ' - . _ . . . . . . �.�� ..�. F�nnl_ . . , . . . . _ , . . .. . . . Entc�on Fron1 � . . , � ' . ' . . . . .. . \ �.