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HomeMy WebLinkAbout0823A 0824A WORKERS'COMPENSATION DECLARATION �`�� E������� ���� � �ti I hereby aFf,�m �hat I have a certificate aE�o�5e�„o 5a�f _ APPLlCATION -FOR BUILDING PERMIT insure,or a certificate of Workers'Compensation Insuronca, or a certified copy Ihereof(Sec.3800,Lab.C.) � �,t�7,�5/ �/ • COUNTY OF LOS ANGELES BUILDING AND SAPETY Palicy No. Compony Y-rLt�t�..ix..�" Certified copy is hereby furnished. FOR APPLICANT TO FIIL IN BUIIDING.27�[JQ �� ADDFE55 J J i! � Certified copy Is filed wi�h the counry building inspeo- eUILDMG �L�q. /-�� 71 Qn tion de otlmant. ' ADDRE55 z3 07 O C� . LOCnu7V i�'�/�J�.GY7� oare ��3��� Applicant c�Tv I�/�1d/V /� z�r c"osss'T. uNStfi� C N� CERTIFICAIE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT hV+P BOOK PAGE PARCEL (This section need not 6e[ompleted if�ha permN Is for one TRqR a 7�/� BIOCK lOT NO. U5�%E N�pP �.z 3 — 3�S hundred dollars($100)or less.) p,� TEL SPECIAL �- I cenify iha�in the performance of the work for which�his OWNER /�[� L��S NO.�s���� ��v ConIDrtIONS n. permit is issved,I shall not employ any person in any manner ' ��1� Q -�- - � � oiSiaiCt GROUP tvPe Flae PROCESSED 0Y O so os to become subject to the Workers'Compensation Laws. AooREss .2-�J � L/� ��i7 CONST. ZO � /o �'3 � � .�y Dafe AppliCont C'TM ��� �� Z�P STAiISTICAL QASSIFICATION APT. CONDO. O ARCHITECT OR (El. q/ V NOTICE TO APPLICANT: If, after moking this Certificate of ENGiNEER �pX��(/`/�(1ff/P�,V�S NO.�� �y ClASS NO.�DWELL.UNITS � Exemption, you should 6ecome subject to the Workers' �+ d Compansation provislons of the Labor Code,you m�st forth• ppDRE55 � .0� /9 I(�7�T SEWER MAP V' with comply with such provisions or Ihis permit sholl be z deemed revoked. � d TE�'� � BK. p�, VALIDATION CONTRACfOR F,�L��s/ F n,o. �b7 LICENSED CONTRACTORS DECLARATION ���_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS� .3 � Ei� NO.3Sy�1Q VAIUATION � (commencing with Secfion 7000)af Divisian 3 of the Business and �,/ t� LIC. /1 '/ � Professions Code,and my licenze is in full force and effect. CITV G//��V �� CtASSV��� E�f'��� LI �fy� S�.Ff. NO.OF NO.OF CHECK , LlCense Number ��7/�v LI[.Class�/- SIZE �� 570RIE5 FAMIL�ES ONE co���a�, oma/'3"$ q "�" 0 DESCRIVTION OF WORK /�l1I�II LI/f> �D �l�L`�1 ADD � `� ❑�om exempt under Sec. f"' (�G54 F �" _ A�TER � DATE � � $`-� `p 8 2 3� BP.C.for Ihis reoson REFAIR ❑ �e • • •'Z�j USE OF FINAL q Date: E%ISTING BLDG. � - - DEMOL ❑ � S�9nature APPLICAM `-• 7EL. By �``� I • •3 8 2 5 OWNER-BUILDER DECLARATION PRiNT �LD /Y��F�( NO. 3 ,/G� �UG�P ' • 'J$2 5�' I hereby affirm that I am exempf(rom fhe Confractor's License � Law for the follawing reason(Settion 7031.5,8usiness and ADDRESS �r?/P � �1.0 3—8 4 Professions CodeJ: N /}� MQ � � I, as owner oi the properry, or my emplayees with AooRE55 �'����C'"���r� ages as thetr sole compansation,will do Iha work and the structure is not Intended ar offered for sale(Section ����tV ,., 7044,Business ond Professlons Code). MOVING TEL. yR, � 1,as owner of the property,am exclusively contracting COr�ivaC70R r,o. _ 0 8 2 4 A with licensed contractors fo construct the project(Sec- qODRe55 �• • • • ' � tion 7644,Bustness ond Professions Code�. . . REOUIRED TOTAI SETBACK FROM EXIST. CONSTRUCTION IENDING AGENCY Sei BneK YARD FIWY pgOP.LIN WIDTH �� • •5 5 5 0 1 hereby aftirm ihaf 7here is a construction lending ogency for FRONT -� - fhe parformanca of the work for whith this permit is issued P.l. � • ° °5�5 0� t5ec.3097,Civ.C.). SIDE - c.i. 01.03-84 lender's Name a Lender's Address P.G Fea S -3��� Parmit Fee �-� �� 1 certify Iha�I have read fhis application and atme that the ieso <e Fee /O• -Sd � a6ove information is mrrecf.I ogree lo comply with ali County i�vesugar�on Fee a� _. g ordinancas and Stote laws reloting la building conslruction, - � Torol Fee `s'�'3 d " �- 7 end hereby authorize represen�otivas of ihis Counfy to enter , � upon the ova- on proper orinspection p�rposes. � � - `3`(,! SEE REVERSE FOR EXPLANATORY LANGUAGE � ignature of I�canf or Agent poro . . . 0i PlAP:S TO APFLICANT ' � INSPECTOR'S t�OTES , ONtiLF-DUILDLS DECi.A2ATJ0\ ,.,,. ; , .1 heieby oifirm�lhat Lpm exertipt from the;Controc�ois To: Roturnod ._ . . . _ License Low tor ihe following reosan. (Soc: 7D31�5} ' ADD�eved QuJir.ec�er.dProfr.vsioncCodr:Axytityorcount�•u�GkG I.o: ---- -�-�oto-- �"'-No. , -: Dato :- .._: . .. 'rrquirrsah /+ - nrit to co:utruct,a7t:r,-fn: rorr,denrnliab, - r>craircnp strtrctum,J�rrnr to its ir.cnaaCe,clso requ�irci ._ _ __ .__. ..... ._. _ __. . . . . .__._ . . . . . _ . •,,�,_; . � �� 1!r'Rp/�licai:dforsucl pervnittofile-asi,qncdstatcntcril _ .. � ", ��'... � � ,..�>.r`,�•.�+:'� � ., , • �' ... '__. _.._ _ _ _ . ' ,' . _ . . . '_ � � _ tFi¢t Ire is licenseJ pr�rsuarst!a tl e prorrsinns nf tJ e�'on- � �`�.�. � � . r' tractnr'sLicer�sr7.au�(Claprer9J(cmrsn+er.eirngu•itb5en � • '•, �� 1.'. . 'S. \'c.�:.��'� . trnn 7nool�J Ir���s«,„3 of tlic IJusiness ond Pr fes.ir'�ni j ,� � �, CndrJortbatJerscsim�(ittLrrc1rnntaxd7Ge�LasisforlGe a!(qqed erenrptenn.Aqy riolatinre nf Scction 7031.5 by � ToGulro3 DafeRoe�I»d � . . . . � ' anrapplitar.lJnrefern+iesvljeCsth<nQrlicar.lto�aerorl i - . .P,'?revelx --� -" Yos No or Approv�d .\i:�`, ` , . `,'--i:..^ 1 , .., penaltv q/nnt nrore tGen fire I uaJred dnllars(SSOOJ.J: .. - _ ��� _ . .:L� I.�s owner of tne propeny,nr my employees with Wafer Cerlifico�n � �.,,��,�,;.���J , _ , , w�ages as ihcrt sole compensolion,will do tho work,and � ---� -��-�- �� �• � � �he slructure is nor intendcd or ofFerfd for�s�le(Sec.7044) F�eal�h Deparimenl . _. . ' , `ti,� ��, ,,,_ , Gr:sio�css cnd Pr fcssim�s Code:7�bc Contractnr's Licensc - -�-- � -- - .__f.a¢•dncs not af./:Iv tu en ou�rrcr oJ property wbn builds Fire Department , . , � • , _ - ,.. ...- . - � � , � �nr im/�rdrrs tLcrenn,'and i.!ri coea srecl��i�rk binrtelf rir �` _ ` . _ ' thrnu,�l 1 ii oun cvrpinpres; prnridrd IFat�auc7 im- Grading ' � � ,. _ . . .. _ prnnrmen[c arc r:�ot inlw+Jrd or nffc�rcd for salc. '/� •. �;•r, � '�. _ �,-"� . 5oia•ri�cr,thehvifJinqurrorprr>i�rr.:rntissnld�ei�lrrrnxe Geolopicol ..- -- . . . . year of cnm,n!eJrnr.. 11r n,+�nrr-hc�i(�!rr t:il!bace 1!e �:.�'.:.�,.+�• - Gurden f prnx•r�r,;tl:;�t.�r d:d cot F'reil:l nr�ir,�pmue fnr �� �'•-�\"�. �� ' ��tl c pu fosr af sc/;J. : . �, ... . Pedestriao Fro�edion � ' - � ' •� " �� - . (Fence)(CanopY) , � � ` � ~��-' �� .��\.\�' . � � ❑ I.asov�n�rofth^proprrty.amexdueivelyconfraa - , _ ting w;lh;icensed wniracto�i lo cons�ruU the project(Sec. Special Inspection . . . ' ' . _.. . . _ ��' �`.: �.� _704AJ Br:rrr.os:��r.o�d Prnlesa'ie�i;s'�Coila^Ibe Cnnlrnctor's � (Conc.)(Masonry)(Weldin9) . , J.iccr�rc Lau�docs not af�plv to au o:c:arr n�j+raper(y u•Go -- � - -- � " � � - F7+ildr nr ii+r��anc..,�l,arcnn,�aia,''c^bq rnnlrcUsforasscb Lol Droinoge . i�. .� ��`�,;; _ _ , /�rnjecG: u•itb a cmrtrecto✓sJ lices.rrd pursrient lo lf+r,.- . . . . • . -.-_Cnrttraclnr:c l.i:rr..ee L.n.�f.-. " •:.:J , _. . .. . �. ... Parking , � ' � . ' . . _ _. _ .-_�..... :.;--, ... • ,�, . - . � '' � � --- �-�- � � � �� ❑ �Idm�ex�emptun�!.rSec ,B.EP.C. . _ , . .. . .. . __... .__._ . . . ., . . � - - . rcason ' .� ��: � . _ . '. __.+ '.�.\ ' . . _ � - ,�tr �\'•"`,C;' '-- � - --- - - - - '- - - ' .�. . ` , ,�.. . . . Date Owner hFProvcL• � Dete InspoHori Slfln�ture ��.,,. ,,.\�:^,,l t.,, .� � . . . „P�SP[CT6"'S t1OTE5 .� �..•. � Location— - -- ----. ..- -. . ._ ' .. � (Se�back&Yards) ' . . . . . . - � . - � , . Founddllons, . .. .. . . ' - .. � SIa6 � � . . - . . . .. .. . . _ ._ . ..__ Frame'. . . � , . . '� � . , . � .. � � - Energy Insulalion �'. . . , '.:� . .' ' � • ��' . . - ; " ' � La�h/Dry3woll— • � • . Interior � .- . . .. . ' La�h—Exterior ___ .. ._ . ._ . .-' _ ' ' _ ' .-- ' . , . . : . .__ . ._-.___.... ._'... _ _-_-.-. House Numher— � � �" �� �� - ' � � � Correct&Posled - � -- � � � � � Finol— � '� � - ' Enter on Front ' � � ' � ' � � - - . . _ \y� � , . , .