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HomeMy WebLinkAbout0947A (5) , WORKERS'COMPENSAiION DECLARATION � � � � � � � � �e,�bY of�,m�hat 1 hove a cenifimie o<<o�,e�„o 5e�f qPPi.ICATiON FOR BUILDING PERMIT � insure,or o certifico�e oF Workers'Compensalion Insurance, or o cen�Hed copy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILD►NG AND SAFETY I Policy No. Company � � Certilied copy is herehy fur�iihed. FOR APPUCANT TO FILI IN qppREu �0 2Q �, PGY'�r� I� Certified mpy is��led with Ihe munty building inspec- - 6UILDiNG )� /' � tion department. ADDRESS ��sz6 � CL��/L n�/' `;�G l ) 1\� ' Da�e ApplicaN CI7v(/�-�I��L L�-� Zlv I tOfAUTY CERTIFICATE OF EXEMPTION FROM WORKERS' SiZE OF tOT NQW ON`LOTS / ROSSSST. S� i COMPENSATION INSURANCE /� �P-N1�� , (This section need nm be mmple�ed if the permit is for one . TRACT �� gIOCK - tOT NO. �W A�ESSOR • hundred doilors(E��O)ar less.) �P�� 7AGE 7ARQl � TEL. USF ZONE O? l�3 2 OWNER E NO I S �O. } �, I cenify Ihot in�he performance of the work for which lhis I� a permit is issued,�shall no�employ any person in any manner pODRE55 zOSrO L• � �✓ � SPE��a� p I��� CONOI710NS ' so as fo become Subject to Ihe Workers'Compensation Laws. " C� / ,l ' Dafe Applican� CITY 21P 7C � � � NOTICE TO APPLICANT: If, aher making this Cenificate of ARCHITECT OR TEL. �ISTRICT GROUc ttPE FlRE PROCESSEo 6Y � Ezemptian, you shou�d became sublecl to �he Workeri ENGwEER NO. - `� CONST. ZONE '� Compensation provisions of the Labor Code,you muzt 4orth- pDDRE55 ��— �J � � �'r W a �, wi�h comply wiih such provisions ar this permit shall 6e N 7E1. - STATISTIfAI CUSSIFICATION APT. �O. Z deemed re�oked. � corlranctoa � NO. — LICENSED CONTRACTORS DECLARATION " �iC. C�n55 NO. 2'� DWELL.UNITS ! I hereby affi�m thot I om litensed under provisions of Chapter 9 � A��RESS NO. � � � (commen<ing wiih Seciion 7000)of Division 3 of the Business a�d ��� SEWER MAP � Professions Code,and my license is in full forta ond effect CRY CLnSS BK � VAIIDATION SO.FT. NO.OF NO.OF ) CHECK � liCenSO Number Li[.C�asi SIZE STORIES � FAMIlIES I ONE � Q VALUATION Contractor Da1e' OESCRIPiION OF WORK NEW ��� �I om exempt under Sec. � ;r,ef -_ �a-'o Aoo f , �f ALTER 8.8V.C.for this reason L--O�E REFAIR � ,S . USE OF � Date: E%ISTING BtDG. OEMOL SignOfvre APPLICANi �,/ �/TEL. FINAI �L'C��-! Fl PRINT � LC .!ti'//NO -Oj�..4 �� � OWNER-BUIIDER DECIARATION /J) DATE ji. . � o . � I hereby affirrtt that I om eaempt from Ihe Contmctor's License qDDRESS r//r�L�L". (%LE�P. ,<�,r �.i '� Law for Ihe(oliowing reoson(Section 7091.5,8usiness and FINAL _ � o • ' � Professions Code): . x _ gY .� ���•� � BUILDING e-� t, as owner of the pro0erty, or my employees with ADDRESS '�u 7 J��:, wages as Iheir sole tompensation,will do the work ond �OCALITY • the slructure is not intended or offered 4or sale(Section � ��.C Y-{�FS 7044,BuSiness ond Professions Code). MOVING TEL. � I,as owne�of Ihe properfy,am exclusively mntmcting CONiRnCTOR NO. wilh litensed contractors lo conslr�[1 tha project(Set- . qDDRE55 tion 70aa,Business ond Professions Cada). CONSTRUCTION LENDING AGENCY . - - SEi�BaCK YARD HW1' T�TAp OTP.UNE� WIDTH � .1 hereby affirm thm there is a construction lending agenty for fRONT Ihe performance of the work for which this permi�is issued D.l (Sec.3097,Civ.C.). SiDE v.�. �lender's Nome � � C tOAM Ref.M Lender's Addr¢ss . v.C.Fee S Germ�i Fee �6��'J , , I tertify Ihot 1 have read fhis application and state that the issuonce Fee �f �DnnP.P/C M above information{s correct.I og�ee to comply with all Counry �n�esngai�on Fae �1/ �7� ordinances and State laws relating to building construc�ion, Toiul fee ✓�P� ! LOMA Perm.M ond heraby erfhorize represent fives af this Covnty lo enter on Ihe e-man�io�ed pro (ty for inspection purposes. L �'f I�!, �i� /-.7��/� SEE REVERSE FOR EXPLANATORY UNGUAGE � � Slgnoture ol Applicont or Aqenl peie . . . . �� (11PNI;H-HUII.U67t I)1�:('I.AHA�I10.A' PLANS TO APFIICANT INSPECTOR'S NOTES I,hr.,eby nfhrm tho!1 am czrm�n ir�m ih�,Ccr��_1r"s� To; . �. � . Returnnd �� � �. , ' :icmue In�w lor +he�(ullow nq n.n o+ (5..c 7031.5 ApProrod liusinro��rtJY.oJ:�.�si.�rss Codr:.9 np citv n.niunh�u�LrrG Na. Da1¢ No. ' Dofe.. . � � .- � reyui ��o per rri!�u c�o��frnrl.�l(rr.im/.ru r.JenroL:�h. --- -- '---- — iirre/�Jir�(n,l'<<rurli�rr.1'ri,rr'1,.i1<iss�.Jr�ir'Jlevir��yuirr. -. , , ' . . . f!)r u/��,liiJut/„r Surl,�r,•rntit Jr,Ji/���e siCRrJ 51�f.•�ni'�i! , � �� _ '. ..��� �— -�� "�-- - - -- � � --- - tGne 1 i•i�li.rn�rd pnrrudnf tu�hr prned��ri,rts uJ N�r(:nn. � ' ' '.� . `,. _ .. ,•.. .` ' _ �..�. �. h✓c�nr'.I.rrensvl.��r/(:haf�/rr J/(o�nrornnn�u�itL Sco- '__ —_ . _._. ..�.._. __ ___. . __ _ _.. .._ . . , c -- . . . riun?OOfIJn/Uiriseun 3 u/(!�r Nusinru dnd ProJrsriuna �. . . .., . �. •'. .� CaJrf nr tl��Ar i+rr�.inpe t/drrJrmm�nr!tb�Fnsi.�fnr�Gr t.'_ _ . ____.___ __. . _.._ ..._. . _ ._. . , _. ...._ ._ _ . ... .. . alf FrJ iu�eniplii�n.Anr e�inlolinn rf J�rdrnn-7U?1.5 h�. �'._____.__._.__, _.. .-. �..Roqvirod � -Dd�eR�c�iv�d .. � - . . . ... ,..� i - . ._- �nS'uppli.ant/Srafe�mitsuljudsfhnp��pli�vn�tr.dri:•r1 AP7rovals o . ��na111'n%nn!mn c tf.�dv Jivr bundrnJ JnUorc SS00 t. ._ .'_. . _. � Ycs No r Apyrored _ . ; . .. . . . � � � � � � , 1��� .— -- - . . . - .. . �- �_. I.os owner a(Ihe piopeny.�or my emp�nyrrs wiih � ` � —' ' "�. '� ' � � � ' � wo .s os ihe�r.sole com ensanor..w�ll do�ihn wo.:�.and �'va:e�Ce�:�ncote__' _. .. _.__ _ . - - - , - - � � 9� V � - , � ihe svuUure is nm intended or o(Icred for sa�e(Sec.7�4a; Hrv�•n Uen�rr�cnr --'- - -.-.. . - . . - . . , , 'Uufineu unJ Prnleisinnr Ca.te:Thc f,nntru<1nr's/.icrn�e ' . ' . -, . /,�u•Jars nr,!�pply�o mi�iu•ner nJ f�ruprr[r i��f•�,I,Nr7ds ! or im,rne�t•a tb.�reun,and u�l o dues m.J u��nk:hin�s.�l/nr .r fleccrr�nc�r - - -- -- - , � , - / � ' ' � ' � lhrnv,Qh Grs'nu•n rurpl�{vee>, fmriJed t/at suih irn• . . . .... ._ . __ _ _ ._-. . G � I . ... .. ' rn��ernrntr�air nnt intendrd F,��ng '� . . . . _... ... _ _. _.'_ _ �nurmr�tL�building nri�npmnenirn[ii a�ld�u�itJ�n on�• Geoicq':a�:,; ' . . .. ' . 1�rur n/cnmf�/efinn, tl r nu,n rvbuifder ri�il!Gar� !/'r -. . -. . . _..-_ . _ . hurdcn nf prni,inK rl�at Lr diJ nut huifd nr imprn�•r/nr - - t5c/rurJ'�o:e nf anlrJ. � � � � Ped�bi�on ProleUion - � � . � . , . . � ;FencellCanopyt � . -�--- - � - �� ---. . . - ._. � . [i t.osownerof�hePraPerlY,�merclusivelymmra:- . .. ..-..�.... hnq wnh Lcensed<antratrors vo consrruc�tho pro�eci�Sec. --- _- .. .. -. . .... - ._. ..� . � � � 70e4)IJusiners und P�u/essinnr Cndc: 7he G.nhartnr's -___._.- - _.. . 5pr:iUl InSFe:tipn � �Con<.I(MosonrY)IWriding) .. . - .... - � _. .. . _. l.irense Luu•Jnez nn!u(/�71'fo an u¢rnrr nf pruj��t5'u•[rn � ' � � ' . hu;1Js or;»�rn�•�r fL�rco�,unJ u�Ln cnnrrac�+fnr sie./ � �� rn �s u�i16 u cnntrada s li��ensed r rsuant m.1he ����.o,o��,�� ° r ,�� �r� r, - . - - G'untracturil.irenarl.auJ. � 'rO�� ' . . . —' ` [� Iama.emptunderSec � ..�.B.BPC.forrh;s � � � , reason . � , , , , .� �_. . � .. . .Dote Own Approrala Oota Irtspector's Sfgnofuro . " . � • ' � � � . , . , . .,. ' • . . � INSPECTOR'S NOTES - lacoi�on_-- —�' ._ .-..— .. - iSe�back R Yordsl ' - .- . .. -. .. . - ._ ' ' .. .. . . - . - Fo�ndcr�ons . �' _ - - . . _... _ _. _ - - � . �. . . . � .. . � Slob _ _.__._ ... _._'_.'._ _.. _ -, , .. . . . . ..... . � . F�OmP. . . � � ' . . . EI1�•py IlISu�01i(:� .__ ' _ " _ ." __ I . . . . . . lo�h:Drywall- -___ ,- . � � . �• . �. . �. Inlerio. -- ... . � . lorh-Ezrener . . � .__. ._.. . .. _ . . . _ . .. � I(o��se t���mber_ , - .... . _ ._ _ . . . ._ _''_' Co'reCl P.Posied I � ' � . � . . .. .. . .� .. ' Finol_ . �� , � � . Eni-r on From . • � � ri � ' ..` , .. � +