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HomeMy WebLinkAbout0767A 1633A (4) �^�-{ �WORKERS'COMFENSATION DECLARATIOIV � � � �'� � ^ ' Y-hereoy uffirm ,ha,I have a tertifiwte of�o�=e��,o 5e�f�..: � � � qPPLICATION FOR BUILDING PERMI~I'--�� � s insure,or a certificate of Workers'Compensation Insorance, � or o cerlified topy ihe�eof(Sec.3800,lo -C.) � 4�' � ' �,�3�j_� COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy Company - . .. � � � . O; Cerlified topy,is hereby.fUrn shed.` �� '.. . � , .. . ' - . � - BUILDWG � �-� FOR APPLICANT TO FILL IN nooaess ' � Certified copy;fs filed wi16 tha tounty buJdmcj.inspec BUIL�IryG �� �• . � �- � � . , tion deparfinent ADDRE55-� �.'. . �. �� � � ' ' ��'� IOCALITY� ��c71II'L'3$dY' .: �L NEAREST p S �o�Q.� AppLccnr .. � ': - ��'V�l.�� c�n� �. .�2iv�' � Ceoss ST. .. ' � � � � � ERTIFICATE OF EXEMP710N FROM WORKERS" � . � �� �� NO.OF BlDGS. � ASSESSOR COMPENSATION INSURANCE � � � . � S2e oF iOT '- - Now ON LOr � � n�w.v BooK� ' PaGE - caRceL (This sec�ion need not 6e completad if the perm8 is for one � � ' USE 20NE M".P hundred dollars(E100)or less.) Taacr � BtOCK tOT NO. I I ��r No. (Q �'�'3 . TEL G SPECIAL I certify�hat in the performance of Ihe work for which this OwNER Iv�, - jvgg NO 1 0'�(� CONDITIONS � d permit is issued,I shall not employ any parson in any manner DiSiaiCT GROuv 7yFE . FiRE PROCESSED BY Q so as to be[ome subjed to the Workers'Compensation Laws. �. ADDRESS 1763 ]� � CONrS,S/.,, ZONE � ' � ' � �� �Y�— DGIe AppliCOnt CITY Z�P . STATISTICAL CLASSIFICATION APT. CONDO. O NOiICE TO APPLICANT: If, after making this Certificote of�� ENGWEER�R$3Q�iYp N . �_ � U �Exemplion, you shouid become subject to fhe Workers' ClASS NO. � DWELL.UNITS �++ .Compensation provislons of ihe labor Code,yau musf forth•` qDDRE55 SEWER MAP � with comply'with s�ch provisions or this permit shall 6e . Z deemed revokad. COMRACfOR �QaYD Q3�1L�'1C]1 N 71�] rj9$].�Q gK PG,� �VALIDATION � LICENSED CONiRACiORS DECLARATION � , LIC � I hereby affirm Iho1 I om licensed under provisions of Chapler 9• ADDRESS 7�$� ]�9C� O. VqLUATION , � � (commencing wiih Section 7000)af Division 3 of the Busines;and� � UC. Q C� Professions Code,and my license ie in full force and effect. CiTv � Cts�55 E �,��� . � License Number '�r7J7O uc.Class B 1 s�e�� � sioa�s � Faili�Es 1 �oNeK � ► f 0 7 d 7 p - . COnira[rof�D�1Q1Dale H�11�1 DESCRIPfION OF WORK NEW � 5 � , t�• o • •'�j� . . . � �I am.exempt under Sec. � ' ��i�� ADD �s � � o e 5 9.5 0 • • ALTER � FINAL � B.BP.C.for this reason � - � DATE Z�� • ° ^��.�i Y � REPAIR � Oole: u5E OF . FINAI ' ' � E%ISTING BLDG. DEMOL ❑ By /7 O B � E—G 6 C_ Signatare � APPLICAM � EL y / O _�� OWNER-BUILDER OECLARATION vRw - i � , �, , • I here6yaHirm that 1 am exemp�from the Comracror's License� qDDRESS � � � /rl�ic� �, / �� Low for the following reason(Section 703I.5,Business and� � � Professions Code): � g N � � - � �, as Owner of fhe ro ert y P y BUILDING , p p y,"or m em lo ees with ADDRESS wagas as their sole compensation,will do the work and . �� . � �� 6 3.�J F the strucmre i:not Intended or offered for wla(SecHon ��`��T�" �� � � 7044,Business and Professions Code). � h�OvwG TEL. � �• • • • •� ' � i,as owner of the proparty,am exclusively con�racting NTRACfOR NO. �� . - ' � • •8 G 5 0 with lice�sad contractors to construct fhe projetf(Sac- qD�RESS ' ' � ��on 7044,Businass and Professions Code). ' '�. � - REOUIRED TOTAL SETBAIX FROM EXIST. � . • � °�O,5 O� - CONSTRUCTION LENDING AGENCY sei BACK YARD IiwY puov.twE wioiH , � ;,{ I here6y affirm 16at there is a construction lending ogency fw FRONT ' �� � � � ' ' � � 0 4,0 5—8 6 the performanca of the work for which ihis permit Is issued p.�. � tSec.3097.Civ.C.). SIDE . t�, � m P.L. � ' �. . . , � � Lender'sNome - � r�7 �'� �i . �',:''.,.:. ; $ P.C.Fee E S r S V Permit Fea D•�� ' � j��`� = Lender's Address '� � �., �, � I certiiy that I have reod�his applicaiion and'state that the � � - is:o <eFae �Q"5� � � � above information Is mrren.I agrea to compiy with all Coumy . � �nveanga�ion Fee �� - �' - - or inonces and State laws relaiing to boliding construction, - � � . Tmal Fee - SD•SU � � YJ hereby authorize represenfatives of ihis Counry to enter � � . � po 1ha aho mentioned property for inspection purposes. . , . � � � �� � � � .,,c.�-o�.�� CTII"CJLr � SEE REVERSE fOR E)f�UNAiORY LANGUAGE � Signmure of AppGcani or Agent Daie- � � � m� � - -... . .- _ -._ _ -� _�._ _. _ ..._._ _.. _. . . . _ .��- _.. i u;;:�c r�e.uct r.� . i r ,. � ot �5 i u��n r i �t�a »tc� '� r ' � �rl hcrc i c 1 i� 1 c c� ,.. i(.cm�hc.0 ntrado's To: �I- �;.Icrncd . (� . � ,��.:L. , Lic.i L�f� i L �f o n� rcc. (5 c 7031 5) ��. :� 1�._.c 1i . � -" � l��r��,�l� - • C.pprcvcd � • �� -' ��— !: . I F . ( a rr�n by xrhrtL+ No. . __.Gcta. _ _ Na. U c. - � �Il����: ll� r� �1Jr.��: �' (/.. �� t o r.c Ir!., _=---_�— .�_ �' �14- I r• - � �.! . . � E� ' . . - ----- -- y-`— n r v � t r+r i n clsorcquores _ __ _. .... .. . ., . � . .. .. �. . . . � ,y� . .. �. i � � . j . . �`[ r��� _�., � �ti;�cl��,p tl n 1�cr.t l y d.(r � t f f:c sr�r.ed s!u cmm�t j _ � _.... .. (� ��t t.-- i�.��J = �J l r kn �J r . 1t ticfm<rsewiso�thrCorr- . _ __._ .... . . . __ _... . I . . . .. . . . es � � � � ;r r ! 1 a.(({ r �J(c r ar'nr u i!!Scc- � .. . - n ,j� � L'�1�1 v� '•:r.-�Q� :.C, C.`�.l`:: 1. ..ii - O(J�j !I7 J rf tl F-L . .. u 1 Ffof siotts i _ .! � �� I ' � -! l �� C ) ���-t7 ret�„it -��r irdtlr7rsisnrtGc �V C �G�.Itv����.:IC' 1 a .��l1rl'� f t t, 1 r � f ce r 7031.5 6y. ._. . - �--i ..�c;�!-cd.. . . 1. , � �''- � .;� c.fyc,�� ;if �. ts � -t't�. c�.nl int7naciril ,_ rar r �_��_d, �.� =.Lu.�r�1,10. '� �� . __o �AP,r..:�! ..._ . 11/"s.�� �� 11 ./ � t �,�, tn�. / �! -e..d��ll.ers(�SDOJ.J: � ... Yc^ te ' arA�prwcd . _ ���- � ��' - I _�..,f�j 1 �C.i - ' l'..�r,C ..�!'(� �r�Z. Qa.Lt.���� . � 1 c.�o IFe��op rty or.my employeas with Woler CurliFicote �. - � � '-_ �-..��, � .--'_ � I... _. . ..__ - - . _ -' -_( \ �t I t;' . ,t ca 1 I. c mpen. o will do tho work,and ���., s,�.�p�� �s.ucti �al d nt_.,d c e �red fcr sote(See 7D44J Health Departm.onf _ , . _ . . .. .,� .. _ . �7. �/y . . P, s c. 1) (�. . _ ( IJ C trnclnriLicanso . . ���d�/��O,��G��f/J --L �� !/! i n � fi �lcrtYwG bu�,k Firo Dcportment _. . ._. � . .. . .:� .:.� . .. _ '�»1 t r l_ i ! -� s r a. ie ord{� r sc!nr t1 1 Lrs� �i e.rl yr � frne f 3-1f a!sae! im- Gradin ... . . d•2;. �i��L G���' . .. _ . ._ . ��:r an�.,.,fs'r c ,?�o (�•r.�d for'sila-lf� 7 I I ' . . . r, r . ... . . , ,, „ . .` . � Z, � t'. , :_ .-cl-��c�rt�n �rr: Gcolopieal . . . �f._-- ___ . .. j � � . __ .-_ �� . f. ,r.v 1.r t(� .: t<ff L e U>e .. �� . , , �I,a : �ryr��. , .c..,., � o i:c,^,rorr�r Pedestrian Fro•ecl'en �. � . . . . . . .11 / r(esr J �l . ' � � . _ -....-� (Fence)(CcnoPY) . .,.,�� � �:'.� � ,- ' "� . l . I;nso��nr.ro; h:: �., ly,cinreclusive!/.contrac- � . .. .. .. . ' . ' �.. _ . _ _ ..' . "� . .- . . . � . .�i , Y��. � �. . n i e fh=�ro�ect(Sec. Specioi In:pection � I -. . --. .. � � . --- .. ..�-. . __Z011) s a J t -. r �it La.� I�n Contractor's (Conc-)(M,asonrY)(Weldin�j) ' - !r r. La�• �. �! � � r /��rr./�rrly¢�10 . . __._ . ._ . __ .. .__. . !.e%!,(s nr.i �r�s I�a , ..�w, �rlr�:ta fnr sucb Lot Dmincnn. . . � �' �, ' � ,� f +� . + -. -r�ar.f eo�11 r ; � ' I . I , .. ..._ _.__._. _.. .. . . .. . . . _ _'_( ,.,,�..,. . l. ,... .. � . .... 9 , . .. ...-__. . _� .. .._ _ . . r . ' '.' . . _. _.._. __ __. .._.... ._.. ���....: � . ., . Porkin � ' � - � '-]-I r.m c cmpr�odc ,O.GP.C.for ihis - - - . . � . . . ._. __ . _ ._.. .... .. _. __. ,_ ,. _. .r.:��on_._ . _. ._. .�. _. __ . . . ._ . ... . . . � .. . .. �..� � . . . . . , . . . �. __ .___ ._'_' __ "_"'..___...�. Dat^ - O�.vncr � � . . " . � . , , . � " . ;ii i ,. _ . . . . Appravcls I Ccts ir,'?ocS>rc:i�r:lcre � �;. . .. . . . . � . . . . - . .. . �, _ _�—-. ___'__ .. , �� _-_—'_ location-�� , I - _ . . _ . . .__ .. , . � . .. . .. . � . � ISetback P.Yards) �,'�i i�.f ��.` � ` . •. . . ., . .... ..� .� Foundations � ���! '`� _ , �\+1�., .. � . . ., - �.. � . ,� � ,. Slab :�'�5 I . ' .. , .... , , ., , � � . . . . . . . . .. � Frame Q.'S�f'fn I .. ..� .. -_ � .. . �.' ' . ..� .' .. , t. .. Ub . .. _._ _. _._._. __.. . .�.. -�. _ . . .. . . _ , �.— .. . ,...._ _�_� . : � , .. _,...;..i... .I ' 1 I : �.•J-.; 1 r�i�: - �. .. - i Energy InsulaGon _ _. ._._ _-._._ ' ` ' _._'._ .'_._'.__... _ . . . Lath/Drywall- (� — ' . � .. . . ' . . Inferior Y , � .� . ..� - _ ___ _-.. .__.____ _ . � ���� . - ^- Lath-Exterio- . I . . .'. : ... � � � .� _. --. . . . __ . . . ., . : House Number- .' . � .. � .. . -�. . . . . ' , . ' __._ _ '... ' '.. ___ .. ..... _.: . ., � ... . �..::• r�....�, ... � CorreU&Postsd I .. . .._..�� .. .� . . . . . �� . , . ' . ... . , ,. Final- —.___, " - Enter on Front � ' . . .. . . . � . � .,. . . � . . -. � , . .