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HomeMy WebLinkAbout1610A ��/ WORKERS'COMPENSATION DECLARATION - , � ' �` � _ � �- � I hereby affirm 1ho1 I have a cerrificore of tonsent io aelf � �pp��CATION FQR �BUILDING PERMIT insure,or a certifico�e of Workers'Compensotion Imvronce, or o cerrf�ed capy ihereof(Set.3800,�lab—.7C�.) COUNTY OF LOS ANGEIES BUILDING AND SAFETY Policy N���Company_J/f��� O Certified copy is hereby(urn�shad. FDR APPLICANT TO FIIL IN ADDRESS '�-D 8 n � �. � Certified opy is filed with the county ild' insp BUitDiNG � tion d ortm t. ADDRE55 — Date Applimn CITY �� 2iD / � LOCAIITV CERT ICATE F EXEMPTION FR KER SRE OF�Oi NOW ON IOTs C OS555T. 1'.�C ` `�� � COMPENSATION INSUR CE 27.�t � (Thiz setlion need nof be comple�ed i Ihe permi�is one TRACT 37�O BLOCK LOT NO. / �ESSOR hundred dollars(E100)or less.) MAF BOOK VAGE PARCEL TEL. USE ZONE MAP OWNER � I certify thaf in the performance ot the work ior which this N� �_' No. v — � � permil is issued,I shall not employ any person in any manner qDDRESS SPECIat � So as to 6ecome su6ject ro the Worke�s'Compensafion Laws. CONDITIONS � CITY 21P // S U Date Applicam �v � NOTICE TO APPLICANT: If, after"making this Cer�ifi[ofe Of ARCHITECTOR El. DISTRICT GROU� TYPE FIRE PROCESSEDBY Q Exemption, you shovld become subject lo the Workers' EN�iNEER O. � CONST. ZONE F— ` Compensafian proWsions oi ihe labor Code,you mvst fortb- ADDRESS � Q 3 �• W , with comply wilh suth provisions or Ihis permi�sholl be �" � /�'�-��J Q deemed revoked. TE�• S7ATISTICAI CLASSIFICA710N APT. CONDO. (n CONTRACfOR NO� = LICENSED CONTRACTORS DECLARATION ���, CtASS NO. DWFLL.UNITS I hereby offirm Ihot I om licen3ed under provisians af Chapfer 9 ,4�OVE55 NO (mmmenting with Seciion 7000)of Division 3 of tha Business and ��� SEWER hWP Professions Code,and my license fs in full force ond eHeU. � CrtV CUSS VALIDATION � �/ Sq.Fi. � NO.OF NO.OF CHECK BK.� � PG. LlCensa Numbef ��j liG.[�a35 SRE STORIES FAMILIFS ONE . /� �y1 VALUAT�ON Conlractor�0 �%// ��G pa�e DESCRIDTION OF WORK . `n ; /� ��^ ♦ D � � ❑I am axempt�nder Sec. � L�R ❑ B.BP.C.for fhis roason �f"�''+`� �` /-'�--�-��- -3 O REPAIR � s . . �� (��.U� . �e: USF OF EXIS7INGBLDG. DEMOL ❑ ,p • • � e C'C�^F Signatur - AP7LtCANT TEL � FINA I�� � '�.. R DE ECLAR PRINT rv0. . I hereby aifirm that I o exempt from the Comroc�or s license � . DATE � . o �y�,�J` law i0r fhe follOwing reasOn(Settion 7031,5,Business and ADDRE55 � � . � Professions Code): O r ' �—�7 ❑ BUiIDING I, as owner of ihe property, or my employees with a�DRE55 r ,� . waga�os their sole compansation,will do the wo�k and . � � - j�,j�� �he strucfura Is not imended or offared for sale(Sec�ion tOCnliiv � ` 7044,8usiness and Professions Code). MOVING � TEi. .p� � CONTRACTOR NO. ��! r'�I I,as owner of the property,om exclvsively comrocting ; `,, wtth licensed tonlracfors to construct the project(Sac- qDORESS � - � y tion 7044,Business and Professions Code). REOUIRED TOTAL iB K t�� t � CON57RUCTION LENDING AGENCY �T gq�K YARD HWY pppp,�WE WIDTH ' �5t ,.t,'� 1 hereby affirm that ihere is a mnstruclion lending agency(or FaONi �'�':�i� tha performanca of the work�or which ihis permit is iasued . P.L �� ' (Sec.3097,Civ.C.). . SIOE - �,;� v.t. � i�'t�, lendm's Nama � � '`' lender's Addross " - � P.C.Fee f�� PermB Fee 7� LDMA Re},H �� 1 'r .t:: � 1 cenify Ihat 1 hava read lhis applica�ion and slate that�he laauance Fee �D.� J �pM,q piC N �.,�,: a6ove informolion is corroci.I agree lo mmply wilh alI Counry In�ev+garon Fee r � $ ordinancas and Sfate laws relo7ing to buiiding construction, Tofal Fee i.a V IDMA perm.M � �and hereby o (orize re tatives of�hi nty to en � i � u n the van� pert ction purp es. r� � � 7 SEE REYERSE fOR E](►UNATORY LANGUAGE r Sign of Applicom o gen . , , f/� . /, FLANS TO APPLICANT INSPECTOR'S NO7ES ..O��'�lili-IlIqI.U1fK UCl'.I.AkAllO\' � I hereby,offi�m Ihai I om e.empi trc�m the Con��acta�'s � ' To: • . Hefurned ' . �� . . . . ' lia isc,Law fo. rf,c �ollowmg r ....(Src.�70J7 5i ' . Approved � . .�Iliisirersc u.rd 1'� is�ion��(;ude:An rcit r .. , .. .. �1 r r.,..,, nes��rbi�l, No. oere No�. - -Dof��� �- � . . - . , � ,ieyid cr'a(;�i n�r�o ronsrn«�a✓Rrr,lw(��� ��kJ��nrnlBl,. . .. .—., . .. . -•-��i�rrr/riirnni-sinldinr.'%�rinrbrif;is�van,e;rdlinrryuirre . - � . . . - . � 16e appGc.,�,r Jr,:.��,cb����.n,;r rr�/J1c•a sr,pnrJ sr.;rr����•n� '... - . r._� .._' _ .-_ _` .'_. _.. . - . ! / '! J / . , '. ._. _ . _._. ��.�\%, �_,..,. ,_,''\' .:.` ..,:.�:�. , ��'� �"_. . � .,1ru�r1nr4'�i�rr�c�f.���(Cleph•rt')1(�+ c r �lt!(.1.1. _ ... .._. __ . . . - ". � , � . . ; � � . . .�. _ .. ._ . .-. . _ _.... ... __ � - . �..' .. ��.' ` ._'i�. ��_.�'_�.' . �lrJ prr!lJI�(I f'It'<''C�hl�i'!I'1`YOI\s)A �I fT�PS/ r 11�e �';! r/r ., , , `� \ullr,grd crernptinn.ilnv�rinlation n%.lrrtin�r:l/31.5 1,�. ' ,_. ' Raquirad � . ' ' . . . .. ` '•.' � ' -.-�. .. . _ _... .`rtvapplic.�nt/nrn/crn�itruhjer[s!lr�ppli�anl(naiird ._._ _ .__ . ._ ... _.. . • � - Dato Haceived � � � � • � APProvais ��Yes _No or APProved� , � . . .. prn�!!Y n(nnt rnorr thu J �r Gvadrerl Jullnrs/SSbOI•J `.- - - ___�__ . , � .��.._ -. .-\� , �•` . . f.\ . �_� I,ns owner of the p�oper�y.o�my empfoycAs w�i+h eVo'c�Cerirf�m�e ' . � . . __ . ____ . ._ ... ; ��, ��. -•.� •'_ ..... . .`-:._- . .• ... - . , wogr.s os their sole mmpenso ion,Ni I do Ihr wor .a�d 1 I 4 ' � t - � ..�ihe s(ruuure n nm iniended o�o#fe�ed fa�sute($ec.7041; Hen4hDcpn.rmeni .__. . . __ -�.. ..-.-`.- . �.: _ . _. . ._- _ . _ _... _ _ . . ...••...�... �. - . �. U«rirtrssundPrn/rssim��CaJe:l'bcCr�nhart�v'sl.i:rnsa . � l.a:o dnrs nor uppJv in arr.nvner n��,,,�rrh��rL„burlJ� . . Fne DeP�riment " , -- - ' - ,._ur irnprni i�thcrr.rn,anJ��I ri Jors su!�u orF biruscl/nr ' ��� : . �� ,C_' � . . � rl rou,�G Li� mm� ernptqyro�.�.�rn, d.J tl Jr��st,,b.,rr- � G«uiing . _ �..pret�ernerifs arr nnt irslrndrd nr o//errd/nr�snlr.�f/. . - . �. , '[mu•ee�er.tl�e 5vildin,q nr inr/�r��numrn(is snlJ i<+!l in one , 9� '' Y��r i�/rnn�plcti�rn. �U c�nu�ner-huildvr irif!Gnr r tba• Geolo rcnl : � .� � '. . . , . _ , .. \���?---\ . . ___. burJrn n(prnvL���hu1 he Ail/nnf huifJ or irnpm��e fr�r PF e cer)IConoPY�non .. ��'�.: . ... . :, ... `�',`•� :..`,C;. _^`..�• �.l `�,, .a_ . _ . . � rl.`os,owner of tiie property,am eKdusl�ely�coniroo e! /� �� , �iing weh licensed contraUors to<onsttuct�he pro�ec+ISec. . -.. . -__ ` �- .�r_.. . ..- �`.�; � :'_.�. � . ".'.. 70na)U¢sineu�nd Prnhssrnut Cud<�: '1'bc C�+rrtrurtnr's Sprtcinl InsPeuion � - � � - �-.::� . ".� �.� \ .; , �'. . . �Conc.)(h1asonrYl(VJeld��g) ' , ... . - , . . . . .. �� � . . .... _ /.icrnccL.�ioJ��rsm�rsp)li! en;,u�uervJQrr�ferhuhn - . '..huif�fs.+�.jmfrores!lrerr n,a id u•bn i'un(rucle Ju n�c! Loi Or�inaae �'� ' �i �.,�` .. . � � � - . �� ... .. � .- .� �\T�!' J rts udtl,u tnrstlactrv{v).licims 'I:prirsu�inf to 1he .'' . .. . .. ' ' . .�``���, ... �.. .. -� , �,...C��ttlTfl<liii.i I.iC('/13('�.tlY�.. .. . . : . ��..��.. � .. Fo.king . , . _.___-___ . .. . . . _ . -- . . .. ... r �. _ . � . . . , .�.'s . . .. . .�_i...�ameaempiunder5ec .8.8P.C.to.�his . . � . . ' . . ieason• . .. ... . ..._..__.: .._.___. .. ._ . .._ � _- . �... . _.... . .._ .. _ . � ' . . . �-Dain ' \ Owner ` .... . � .._ .. ....._�_ .. .. ....._.._..... � � � . ...... •_ . .__ . / . '_ _ . . ��.� . \`. '. . :INS.. \., .. . Approval� Dato I spedor's S�gnature . . . . � � � PECTOR'S NOTES �- � Loco��on- . ..._—�._—_—. ._ ' . . ""' ' `� . ISe�bac4 8 Ycrds) _.__._ __ __. : - .� . .. � , '-". � FcundoGnns - ' �� ' � � � � . i . .__. ... ._. . ._..._._ . .._ . _.. . ._ ._. . �. , .� . .. .,„�., Slab � ; ._ . ._. . .._. . _ .. . ._____. . .'. _�.. � .. .,, . �, _ ..... ., . � .._' Frame - . � � � . _ ��.. . , , � . _, . . Eneryy Intulotion � � �'-- '- � � -' �- . ' ', . . �. . . _"_ .__.. .__ .._ .. ... lnih:Drywall__ � �. __. . - . . . � ...__. .. ._ � ,-,,. , , , ,� .,.:. ..,.. , INcrior ..__._..__.. _ . I . . . .. lath-E.�enor �A�� I ; . . I ..:� . . .I . .. . . � . _._. . _ . _. _, ._�___. . .___.__ .,. . , � . 'yy _ . _-.__..___. .. . . Hause Nomhr.r._ , � , .__ . ._ . .. . ..__..�_ .. . , . . __.__._____'.._.. __._. Cor�ectBPos�ed � "' . ' '., ._'-- -. . .__-_ . ______ ..._. +-- � � - �. F�nN. - . . _ . . . _ , Enre.on fronr � -- �� .... - �� . .. ..�� . � . .. � . . � .. � � .... . ,...� ... . _ .. , � ��. .. ' , '. � , . ,�: .. ' � � ' . . .-. - . ' .`•. . \ . . . . . ^.�.. � :`. . � .. �.__. .. \ � .