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HomeMy WebLinkAbout1104A (5) WORKERS'COMPENSATION DECLARATION � Ihere6y`afFi�m�hai I hove o certificate of consent to self insure,orotertificaieofWorkeriCompensotion��,��a��e, APPLICATION FOR BUILDING PERMIT- or o certified copy thereof(Sec.3800,tab.C.) ,• COUNTY OF LOS.ANGELES BUILDING AND SAFETY Policy No. Company . ` ,`.,r . ,•.. • ..• ._. -r: . ,; � Certified copy is hereby{urnished. !;��, . �F,OR APPUCANT.iO FILL IN.. � ADDRESS �'�g/� �, ��.��Si�t-' �/7, � Certified copy is filed wNh 1he counfy bvilding in3pe[- BUII�ING . �IIOn depOrimeM. ADDRES$''�7 J�� �����6 Dare Applitani . CITY IN G U/ ' 2iF•- O tOCAtiTY Lt�c(In�,! CERTIFICATE OF EXEMPTION FROM WORKERS - � :�''�"'NO:OF BLDGS. ' NEARE57 _ � COMPENSATION INSURANCE SRE OF LOT. - NOW ON LO7 �� GROSS ST, (This seerlon need nol be eompleted if the permit le for one � �'����' �'• A55ESSOR hundred dollars(E100)or lesa.) TRAR ' 6LOCK l0T ND. Mq7 gpQK VAGE VARCEL I teRify that ln the periormance af the work for which thfs r �}�� OWNER �G � � N �� 1 USE ZONE � O _—�Z permit is Issued,I sha�l not employ any person In any manner AOORE55 C�• KI � CONDITIONS � so as to become svbject 10 fhe Workeri Compensation laws. 0 oa�a Applicant UTY L<1 L/U✓ �/�I' zic / P a` NOTICE TO APPLICANT: If, after makin �this Certificata of ARCHITECT OR TE�• DISTRICT GROUP TY7E FIRE PROCESSED BY �7 g ENGINEER NO. CONS7, ZONE U Exemplion, you nhould become sub�ect to �he Workers' 7 p !J �y Compensatlon pfovi�ions of The labor Code,you musf forlh• qDDRE55 v K-� �cT(✓�'rr� �/ %� W with comply with avch provislons or this permN shall ba TEI. STATISTICAL QASSIFIGITION AaT. CONDO. N deemed ravoked. � cONiknCiOR n10. '�� Z LICENSED CONTRACTORS DECLARATION .UC.- CWSS NO. �.�L_DWELL.UNITS � 1 here6y offirm that I am licensed under provislons of Chapler C ADDReSS NO. ��R�P (commencing wlih Section 7000)of Division 3 of ihe Buainess and .���, Prafassions Code,and my Iicense is In full force and effect. � CiiY -CtASS BK � YALIDATION � 5p.FT. NO.Of NO.OF CHECK License Number Uc.Class SRE � STORIES GAhULIES ONE � � � � � VALUATION CaMto[tor po1B DESCRIPTIONOF WORK � A D Q s /�GQQ �I am ezampt�nder Sec. � � , � ALTER B.BP.C.for fhis reasan � �'So e'* . STo n REPAIR ❑ _ Date: Ex15T�ING BtDG. �EMOL '�1 1 Q�t A SlgnOtVte ' APPLVRINTT Np. FINA (� #• • • • • � OWNER-BUILDERDECLARATION DATE�, L�� I heraby affirm that I am ezampt from the Confracior's licensa qD�aESS � FINAI � "�3 Q 5 0 Low for the following reason(Section 7031.5, Business and Professlons Code): ' � 8Y • • •3 Q 5�� BUIIDING I, as owner of the prapeny, or my employees with qDDaESS ., � ,-�+��F�`.,�} �Q� 3_$7 � woges as Iheir sole compensotion,wlil do the wo�k and i���TY � � �'`� 1 �"�•� �;' tha structure is not intended or offered for sale(Section 7044,Bvsiness and Profess�ons Code). 7atOviNG 1Ei. . � 1,as owner of the property,am exclusivaly conirocting CONTRAC70R NO. with licensed contractars to canslruct Ihe project(Sec- qODRE55 � � tion 70E4,Business and Professions Code). � - CONSTRUCTION LENDING AGENCY SE7�BAC� �ARD HVJY � T�TApR07 LINE Wi�TH � I herehy affirm Ihat Ihere is a conslruction lending agency for FRONT . Ihe performonce of Ihe wo�k for which Ihis permit fs issued P.�. , (Sec.3097,Civ.C.). SiDE V.l. Lender's Nome C �� LDAM Ref.N � � P.C.fee S Permil Fee � ' Lender's Addrass r�5 � I cerlify ihot 1 have read this application and slata that Ihe lisuonce Fee �� 'l v tDMA P/C M . abova Informolion is corcect.I agree ro tamply wilh all Counfy Invesrpoiion Fee 2� $ ordinonces and Staie laws relming to building wnztruction, ioiot Fee .N' S0 IDnM pe.m.i� nnd hereby authorize reprasentaiives of Ihis County to entar upon tha obobe• e ne ropeny for inspectlon p poses - , . � A , _��� SEE REVERSE FOR EXPLANATORY MNGUAGE Slgnaiu o Applicofr or Agent Dota � PlANS TO APPIICANT INSPFCTOR'S NOTFS , OR'nh:H-fS1�11.U1?H UBCLANA'l70\ ' ' � _ I hereby afLrm 1Lai I�m rx�mpl from Ihe Cn�!�n+ro'4 � Toc � Retornvd � �. . � � .. - License la•+v lur the (ollowinry ren;on,� (Sec�7091�5) - ` APProved � Uurrnrsa rtnd 1'rnfe�rir�ns Cndr:Anv ti[Y��r<nunty�rl�ia! No. Oore No. 'Dote � � �,���G� 1�11.e -�q �'� rcyuirre�o�rrnrit!n rnnrfnrrf.u!lrr,ior�,rni�e,JemoGs/r, . -. .nr rcfuir any arrucRrrr.�rriur E�,itc ic�umir<�,ulan rrquirrs . _ _ a++._..��.n . ....�� ��, Il e�/,�,li:mit for sarb�p�vmit!n file a siS�n�d smrr�,�e,:r Ui W�r�W�� 1 1 ' j , , [!ut I e is(iirns�`!fursuont folbePru�axir�ns q/t/,��(:�m. . - �� "l _ �l� r tr�.tnr'.�i.;��•n„�r.�a�rr:i,,,rr��.��r��,,.,,�,�•„�,n���,���1ca�' �� ti��n 70011J r/U�rivun 3 oJ tAr liusiura,end 1'ru/rsuun� _ _ . _ . . . _ �. � Y ��, �` �-� ` ����~'.__ _. Cndr/oell.�al b�ic exenrpt therrJrum unJihr Fn�rt/nr[br �� �——�} a!lr,�rJ rronrptinrs,Any vi��l,atinn r/,Sctlinn.7(131.9 br - . - ' -Raquirod - - DateRoccived.- .. .- . . . �� unl'up(�liratttf�rafcrnrrtavhju�ltll�rapfli�unfln�:iril � nnaltp n/'�nnt nmre el mi rre Landred Jall�es(S50(N.: '. Approvals ar Approved ' —� -�-'l' f I � � Yos No � - . - - (.j I,os owner of rhe o eri� or m em lo•e�s with __- -- __ ��..r:�'•, i' P� P V. Y b ��- Wo�nr Cr�bhcu+e "v ~,�� • � -`1 �` • - `�, .•'Sr'�. , `�+�ges as Ihe�r sole compensarion,wdl do Ihe work.and �, ��\':��;A`��C'� �,��(�, ' , ihe srruuure is nor�ntended or offe�ed fo�sale(Sec 7D41) ;.l3urrreexs amt P�n essions C.nJe:7Rc Contrre'mr's l.iccnse Heaqh Dnponment . . - .. . . -` . •. • � . � � , . � . • �",1���•\' Y:J ^��'1*.,�`tl�}\ l.aoo dnca nof uA�lv t�i�n na��ner�f prnprrty a•1�n huih/c r bn�r rrx 1Lerenn,und u�/o Jues srz�b wurk:l+inrse! or Fi�e DepartmeM . - - - � -- . - - / � � � "' �� /lrrauRl l�is oi��n amplqt'res.�(�roriJeJ tJwt eur5�i�n- � G•ad.n� ' , . /nnrrments nrr nnt irelendad ur f�•rrJ Jur�salr. !/, . Gn«�r�rr,!hr biiilJin,q or inrpmncnicnl i.�iuld e�•itfiirt nnc Geolo97cdl _. � � - � - � ' '����rar n(cnm(�letinn, the�'nsrner-hriild.v milf lore ehr . .. ._ . .__. . _ . . _ . !urJrn nf prm�in��tLar be did nu!bvilJ nr irnprore fnr Pedestrian Prateclion " � � !hr/�ur/�nse oI�alel. ' . . � .. (Fence)(Ca�opyl �� � ' " �� - �� '- -�-'�' ' - ❑ I,asowneroFlhcpraperty,�amecduvvelycenrr�o- '� , �ting w�lh Lcensed mnlroctors io consiruct Ihe project(Sec. Sprcial Inspection . _ .- - ,. . � -- ...-�--�-� " 704a)11r�sine:s anJ Pr.r/esainus CnJr: "1'l�e�Cnntractn>'s (Conc.I(h1asonryS(WelJmg) � ,__ . � . . . ' ._ _... . l.itcnsr I,a�v J�ies nn1 u/�f14�n un au�wer r f froferlY u�bn , . � .....huilJs n '�nprbrrs tLcreun,unJ u�Lii riintra�[s fur suc! - ri lot Dm�nage ', .. . ` . - ---. . . . -- . . . projrcts u.•ith ¢ tuntractnr(sJ Grerin�d p��rs�ant tn 1hc CS.�? �aSJ,\ : \1'��t.\j+\_'�C Contrurlrir's l,icrnsr l,au�l. --.... .._.' ... Farking . . , . , � _... , _ . _ _ - . _ '� � ' [_� I om eaempt under Sec. ,B.&P.C.fo��h�s , . .. . . . ._ __._._._ .. . .... _ . ;, ., -:� i i . . . reason � ,- . � . . r :; ; ' __ _ ___ ._.� , . __Date . .._ . . .Owner �App.orals � Dofo lospaclor's Sfgnatvre � � � , . � � � � INSPECTOR'S NOTES-� Loco�io.+=- - . , , (Se�bnck 8 Yqrds) ny A'y� - . . . . . . -_ ". - - ;��� Foondations V�V1,''D� _ . � � _� _ . . . .. Slab . . . . .. . . .,. � , . . . Frame Energylnsulotion ' � - � �� - -- - ; . , ' .. , .� , La+h;Drywail-- .. . . . .� _ . Imcrior ..- .... � . � . , ' . lalh-E.fer�or , .. ' . .-- - � - � . Houce Numbe�- � � � - � � � - � - - - - � Cor.c:t 8 Pos�ed ' - .. .-- ��-- ... -- .. . .- . finb�- .. . . . . � . . . . ., � Enier on Front � � D � 't� S23��. `�--" � � : , -.. , „ ,- y� .�., ,,, ,.,`. ,� , �,, , --- - -,; .