HomeMy WebLinkAbout0869A (4) WORKERS'COMPENSAT�ON DECIARAiION � � � , inzure}or�afcertiica�eofWokers''Compensotion��=�,a�e` -- ����APPLICATION FOR BUILDING PERMiT or a cenified topy thereof(Sec.3800,Lab.C.) ' ' � � . COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo Compony BUILDING � Cer;ii�ed copy is hereby fwnished. ' FOR APPLICANT TO FILL IN ADDRE55 �..Q 3� � Certified copy is filed with the toomy building inspeo- gUR01NG�og?rL � C ' ��,r . tion depanmenl. AD�RE55 T q Dafe ApplitaM C�N �^"�yLw� Ga' IIP �"/0 LDULIiY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtoGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON l07 CROSS ST. (This seciion need not be complefed if the permit is for one I� �i/ ASSESSOR hundred dollars(E100)or less.) TRACT t7 BLOCK t l0T NO. "1 Idqp gppR 7AGE PARCEL � OWNER �ut� �AN .C!]Q I NO.�' ,S�S�'�r USE ZONE �P f1'L � 7 3 I certify Ihat in the perfarmonce of the work for which this _ �CIA` Ll J permit is isaued,I ahall na1 employ any person in any manner A��u �08?l�• �. ���.dt�(.E �cy� CONOI7ION5 �� 2O� � so as lo become subject to the Workeri Compensation Lows. 7 O oare ,appucan, aTr LJc�1uc�' C"— na 9� � �yu�, V S� e� NOiICE TO APPIICANT: If, aiter making�thi:Cerrifimre of ARCHRECTOR TEL. DISTRICT GROuv TypE FIRE PROGESSEDBY � Exemp�fon, yov ahould become s�b�ect �o Ihe Workers' � EN INEER NO. /{�3 �pµ57— ZON� �'` U Compensatlon provlsions of the Labor Code,you musl forfh- qDDRE55 � " ` � �1� �� W wlth [amply wilh 3ueh provl51on3 or Ihif psrmit Shall be - TEI. STATISTIUL CLASSIFI ATION APT, CONDO. � deemed revoked. � CONTRACTOR �J'�2�1. NO. Z LICENSED GONTRACiORS DECLARATION � IIC. - � QASS NO. DWEIL UNITS I hereby affirm that 1 om licensed under provlslons of Chapter 9 AODaE55 nlo. (commencing wllh Section 7000}of Divialon 3 of ihe Busines�end _ ��� SEwER hV�P P�ofevions Code,and my license Is In full force ond effeet. OTY [USS gK � YALIDATION � Sp.FT. NO.OF NO.OF CHECK Litense Nvm6er Lic.Closs � � SIiE r STORIES Z FAMILIES ONE VAIUATION CO�IfOC�Of Dot� - - DESCRIPTION OF WDRK ' - � NEW � s 'OO�' �I om exempt under Sea - "�� A�d �� � �'3 ADD � , r�8'�l 9 R , ALTFR �'• s • •'� B.BP.C.for th�s reason ' _ REPAIR � f � � ' 5 USE OF I � ��:�S�� Date: - EXISTING BIDG. DEMOI ❑ O.�2 g � APPLICANT �.,/,�J TEL. Signature PRINT �� ��_ �`vV NO. FINAL � OWNER-BUIIDER DECLARATION Q � � DATE . . I here6y affirm that I om exempt fram the Controctor's License pDOReSS .�-�r^-9� FINAL Law or the following reason(Sect(on 7031.5, Busineas and ' Pro eestons Code): � sY � BUILDING . I, as owner of the property, or my employaes with A�ORESS wages os iheir sole compensoiion,will do the work and the structure is not intended or offered for sale(Section ��'��TY � G�D�P� �U� � 7044,Business ond Professions Code). - MOVING- TEL - � I,as owner of the properly,am ezclusively conlracting CONTRACTOR NO. with licensed tontractors lo tansiruct Iha projeU(Set•"- qDDRE55 x-30��g tion 7044,Business and Professians Code). u CONSTRUCTIONLENDINGAGENCY �SEi�BACD YAR� HWY TOTApROP LINE �WIDTN � I hereby offirm�ha�there is a tonstruction lending agency for FROM ' the pe�formance of Ihe work for which Ihis permit is issved P L � ($e[.3097,Civ.C.). SIDE R L. ' lender's Name .n � �v,(f1O ioav.aef.M P.C.Fee S - Permit Fee / lender's Address � I certify that I have read this applimiian and s�me that the _ .i...ua�ca Fee � '�� �oha viC N - obova inlormolion is mrrett.I agree lo mmply with oll County Invesiipaiion Fea . ordinances and Stata laws relating to building construction, To�ol fee 0� � LDMA Perm.M and hereby a�thorize represenratives of this County to entar . y on the a6ove• ntioned property for inspec�ion purpozas. ( e � ' Zp i (9��I SEf REYERSE FOR EXPLANATORY LAHGUAGE SlgnoEu e of Appliconl or Apenf � pote � PLANS TO APPIICANT INSPECTOR'S NOTES .. O1\'I\IiR.11U1LUJiK Uh:C1.ARAll01 I here6y afhrm:hol I am rxemp�frnm�ihe Controcta's To: . ' Refurnod ^� . . . � , � license luw lur the.�ollowing r-n�.on� �(Sec.^9�'s-t-it' . . .APProvad � .. . lJrc�inrs�rsnd!'rJ.�scinns(:odc:An�f.cityor:uuntl'�+<d�i�l No. Date No. � Dafe' .. .... ' , .., ' . . .. � rcyuir��s n permit 7n rnnctrurt.ult�•r.impn�r��.drrrrnli<h, . . . . -._ .r rv/�ui in v.�tructurc,/�ri,r N�itc isaurrur,alsn rryairrv � � i-� . . - , ' � i�' - � tl r uppfi.'m�r J r surh prrnrir er�/i!e u si,enrJ smtemrnl i 1 � . .. , �" - - , -- , lGal Gr iz fi.rnsrd pursrsant tn fhr pruririnna nf the Cnri- . .!._ . . � _. . . o-a.�,i,•s l.;�enxr I,.�i��rc:r.., r<•.9 . � �R,,,,,���,�<�;n.�v�,r��sc�� . . _- - ----- -- --- - � .....----� . -- - - - rlon i00(IJ„/Uirici�,rs 3 nf ahr It,.siurss anJ Pr„/ra�t,�n: --. ._..-- � - �--- ' ', ,. .; . - .... �� - r, . .. . ..,.,_ __. � � , ,�. _. . .. .. .. ' __.C�+Jr/oralJtl�ri��r�mptfLerrJr.manJfhrFrrd��r,.lhr - — _ , _ ._ __..._ �. . ':: __Raquirod�'�. '-.�DateRaceived ._. .. . . �•.� '�. _ . ' _ ". unrY�/�Ql:Jnt/oraf rnritsubjrihll afpLwn!(h du�a! Apvrovcls . ar Approved penaltv n/nn�mnre tf�n/re Irundrrd Jnllm�/SSl�011' � i � .� ��. �_ . __ Yes No .___�'_.' ' ' .'_- � ' � � - - - � � -- � �� - ' - � (_! I,as ownr,r of the propr.rty,�or my r.'mpinyr.es wnh Wa�e�Cen�hmte '� ' ' � � .___ wnges os Iheir sole compensabon,wdi do Ihe worL,ond �.. . _..._ _ . . . _ _.. __ _ .. , . . � � - �- � � � �.�ihe struUure is not iniended o•b��ered for sale(Sec_7044) HeollhDeoanmen " : . -. .�. - � �� -. -. . .. ..-- '-- �. � � �. . -' - -� s u e:l/rcCnatr���tr�r'sl.icense ->. .. .. _ .. : _ __. _ ... ___'.. . ,.;,Uusinrss andPrnJcssiun C J � , � • Iw+u•dnc���,:ur�i,�,,,u�oumrr rvf propert�•u�!„�l�urld�� ' F�e OePo•rmem ,. --" � . .� . - -- � . . __or imf�n��rs tLvrrnn,�mJ�r!u dnes sui�L u��+rf:l.inn�r//nr � ' . , . ' .drroq�b (�is.na�rs rnrrlu.yees. prnriJed t1 ut .�urb�rm- Gr�ding,� I -`- • fm��emrnn�nrr nnt intended ur nf/cr�J fnr salo. !/, , � - - . :'bnearncr.tLe baifJing nr r�nprnremnn!is snld¢itbin nnc _ .. . . � . _ '- ' ._. ..� ...� � .. . . ..._ .�_..._ . _..._..- ' ' Geologiml � , . , ' . � . , . . .. '�.1'rar nf mmplrtinn,�1be n+t�nrr.6uifJrr +riJ! hair the - � .��' �� . hurJrn n/prnrinx rGar l�e diAnnr/wild nr i�npmrr/rr _. _.. ---_ .. . __._ ... ._ _. . _ .. . . pedestrion Protecrion � � . � � . . _� � . . . .�, 11 e/�ury',uac n�t�lr/.�. .. , . ... . � .. .. �.. , , �Fence)(CanoPY) , '� -- �"' - �---.. . ..-.--. . .. - . ' �;�I.�as awner of Ihe properly,am ezdusively contrac � — ling wllh licensed controcto.s to construcr Ihe pro�ed�Sec. .-. _ . .��.''_�_._.__ �_.__ _"".._ . . _ . .� 70a41 flnsiness and Pro%stinns CuJr:!hc Corslruclnr's Speaal InsPecfian - ..--, � , , ' - . � (Conc.l(MasonrY)(Weldingl � . __ . . . . . . -. .... . ... - Lrcense Iwau Juet nnf upflpin qn nu�urr J�„���.�,�u•c,n , . ' . - �huiJJs nr i�nprure.i lLereun;dnJ u�bnTuntrac(s jnr srerb Lol Ora�nage � .• _ "�� frujrcu n�ith n c�nlrurtnr{cJ literurd funuant !n tbc ., . . .._ . . _....... _ . ... . _.. .� . , , - . "�---G�nhur7ur's l.icen�e i,uuJ. - � - - - . Parking, � -. . . � ...__.� . . � . , ,�. ; .. ._ ._.�..... _._ _ .. ___'... ,. . . ' ' ❑ I om exempr under Sec. .B.BP.C.fo�th�s . , . . ' .____ . .. � ' . . - �eason ' � - .. . . _ , .; - .;. _...' . --.-_.. .. _. . ... _ ' . . Daie � � Ow -`.. Approvuis Dote � �Inspettor's Signofure - -: . � . . , . -. . . � , INSPEQOR'S NOTES � Lom�ion- . ___ ._ . . . - �Setback&Yards� , '- , ._. . � � . � .- - ._._._. _ .. _. ,. Foundaiions -- . �/ .. -�� � � . �.;. ��. �. � . . . . ' ,. i .c':� �.,- � � . ... _ . _.. ._..__ . . _ . .__'. . . � , . . S�ab " .. .......... ... .'--_ -....._-- � -"- " . ' .,' .. __ . - . . _ , � � : Frame `- - . . . ... . . . . . . .. . . _'...___ �_. __... _.`__ _._'�__.__ ..� � ... . .. Ener�y Insula+ron ' � � - - � „ . . . . . . , larhiDrywall-- , . __' ,__. _______.__'___., . .- . � , . .. . _... . _. ___.._-_.__, :� ". . � Imerlor � � � � larh-EM�enor , . , �, � . ___.. . -.___. _ ... �- .. . . . Hovse Number_ _ . _ _ _.__.. __ _.... .... '_ ...___ _. _.... _ _ .____._ _.___ _.. _ , . . Coneu R Posred • . � � �� ����. ..-����� �. . . . 1 —_ . Fmol- ., . . ._... �.__ .,...__.._ .. - �,. . __.. , , . . , .,�� • , En?er on Fronr �(' , � i