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HomeMy WebLinkAbout1021A WORKERS'COMPENSATION DECLARATION � � - � I hereby affirm Ihat I have a rertiiimte of�o�=e��,o,e�f - AP,PLICATIO.N. FQR BUILDING PERMIT - insure,or a ceNiiito�e of Workers'Compensalion Insurance, � � � or a���certified copy ihereof(Set.380/0,�_1ab.C.J) COUNTY OF LOS ANGELES BUILDING AND SAFETY Po�f cy N���t�'��Compony L���I�A^u✓�c'— � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ����� �� Certified[o s filed wi�h the munt buildin ms eo- �� GN py� y 9� p BWLDING 7�s�,0� /' � ��ondepartment. ADDRESS `"'�/ Ch� n Dale Applicant CITY��A�- ZiP �p�q��7y /J�� /y� CERTIFICATE OF EXEMPTION FROM WORKERS' - NO.OF Bi�GS. nIEAUESi / COMPENSATION INSURANCE - SrzE OF l0T NOW ON tOT fROSS ST. P_�-�/�`� (This section need nor be complefed if the pe�mit is for one TRACi�37�9 BLOCK LOT No. �ESSOR h�ndred dollars(EI00)ar less.) lv1AP BOOK 7AGE PAR�EI /��/'' q� TEL. //� USE ZONE MAP pWNER /N[c�.� �YO/i� �.p. NO. L���� �p I certify Ihot in Ihe performante of the work for which this / A� �� �� r permil is ISsued,I shall n01 employ any penon in any manner qDDRE55{ Lf'��/OlLI/7L��Li'FZrf SPECIAI . a� so as to became su6ject lo the Workeri Compensatlon Law:. GONDITIONS � ��T� c�✓oo,� �-c Z�P 4145$-7S.?o �: Dare Appticanr ' �: ARCHITER OR/ - TE�. L,Q DISTRICT GROUP TYPE FIRE PROCESSED BV O NOT�CE TO APPLICANT: If, after making�Ihis Ce�tifimfe of ENGINEER l�7�� �N�7✓+l� N0.2�^Tp�`�' �pNST. 'ZON H� Ezemp�ion, yo� should become su6ject to the Workars' / �+ �y--� V Compenso�ion provisions of Ihe lobor Code,you must forth- qDDRESY 7rO G�j�LCI-Jl� ! W� wl�h comply with auch provis�ons or ihis permit shall 6e d` deemed revoked. TE�� STATISTICAL C1A551FICATION APT. CONDO. tn CONTRACTOR TGUG� N�� ��NO.��WELL.UNITS Z LICENSED CONTRACTORS DECLARATION - LIC. � I hereby affirm thor I om licensed under provisions af Chapter9 nDORESS NO. (commancing with$adian 7000)of Division 3 af the Businass ond ��� SEWER MAP Prafe3sions Code,ond my litensa is In full force ond affect. CiTY CU+55 BK � VALIOATION SQ.FT. NO.OF NO.OF CHECK U[ense Number LIa Clais SRE STORIES FAMIUES ONE " � VALUATION DESCRIPTIpN OF WORK�T� NEW � Controc�or Dafe � ADD � S G70U , ❑I am e■empt onder Sac. - Ey��sv�� ALTER � B.BP.C.fOf fhi5 r0050n REPAIR � s Date: USE OF DEMOL EXISTING BLDG. � Signafure - ' APPU[ANT TE�� FINAI OWNER•BUIIDER DECLARATION 7RIM No. qTE, � ��j <� O 2� A I hereby affirm thar 1 am exampt irom the Controcfor's license Law for ihe following reason(Section 7031.5, Business and ADDRE55 �FINAI ' �}• • • • • � Protesetons Coda): by � I • •4�i,2 Jr ❑ BUIIDING 1, as owner of�ha properly, or my emplayaes with nDDRE55 wages as their sole compensation,wlll do the work ond i���iv � � • • •�i 9 2 5� Ihe strocNre is not infanded or offered for sale(Section 7044,Businesz and P�ofessions Code). MOViNG TEi. � � 1,as owner af Ihe property,om exclus(vely contratting CONTRaCtOR NO. �Q�8'$7 with licensed tomractors to construct the project(Seo- qDDRF55 �ion 7044,Buiiness and Professions Coda). � - CONSTRUCTION LENDING AGENCY SET gqCK YARD HWY TOTApROP LINE W�DTii . I hereby affirm that there is a consrruction landing agency(or FRONT the per4ormonce of Ihe work tor which this pe�mi�is issued v.i. (Sec.3097,Civ.C.). 9DE P.L. Lender's Nome �L.�r' LDMA Ref.M P.C.Fee S Fermir Fee () Lender's Address � I cenify that I have read Ihis applicalion and state Ihat ihe Issuance Fee �U�1�'� LDMn P/C N � _ obove informofion is correct.I agree la comply with atl Counfy in�asiigauo�F e c+ y,g" ordinances and S�are laws rela�fng�o bullding construction, iotal Fee /-�/ "� IDMn ae.m.k and hereby authorize representatives of this County�o enter �pon tha obove-mnen�lioned properfy far inapecfian purpases. . ^ �//f�ij.(�,J''��s.�'T/ �O—i�v7 SEE REVERSE FOR EX�LANAiORY LANGUAGE S�gnature of Applican�or Agem Dote � e�n�is Te nrruca�ar ir�srecror,�s Nores 0�5'Nlflt•BUII.Uh:R UIiCI.AHA'ft0\ A I hereby ofhrm tLai I om e.rmpt irom the Controcior's To: .. � . • Relurned . � � il� �(�b � '�✓ Li<ense�tmn�'}or'Ihe �follow�ng rcason.' �Sec'70J1 5� Approvad �1 'N J•� 13usinacrandPrnfrasinnsCudr:An1'crlY��r.iiunl��u�Licb No. Date No. Date . . . . . ' �- , reyuiris�Trrruil(nrnnctru��t.uftrr,irnEvu�•e.'d.�mu(ich, ' - . . - �r rrfnir nn��slruttiirr,Jrriur to i[s i.auunre,ulsu rryu� c . . . ' - . , , I,. � , � • . 7bc�ppfi.,ent/or�aurlr prrnut tn JIIC A 3{QttPt�SIdIY�bCIt7 - -- t/u!Gc rs(i rnsrd/�ursuant tn the prnrisionr�/tl�e C.m- - _ � : .. na.i„r'x l.rrenxr l.nrlL'l�aprr.')1/<�iurmrnrin,l'ia•itL.5'c:- , l'n.n 7000/n/Uirisian 3 nf!he Husrae�s and PruJruinrss . . :. �,.�. . "_ .��� �. ..,�;• . _ .. . . -._ . � , _ _. . .. . _ ._. __ .�' '. � ___ ._ Cn<lrl�rtbatbciscxempteLe:refrnniaxdt/rFnsis/orfl�r uflrgrJ eri•nrption.Anv violotinn r f SrCtion 703 L S hY _. . . _� _�_. � -Ra9uirod DafeRateived. . - - -�-� -i-�- - - .+++1'�/��+li.sntfrrru(�rrnrrlrubjectttl�eafflrtnnfl.�acirr! � ' APP�ovols or Approved. � . penufeti'a/nnt nrnre t5un frrx bundred dnllnrs(SSbO/.J: . . � Vet No . . .. . ' • ' ' _. - . . �J I,as owner of rhe prope�ty,or my employeeS w�rh \Vo�er Crri�Gmre � . -_-_ � � • --- • . • � .. woges as ihelr sole compensahon,wJl do ihe work,and - --"- � _ ihe srrutWre is not iniended o�offered foi snle(Sec.7044) Hnahh Deparrment- � - �-� - �- - - - � � � - ' � � ,� (lusin¢is enJ Prn�ruianr,CnJe:7Gc Cnntrartnr's l.iccnsc . _ .;;� _ l,atv Jnrs nnt apflc 1n�n n�rrser u/frnfrrfv�al�u FurlJs Fi�e Deoortment . . .- or irnprn��cs thercnn,and udin dacs snr!u+orl:bnrtsr!/ur . � . � , , _ fbrou,�b brs nron ew/�/qyres,-�fimridcJ tLat rurh im- Groding , � �i � - _,�� :nrnrementr,are nnl rrttended or nf/errd Jur.aale. IJ, ' � . � , - . ..�.j��, �"Lnu•ener,tLeAuilJix,qnrnnproren�cnli.vsuldirithinnne Geologiml � . . . -_ . � - 'v � -�Yrar of rnmpfclinn, t!c nu�nerbreilder�mil!hnre�thc . _, _ -� - , burdrn nJ prnning thu�Le d7d noi b��ilJ or rrnprnrr fnr Pedestnon Pro�echon tl u(�u�nsr nJtale/. - -�� � (Fence)(Canopy) �' � � � - � � ��� � -- - - - � ❑ 1,os owner of the properJy,am ezduslvcly conrroo- . , , �ing wnh Ilcensed controuors io construU�he project,(Sec. $peuol insprction� - :. . . - ' � �� - - �- - 7044)Uusiness and Prn/esrrnns CnJ<�: 'Phe Cnntrar[nr's � (CencllMosnnrYllVJelding) _ .___ _ _ . l.itcrcsel.aardnes»nta`rrlY�nsnou�nrrrf/�ro/�ert�'u�Ln � � -huilJs ur imprnres lberenn,,inJ u�bn rnnlrac[s fur sud� letDro�nage � _ '� � , � _.... ....._ . . . __ . _. Qr jrrts u�ith a cnnlrartnr(,cJ li:ensrJ fursuanl to 1!e - `Conbadur's l.icense f,au�f.� .. Pn•king , . . . . . . . _ ._ _ . . . . _ ' ❑ I am eaempt under Sec. ,8.8P.C.fo�Ihis , ' , � reason �' . . . � _. ... . . . _ _ .._ _...._. , , Dare Owner �Approvols, Dcfe InspecTor'sSignoloro . . . INSPECTOR'S NOTES lncation-� . .. _.. _ . �SetbacA 8 Yardsl� .._ . � � �� ' Foundat�ons ` � � � � Sfnfr - � • _. __. _ . ._ _ _ _" ,. . . . . . , . ' ' Framc Energy Insula�ion -- - - "-- - --� � - -. � , . . � . lofh;Drywall-- . .. ... .. " - - � . In,e�ior - � laih-E.ierfor . �� . .. - . - ' Ho�seN��mbc.... . _ ' . ___. . . . __. __'_' _'_ . __ � Coneu 8 Posted � . . - . .. . Fin�l- . _ ' , _ . . - . . . - E�icr on front � ' - - ' _ � . . . . . . , . . - .