Loading...
HomeMy WebLinkAbout1023A � WORKERS'COMPENSATION DECLARATION �. � � I hereby affirm fhoi I hove a cerrificate aF�o�se�„o=e�f -� - APPLICATION�� FOR BUILDING PERMIT � ' insure,or a certificate of Workeri Compensa�ion Insuronce, or c nihe co y thereof(Sec.3800,Lob.C. � LiJ��S�v�J45'i / � ,/ COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo. Compony K�"G� �K+4-+��c� � Ceni4ied copy is hereby furnrshed. FOR APPIICANT TO FILL IN A�REss Zo7Y�{ Ch�iC l.✓ Cerfified copy is filed with Ihe counry building inspeo g�ilDiNG !� /���. tion departmenL ADDRE)S�S�z d�7 ��K"�/ �� Da1e Applicant Cirr /7/ L (/T Zlv ipU+IITY Yld� /,7.4i` CERTIFICCOMPENSATIONIOINSURAN EORKERS' N0.OF BLDGS. . NEAREST �!` / !/S SIZE OF lOT NOW ON LOT CROSS ST. o c.� L �� (This secfion need no�be completed if�he permi�is for one �ES�OR ' hundred dollari(E100)or less.) TRAR�l37!$ BIOCK l0T NO� hLqp BOOK PAGE PAR�L OWNER /yJ � ON �-O. T E�7/ USE ZONE NWV witc; No. 33-3 /a z 3 Zr 1 certify thoi in ihe performonce of the work for which this � }7 NO. permi�is issued,I shall not employ any person in any manner pDDRE55I� �IGOQI lG�j� S�Epai �i so as to become subjea to the Workers'Compensaiion laws. CON�iiiONS 0� ��TYN�u.o � z�P9.��s6-7s2o �. Datc Applimnl - 0.' ARCHITECT OR /7��� ,y�� TEL./ NOTICE TO APPLICANT: If, 4(IEf mOking this Carlificale of ENGINEER C�(/�'R/� NO. �� DISTRICT GROUP TYPE FIRE GROCESSED BY � Exemplion, you should become su6jecf to fhe Warkeri q /- /J �/J [ONST.�[/y�• ZONE V' Compensation provisions af ihe labor Code,you must forth• qDDRE55�/� GIQ'� ��H"[/tq/�l�C� �-- / � '�"— Y � W with comply wifh soch provisions ar this pe�mit shall be �-` Cleemed revokefl. TE�� STATI511CAL CWSSIFICATION APT. CONDO. Z CONTRACfOR GUGL Np. IICENSED CONTRACTORS DECLARATION ���,- . QA55 NO. ?�� �WELL.UNrtS�� — I here6y affirm Ihot I am licensed under provisions of Chapter 9 ADDRE55 NO. ��R�P (mmmencing wiih Seclion 7000)of Division 3 of the Business and ���, , Professions Code,and my license is in full force and effect. CrtY Cwss � BK � VAIIDATION � - $Q.FT. NO.OF NO.OF CHECK License Number Lic.Closs SIZE STORIES FAMiLiES ONE VALUATION DESCRIFiION OF WORK� NEW COMroCtar Date �y ADD s � L�� , �I am exempt under Set. ��«'OSv/�5 ALTER B.SP.C.for this reason REPAIR s � � Date: use oF . . EXISTING BtDG. DEMOI Sig�a�Ura � ' APPUCANT 7EL. - FINAI s OWNER-BUIIDER DECLARATION vaiNT NO. DATE��27 Jr � O 2'3 R I hereby affirm that 1 om exempt from the Contracror's License � �� ��� � �� Law for ihe following reason(Section 7031.5,Business and ADDRESS FINAL � � Professions Code): . - By � ❑ BUILDING � • •4 9,2 5 I,as owner of the properly, or my employees w(th AD�RE55 � wages os Ihair sole compensa�ion,will do�he woik and � � � • • •G 9.2 5� the strudure is not intanded or offercd for sale(Saction ���ITY , � 7044,8usiness and Professions Code). MOVING TEL. . . � C1 Q$—�7 � I,as owner af the property,am exdusivety contrading CONTRACTOR NO. with litensed contrac�ors to conehuct the projact(Sec- - qDORe55 ' � lion 7044,Business and Profassions Coda). CONSTRUCTION IENDING AGENCY - - SEQeACK YARD HwY T�TApROP.IINE wioiH � I hare6y affirm thm thare is a mnstruction lending ogency for. FRONi � the periormantc of ihe work far which this permit is issued P.L . (Set.3097,Civ.C.). � S�DE v.�. Lendar's Nama ' � q L,i f' LDhM Ref.M Lender's Address � - P.C.Fee S Perm1�Fee OCl . ' � 1 certify that I have reod this opplication and afafe ihot fhe . iseuonce Fee O� iDMA viC N � obove information is corract.I agree to comply with all County � in.e:iipouon Fee zr � $ ordinances and State laws relating to building conslroclion, Total Fee �S ioM4 aerm.M , R and hereby avlhorize represenlatives of this Counry to entar � upon tha oboJye-mentioned p./roperty for inspection purposes. � ����G7�(!kW �� '�`��l{.JCi I6"`��S/ SfE REVERSE iOR E%P/ANATORY LIINGUAGF . . Signature of Appl�conf or Agent pate � . . . ' PLANS TO AFPIICANT INSPECTOR'S NOTES . O��'hlilt•AUII.L1h:R UIiC1.ARA'PI01 I herrby offrtm ihal I am ezempt from ihe CoNracior's To: � ' . Retumed � , � , . �, licrnse Law for �he (ollawing reoson. (Sec. 7031.5 . ,ApProved . . . I)u.crnrssanJProlesSturySCb[IC:AtlyCitY���luutll�'IChid� No. Dato No. - Dote � . � . � . � . � reyuircs�pernrrf fn.cnnvruc�t,d7(rr,'inrpn. c;dern'riliib. . — _- — �- �rrcp�iira++ssfrurturr.hri��rtnitsissuuncr,�ulsarry:�irrs . . . , ' . . . ' . . , . . 1!c applicant fnr such penur!tn/i!r u xr,en��sraec�menr �. , " 1l�t br is litrnsrd purs:<un!tu!Gr prne•isiuns n/!hr Can- . .. ��:. . - . � .' - .�_ '... - . tra:(nr's I.iarrsse Laio(CGapter 9JRnmmen�in,G u�itJ�Scr- � - tinn7000/n/Dirisi.m3njll,rUusepe�sanJPru/rs�i„no �.`-. ' .• � � .. . . . ._)���..�•' � �� ..' CnJcJnr!lalhriscxcm/�1tLrreJroruanJt/rFnsis/r.r11�r . _ -. ..-�. . .. - u7lrgrJexenrp�inn.AnyvinlatinnnfJec[inn7Uj1.5h�. - �Fequirwd� pateReeeived . .. .. .. ." ... .. ureya/�/�licun!/nrapern�r�subjeahlbenpf(rrnn!!n¢rie•il Approvals or Approvcd - , persaltv�/nnt mnrc tfi✓rs/inc L.�,��r��d�t�,n�.:/ssrio/./: � Yes No . . _._ . ._ . . � . . (�� I,os ownAr of the propr.rty,or�my rtmployees wi+4 Wo'�Cen��.oie _. . � - - wages as their sole mmpens�hon,will do ihe work,and � . . the svuUure is not inlended c�offered ia�sale(Sec.70d3) Hcnfih Depnr�ment - - . - . . . . . . 13resinrss and PmJrssio+ia Ca�lr;Jhu Cun(rartur's l.icrn..r , .. \ _ I.au�Jnrs nnt arrl�•!n an n���ncr n/prnperh'ud„�hu7d� Fvc Ocpnrrmenr . . . - - , . . nr inrprores tbvmnn,and p�1 o Jocs s«�fi u�ork hi.nv//ur ;' . . . .. .. . . . � [/ruu,qL�Gh oa•n rrn/�lqt•��••s.-prorrJrd 11 ut ru.{ irn• G.�� � .. � . . � prnrements�arc nnt rrslendeJ or nf/rred/ur sule. !f, - .. . -.., . - Gnurrer.'d�eburldia,�orirnfrnnemrnfissnlJu•itbrnnne Geologirnl � . - ' ��r✓r n/mmpfcfinn, e!e uuwer-6arr1J�•r �idU Lnre thc _ . . . . . _ . '.'\ � , burdrn r�pmri�,�lhol be Jid na!build nr i.nprorr fnr Pedesman P.otecnon - 11 r/�urpnsc/salrl. ' . (Fence)(Canopy) � "�- � � - � � �-� .I,osawner of the p�openy,am exclusively ce�!roc� ling wnh Gcensed controUors�o construa the prolect(Sec. Spcaol Inspeuion . .. . ' ... . . ._. . . . 7044)Unsiness and Prn/essinns CnJe:7'!c Coritrurtnr's fCnnc.)(.MasonrY)(W'elding) � . _ . .. . ... . _ l.irrnsc f.au�Jnrs nnf�)rJl'�n an ou•rtrr oJrrnfcrh'u�Lrri � � � `�, huilds nr inofrorrs!)creun,und u�bn r�,ntrnds fur s��tb Lol Dromaqe . .. , � . . . - - �� - - prrjrcts u�it!u rnnfrurtus/a)�i<ensed pursuartt tu thc - ��Curc trai�nr's l.rcrnsr l.uu J. - va.kinq . . � - . n I am exempt o�de.Sec. .B.BP.C.fo��h�s reoson . . ., _ ... _ . . ._. _ _ . Date Owner _ . . .._. .. . .. ._. _. . . . _ r . . _- � __- . �Approvdls ' Dnte Inspv:toi s Signafure , , . � 'IN3PECTOR'S NOTES lc<uhon- . ' � � . . - . . (SetbocL B Yordsl ��� !�I - � --- - - � � ..._._....._.._. �. . � L�-- Fcut"��IionS ". . � ' . ' 5��� flOI�1¢ . . . . . . . � ' . EltE�f9y Il15ll�Ol�iO� i . , ' ' � "'. .. , La!h;Drywo!I__ .. ___. . . . . In�cr�or ' - � laih-E.renor � , . .:. . . . � ' ..._._ . .__. .. .. . .._. . .. _ . � � � HouseNumber-. . . .-." . ._ _.�.. .. _._.. . . - . . ... _ .. .. __ . ...._._. _... . Coneu 8 Gosted - � � ' � � �� F�nai_ . . . .. , . �. . , . . Enrer on fron� � � ' � � �o�T'C 3l e� U� ' , . . . ��� . • . . .