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HomeMy WebLinkAbout1020A (5) WORKERS'COMPENSATION DECIARATION � � I hereby af(irm ihat I have o certi(imte of�o�,e�<<o=a�f � qPPLICATION F�R BUILDING PERMIT inwre,or o certificote of Workeri Compensation Insurance, o.p$e,r$iqd,f�x��reof(Sec.�3000 lob.C.) ' - WC:Y b� �� ��r���� COUNTY OF LOS ANGELS BUILDING AND SAFETY Po�licyNo. Company Certified copy is hereby furn7shed. FOR APPLICANT TO FILL 1N aunoiNc �f� � ADDRESS G� 7'Jl ��.zs r � Certified copy is filed with the county building inspeo- BuaDWG �o7S'L� G72CST ��� ' lion deportmenf. ADDRE'SS,�/ Dofe Applicont Cltv YY.rtl G/(�// ZiP LOCALITY �/Q �J CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. NEARE57 . _ LOMPENSATION INSURANCE SiZE OF t0t NOw ON t07 CROss Si. ��C 4 I (This setlian nead not be compleled if fhe permi�is for one TRA�'f�3�1� : ASSESSOR �� � hundred dollms(E100)or less.� BLOCK LOT NO. /N,qp gpp�( GAGE PARCEL Jt J �/� iEL.7! USE 20NE N.°�P 1 certify Iha�:in the perfarmance of�he work for which this � OWNERy� , ` LO- MO. NO. • permif ts issued,I shpll no�employ ony person in ony monner ADDRE55�-[ �R�O CONDITIONS � eo as to become subject to�he Workeri Compensation Lows. ' � v/�elvOG � 4'' ur zia�!'2dSS-�SJ� �. Dme Applimrrf �� � NOiICE TO A7pLICANT: If, pfter making�ihie Cartificofe of ARCHITECiOq��,,_� TEl.7 DiSTRiCT GROU7 ttFE - FtRE PROCESSED6Y O ENGINEER L-///�Y �y NO. �s�—'F� [p ZONE �'"' Exemp�ion, you should 6ecome�eubject io Ihe Workeri �^ L M [� W Compensalion provisions of Ihe labor Code,yo�musl 4otfh-, qDDRESS I7S� ` DL�XF�E.T�C , C � ` with comply wi�h auth�provisions or thls permir shall be. �", deemed revoked- � . rWL C N� STATISiICAI CLASSIflCATION APT. CONDO. Z COMRACTOR UCENSED CONTRACTORS�ECLARATION � i��. C1n55 NO. �WEIL.UNITS I hereby affirm that I am licensed undar provislons of Chopler 9 A�DRE55 NO. ��R�P (commancing with Secrion 7000J of Division 3 of the Businass and tiC. Profeuions Code,and my licensa le tn full force ond effect. � Ci7V CLA55 BK � , VALIDATIOH � Sp.FT. NO.Of NO.OF CHECK Licensa Number � �`lfa Class � SRE STORIES fAMtUES ONE 2 VAIUATfON ContfaCfor Dale � � � DESCRIPTION OF WORK ` � a D ❑ S h i/0� v� ❑1 am exempt under Sea � �GG �(/�-� � , ALiEB 8.6P.C.for this reason _ REPAiR ❑ s � Data � USE OF EXISTING BLDG. OEMOI APPLICANT TEL. Signature FINAL �� �G� OWNER-BUILDER DECLARATION �RIN7 NO. pATE �j �'� �� ��� � � ,� I hereby effirm thaf I om exemp�from�he Contractor's License qD�Re55 FINAL Law for the following reason(Senion 7031.5,Business ond Profesetons Coda�: � � BY � • •3 6 7 5 BUiLDING � 1, os owner of the p�operty, or my employaes wlih ADDRE55 � � �g��5= wages as Ihair aole compensolion,wlll do tha work ond , `" the structure is not intended or offeied for sale(Section ����T� . �Q O 8��7 7044,Business ond Professfons Code). � onOvitvG TEL � � � I,as owner o(tha properry,am exdusivaly controc�ing CONtRnCiOR NO. wi�h licensed controcrors to construct ihe pro�ecf(Sec- nooae55 tion 7044,Business and Professiona Code). CONSTRUCTION LENDING AGENCV SE�eAC� YARD Hwv T��ApROe.uNE WioTH I hereby nffirm that�hera is a construUion lending agenty for fRONT tbe performance of Ihe work for which this parmi�is issued G.t. (Sec.3097,Gv.C.J. SIDE v.i. lender's Nome - . ZG.2 r' I�MA Re1.M lander i Address � P.G Fe�i va.mn ree � , I certify that I hove repd this application and slate thal the . Issuance fm /J�� �D1M P/C M . p6o�e in(ormpfion is coirecl.I ogree lo comply wilh all Counfy Investigation Fe 3 G• 7r ardinances ond Sfate lows relating to building constructian, To�ol Fee IOMA Ve.m.N and hereby authorize rapresenlofives of this Ca�nfy lo enfer upon�he obove•mentioned property for fnspection purposes. ���y�. ��� ���a� SFE AEVERSE FOR EEPLANA70RY LJ�NGUAGF S�gno�ure of Appl;com or Aqen� po�e � � � FLAPlS TO APPLICANT RlSPECTOR'S NOTES . Ol1'tih:K•ISUII.DI'.K DISCLANA'1'10� I ho.eby o`ivrn i4oi I a mpl from the CoNroc�or's � To: , _ . . Returned ` � , . . , . . lice s lm�v�f . �f e follow ng rco;o . (Sr.;.. 7031.51 APProvod . . .. ltvs .x unJPr f� r�ns CoJr:AnYdtt + nan7��e�!ieJ No. Do1e No: Dafe . . . . , � rey upen !f rurivfru�A.+ltcr,�i�hfrd�r:tlemabsh, . _ . - rr rrTai un y.�truc6ne.priur ta itc:c.i�uur:cr.aLvu rryuirrs _-_ - ' � " � � 11 c r/�plic�nt Jnr'�sn.b permit 10�IIP tl SI(HIfII Sf:llC1nf117 �. � . . . . ' . `. . _ _.. . , , �" . . . �. • . ;� . . . . �... . .. . . ._ -,.11�l Gr is L..rased purnuaut tn tLe pru�rsinns r f fl� (� - -� ' - ] ��`-\• ., . � . tro�fnrFl.erertsrl.dir(Cl�uptrr)//<�omman<�in,C�rit! Sec- . .. >. . �� - :,..� , ,� . ... ._ _._ _ _ . .. _ - ___._._ ._ ._ ._ .. . ...._ ..._��.. , tinn7(10lIJn/Ur�isinrc3.�/fbrllusinccvandPro/rsciuns� � . �..'. ' .. . . - ''�:'`���• : � _CodeJor tbat(�e is exempe rl creJrnnr unJlhr Fasis/nr tlre �... _ .._ . .._. - ':_. .. .. . . . . . ..__. . . r �...._._ ul(rRed cxen��+tiun.Anv cinlatinn n/Srotin��7031.5 1,i. � "� -,�Roquired ���. .�'DatoRacaivad �� .... .- .- -... � �� .. "..... __ .. . ,�... _... unvapp[�c nl/orapernritsubjccltlPvufrrlicrrntlnu;i�il , . ..__. . __ � Approvals , � �' � ' ' , '��prnulty o/nnt mrnc tba>i/�rc IrursdreJ Jnllart/55(/O)J: ar Approved � - , �� , . . �� . . ... ___ . -.... ... ' � . . � �� Yes No_ � -� , - - � [J I,os owner of ihe praperty.or my empioyces w��h N'oler Cnn�hco�e � � � �� - ._-�. � .. � .. � . �� � . �+a9es as�heir sole mmpensarion,will do ihe wor'q,ond ._ - - "' � - ��" � � .� Ihe s�rocture is not imendad o�ofFered(or sole($ec.704d) . _ - . . '� ..._ , .. . - \ � '. � Heniih Oeoa.vonn� . . -- . .. . -. . .�� . ..... �+ - - ' �--.-- . � - . . -. . . Ousines�unJ I'rn/usioas CoJi�:7bc Cnntrao�or's I.i:cnse .. ...._ l.�u�dncs„���a��r,«,.,n nuxrr u/prnpertv ul�n hurfds Fire Depanmrni -- . .. . - .- . . . .�.�., � _�>r� ) r�..s thesrun,and u�l o Joc:sucb u urA.Ai.nscl/u> , . , .�'� . elrnuR! bis-uu�n enrplq��es. prnrideJ tlut-ruch i G�odmg _ � � _ -/rroi�ements are nnt intrnded or �fJrred J,r sale..lf, � . - •(� - , . bmoet�rr,JlrbuiGling�o irnJ�mrcnrrntissuld�ritbinnne 9 . � ' • ' - qrar d/ mmple/inn, tlx� au�n¢r.luifJer ni(f hae�v'tbe � . � _... - � Geolo imi - � � � �1. . 1 urdrn nJ prorin,q!!m�!�e did nul!uild nr rmprni e fnr � __ . _. `_ � ..:. ... . � .. .. .._- .. ... lr�epu>poseri/safeJ.� . -. . . . . Pedestrian Protechon � ' . . � � I,os owner o�the property,am ercl�s�vely co�vac (Fence)�ConoPr) .. . �_ . . . . . . _ . ..._ . -- . . ting with.l�censed conir�cfors to construcr the project.(Sec. Sp^.��ol Inspecfan � � . .. .. ... .--- ..�.. .. � 70a4)flresinrss unJ Pru�estions CnJer 7'J c Cnnlrur[nrS . �Cen<.11l,1asonryl(Weld�ng) � .. .. _ . . _ . ._ l.iceucl.au•dnesnotupjr(t•lnunawnerrfprnferft•u•!�n � � � -�hurlds�or�irnprnresflereo&;�anJuJnrnnlrudsJursvrfi ,_� ,., _. , Io1 Oroino9e .. _. . . .� . ._ .. . . -.. _ j�r.jecK a•itfi a mnrr�clor/sJ ficenaed pvrsuunt 1n fbe . . Cnnlrrtclr�ri l,itensr'Lau'1• . Forkinq - � � � � ❑ I om eRempt under Sec ,B.BP.0 For th�is . 'reoson . _ ....� . Date. .. . .. ..'�' � �� Owner . . � i : ' � . __ . . _ _ _ .. . ._._. __ . _. . . . . �Approra�ls Dato inspeclor's Signofure . . 1NSPECTOR'S NOTES � loco'lon-- ' � � �Se�ba<k g Yards), - � ' � � ' - Faundotions . . . "�-'�',,,C . . _._ . . __ . ..�. :. .. . . I Siob � . .. . ... . . . . . Prome . . . � ' � ' - � � � Energy Insulo+��on , � � -- � � - � � . . . . Loih;Drywoll-. . . _ _ _ . . __ _ . . . . ,. - � � - . . . Inie�lor � � � Lnih-E.�erior -. ._ . . .- . . ` . . .. .. � Hcusc Num6er-- . .- . . .-.. . . . . . -. . . . . .... Correct 8 Pos1�d � � ' � Finol- . . . . . , . . .�. . ._ _-- —__ Enrer on Frcnt ' ' '" � �f� �J , ���.�._ -