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HomeMy WebLinkAbout0827A 3285A / _.. i ,. , . _ ___ . _._ . _.._. . ...._ _. . _. .__ _.. _ .__ __. _.. . .. . _.._ ' WORKERS'COMPENSATION DECLARATION .��.�. ��; � ��� ;.•.� �� -� � � �,.,.. . ... . , . -. . . . .., . . . . . . .. ..._...._ , . ' he'eeY°"`m 'h°" h°�e°`e""'`°'e°``°�Se°''°'e" APPLICATlON FOR—:BUILDING PERMIT� �, insure,�or a cerfilica�e of Workers'Compensa�ion Insurance, . ar a certified copy Ihereof(Sec.3800,'Lob.C.) ' - � �"�- ------ - - � � - - -� �-��� ' • � .. .. , COUNTY OF LOS ANGELES , BUILDING AND S FETY . - Policy No.- Company ----- � Certified copy is hereby furnished.. , FOR APPLICANT TO FILL IN BUIIDING AD�RESS Cer�rfied topy s(led wilh Ifie counfy bwid ng inspec- "--- BUILOtNG ,�( �,{ " � �+ lion�deparlment ....� . . ' .: ' ' .' AD�RESS �C�.� <„/ �i�j,t�i : � . . . .. ��� .�.. , , �. ., ._ , �.��." - , . _.. ... ..' ' . ' ' " _ _.. .. . .... ' . Date � '�� Applicant CiTY � Lv IOCAUTY � ' ' "� �CERTIFI�OTEN10F EXEMPTION FROM WORKERS'���'- ��"�-""" '"� � ��� � -- � � �NO.OF B��GS. ��-�� NEABEST.... . _. _ ... ..._..._. . . _. - � �� �•� PENSATION INSURANCE � � .. SRE OP tpi � NOW ON LO7 � � CROSS ST. (This seuion need not be'completed if the�permit Is for one - -- iRnCi��7� e�ocK�b702� lOT NO. � -� �ES50R � �-� i - �. hundred dollars(SIOOy or less.� . , . . ' Mna 600r, PAGE� 7ARCEL �� � TEL. USE ZONE M1MP , 1 certify�Iha�in the performance of 1he work�for which lhis OWNER�{ � ---; - ��Np. ^ � , - . ,„ �„ permit is issued,1 shall not employ any person in dny manner qDDRESS �� � � � ' �-�� � 57ECIAl-,-- - � O- �.�� � �I ti ` . . .. .__ .. __.. ..._ . .-. CONDITIONS ' ... �� . ',V � so as to become iubject to the Workers Compensation Laws � � � � - t - ... . .. .. - - QTY.. ��l. -f� TiP �, _ - �v� �z�i2(��-- --_ . ... _ �� Date-�'' � � Appiicanf - � qRCHITECTOR 7E1. �/ - �� � f4lTICE�TO,APPLICANT If, afler mak ng fh s'Cerfificate a4 _ ENGiNEER �` NO. DISTRICT , GkOVP TYPE � FIRE ,PROCESSED BY -� f np�on yoo should 6ecame sub�ect ro'the'Workers' J^ CONSL,1{/ � 20 E pensohon p ovisions of 1he Labor Code,you must fbrih- ADDRES$ 1U7. - , C/ _ � _ . y. . -. . -.. �a with comply.w�lh�such.provisions ac�.fhis permit.shall be - -- ^ TEL. S7A71571CFLL QA5 iFl tiON � � APT. CONDO. � ;Z deemed revoked.�.,. . �,ti . . � . COMenCTOrt `�1.t5�� No. ! LICENSEDCONTRACTORSDECIARATION �:�, ---- --_-�- ����� - --��--��- --�- �- � �- ii�, - � � - CWSSN0. � �idElCUN175 � I here6y a(firm Ihat I am licensed under provisio�s of Chapler 9 A�ORE55 �f-� NO. . (mmmencing with Section 7000)of Drvision 3 of the Busfness ond ,_.___ _.. ��� - SEWER M4P � . � . . _. .__ ._. __ __. ._. . y� .._, Professions Code;and my license is in full force and effect. aiv C1n55 O-� � -��gK - ��� --- -- ' -�-VAUDATION- �� '�- , .. .' � „ . � SQ.FT. NO.OF NO.OF CHEIX � � . . � � � SIZE � �STORIES -- FAMalES�- � -��� � ONE- UcenseNumb'er�-�� �Lic:Class� . �� . � � � � � . . . ... .. .. , . .. VAtUATION � ,, , . �WI 1-�'IDN-CO/ ' . :. . . �., , .._"'. DESCRIPTION OF WORN ' _' _'. ' '. ___ _ _.. NEW-- g�'_ _ ._ _ .. ___._ . ... . ._ . . , ContrdUor. � Dote � S "3 V ' , : . � .... , ADD -�DS27J1 . ❑I am exempf under Sec '--� � - ��- ��� AtlER . �,_ ;�,: . ... ..�. , . .. . , 8.8P.C.forthisreason � ..�.. . . . REPAIR � ...5 .... _ ".-' ..--. .. �.. . #'.'..•.•_2J-.._" __.. ___ '____._.__...._....._. ... Oale:.._.._. • USEOF DEMOL ❑ �. E%ISTING BIDG � . .._. � •_1 91.2 5__ ����� ,. _ _ ...-Signat�re -.� . ._... .""--' -'-- �.... ' --' APPlIG4NT . TEL FINAI x OWNER-BUIIDER DECLARATION .`_... PRiNiI.�� .... __ _NO. _ .:7 V�� -.DATE � • • 1 9 1,2 5 c; . ... ..... .....�___.._ .. . . ' �I hereby affirm that I om exempt from the Contmcror's License qpDRE55 � '- �L O 8-H G Low for the following�reason(SeUion 7031.5,Business and FINAC� '� 'Professions Code1� --....... . _._._ _ .... _.... . .... __....-� Pee . By . _ ..-� I�: . � - . . .. _-.. (�J�. BUIIDING . . . . , '_ _ .. � / '� I, as owner ot ihe property, or my employees with poDRESS /}�, f "wages as rheir sole compensation,will do ihe work�and .^. . ._... _.. �.. . - 'f�sj` /7ii/7�e�l.� R�j C a Jr� � iha structure is not intended or of(ered for sale(Sethon �����T� ' 2 2'� � � �� � - --'�7044."Business and Professions CodeJ. - .. . _- . MOVING... ..... ...� .- ... .. . . TEI... . . .. �I��:S3J`•--��' - ti�• • • .:� .. I,os owner of�he prope.ty,om ezdosively confracting CONTRACTOR NO. - _ . �. . - a. with licensed confracrors to tonslruct�iha project(Seo- ..—." _... ... . . ... . . ... . .. .... . ',, - ' " � ' . . . . '. � � " ' � •2��-5 Q--- fion 7044,Business and Professions Code). ADDRE55 . � ...... ,. � �.. , � ,:.! � � �CONSTRUCTION IENDING AGENGY � ''�� --�- REQUIRED - .ypRO -HWY TOIAL SETBA K . . . . . - __.. _ . ... ��� � �. ��� �'��f�5�2 , SET BACK VROP.LWE WIDiH � 1 here6y affirm fhm there is a cons�roaion lending agency for pRONi � ' � � -� � -Ihe performance of ihe work lor which-Ihis permit Is issued --- - D.L � - --- � �� - - - ��- �-- - - � --- - �- � � -�-�;-- �2.� � --a 7� - � (Sec.3097,Civ.C.). sioe ' � ��� - � ' �� " �A --- . _ _. . /�.:.__ � . ....._...._.. _ . P.t. - � ..--... '. % �' _ ._. . . _- ....._. � Lender's Name�•Cl-LL'v��ii" . . . .� . .� ,,...^ a :'_ �A . .. ,' � / �.L�� LDMP.Raf.M"I - ... -. ,t,�, _`. __.'... _ _. .. .... . . . .. . ._.__._.. .. . _ .. v.C.FeeS... _ PermrFee - . . _ = Lender'sAddress rv : �:'� . � I certify fhaf 1 have read this application and sfate.thal the '_._. ___.... .... .,.. ...._ _ .Issuonce Fae - .�U� .. .�DMA P/C N. _. -.._.__.. '_ __:. - .�- - .. above informafian is mrrect.I agree to mmply with all Counry ���esi gmion Fee � ' :� . _ordinances.and Smte laws relating fo.buiiding construtlion, _.__ . _.__.._.. ......_.___. To�ol Fee- Z 3S� -lDhv��Verm:.N ..- . .. . . .-'.-.-- � �-'-�� : . ': . and hereby authorize represenfafives of this Counfy to enfer u the obove•mentione roperty for inspection purposes � � � . ._ _. .. _ . . _ ._". _.... . .. . . . ���/`/��,«,�J� �/��� p?-�' SEE REVERSE FOR EXPUNATORY LANGUAGE , �, � � /� - ..Signatureo/Appl�caniorAgenr .. .-_ .._._.�fe_ . .. . _ . ._.. . . . ... _. .. ' _ . . . _ � . . . . O I .. __.. ... . ._ _ . ..' ' _' . .. . . � ..� PIANS 70 APPIICANT INSPECTOR'S NOTFS .. OWNER-BUILDF.R DGCLARATION I hereby affirm thal I am exempt irom the Contmcror's To: R��urn�d �. t ' ' � � � � "�Uc�ense law,for'the,folloviing reason. '(Sec.'7031.5) -- � � ' � ` � Approvad ' �Quaixess and Profcssions Codc:Any cily or rounty w•brcl� No. Dute ' No: � Data�� -� �-- � � � �����:` . .-. requirns aQermit!o Canstrptl,after,imf�mue,demolisG, , -- orrepaisanystruclurc,QriortaiUissuancc,alsorequires ' - . � � � . , I� - _ � . . . . lGe a/.plicnnl for sut//rerrxit to JIIC p JI�R¢d SIOICM¢tll , ,.tLnt be is licensed punuant to tbe f�rovrsinns ojtbe Cnw- ; .. , � lractor's Lrtense I.au�(CbnJ�ler 9I(rommenring atitL Sec- .. � ,. _-�:_. . ` .:.- ` .__. _:... ,� tion 7000J of Dirision 3 of tbe Uusiness and Pr%ssions . � , .__ _ . �_ ' . _ _ � _ , _..,. . ,_ .CodeJorlba(GcisexemfltherefromandtLe6asisfortLc . � - -- --�- ��� �� � ��� o!leged exemf�tinn.An_y viofation of Section]031.5 by '_ . Requirod - - -DafvRecetred . . -- --- - �-� '- � - - -... - . �� � - anyappficantfnraperniitsubjectstbeaJflicanttoaciriJ , , Approva(s or Approv�d . . ���penalty of nnt rnore lhan fire GunJred Jollars(SSOOI•I�� . ' � Yes No � � � .. � � -'� - ' ' -� -- � � � �- �- '� . ❑ I,as owner of the property,�ar my employees�wifh 4Voter Cerlificoie.�. . _ _ __. . . _ _ __. � � ,_ „ `Hages as Iheir sole compensalion,will do the work,ond '.' .... . . � � `-... .... . . . .. uclure is n infended o , _ _ . . -. . . ' . _.. ._.. sinest and Pm etiions Cnde fFered for sale(Sec.7D44) I ihe ot Heahh DeportmeM. . . . ..� .' . . . _.. - . - � - � . .- ,�u f Tbc Conrractori l,icense , I.au�Jocs not appfy to an owner af prof�crly adin bui(ds i� Fire DeparlmeN . _. " . . - _ � . or imfrores f!ercun,pxd uLo dors sut�u�ork bimsefjor i ' . - . , :i' - -';�.� - tbrougl bi��num cnrployces,�frnrided 14at-.rucL i�«: Groding � � � � - " . � � � � � �-�QmremenJs arr not in(endeJ or offered,for tale, � i ' ' ' , .;.�. � Go�e�ener,lhebuifdingnrimprovementissolJwitfii�.... � ; .. .._ ` _ �'. �� . ' _ .__- . . .._ . _. . _ . . �' 1. �� � '�' '.'. Geolo ml �` ...i .- . . . .. "-'yeur f oomflelian, tbe�ownervbailder�vaiU.l ave�lbe � i � 9� ' � � � • - � burJrn of pmring Ibat 1 c drd not buikl or imfrorr Jnr . ., .� __.. _. .___ _..___ .�__. __ . _ - Pedeslrion Protection � �� ��-.. � ': . �.. ' � , , .• '�., .. . o saJrJ.:. " .- :'; � ' ��' � rh�r�,.��,se � (Fence)(CanoPY) � ' '� - . � ..-.- .. _- .-_ . .- .. . . -�. . -�---�-� ..,� ❑ I,asownerof the p oPertY,�am�ezdus vely contrac�. � ,., � ,_., . �,_. .. �; . � Special InspeUion -- 1 _ .. .. `�.- .. .. _-. .�.. . -� --'- ' " fess he nn ac jing w th licensed contr s to�fo�slrud� p jec {Sec. .. _ _ 704d)Dasincss ond Pr inns Corfe•T!c C !r tn'r's "' " � � �� l.icenir Lau�does nnt a f to on ou�ner o ro ert_ u�l n n (Conc.)(MasonrY)(Vdelding) ' .. .. . ' -- - �. . ..�!__ ._.� ...'.., b ,rd._.. .- �PP v - J L �P P_ Y � l` . _ .,.. . - . ' � � . . ur s nr�nr roret[ crenn,an u n eorttrattrfor sur� r Lot Droinoge " " "'� . . projrds wttl a ronrractor(rJ licensed pursuant to the i r �-,.. ��. r � �- ����: . ;--._. ._ . . �-- - ---"�-- � � Canlracfor's-Lirense-I.awl. .. .. _•, . _..�:,� . ` Porkin9. � ,..- ..._ _._..-'_ _ . _. ..-'-..� .- -- --� � -- - ' ,� . ,.. �-. , � a � �. � , _ , ' ' _ ❑ I am exempt under Sec. 8 BP.0 for thii . . .. . . , , , . � � .. r = i a l �� ,,. I � • ' reoson . _ . . _ . ' --�Da�e .. .. � �� Owner �-- � 6 . . . , ,. __ _ '. " , ,, . . . . . . ____'. . __ _.. ._. . , . _.�...... . .. l� !ApProdoli `�, t Dafo Inspoctor'a Signntun�� , . . - ��� INSPECTOR'S NOTES .,� . .. . locmion— � .� �� . ��- �I (Setback 8 Yards) , - �- -.� � - '� ' � . . . . . . . ,, '`�. I Foundations�� . ..' .. ., . . . � ' , . . �. . .. , , , �. . � ., � . . . . _. . ._ . � . - _ . . . Slab- ' - - . . :. . .. � � _. Frame . clPn '`./`„ . . .- . . . . �.. . . � . � � ' . . . ... . ,. _. . . �� �� Energy Insulmion �.J__..___:�.�. . - .. . '.____.' ..._ ._�_ '. �,. . . .� . � . , . Lath/Drywall— « � -._...---- --.. _.._- - -' ---'._� -- �. --- . -- � ., . . . . Interior -�"-- � � ' � � Lath—Exterior � O� 1, �--�`O ' . � . . . . � . ' ___. _.._._.__'_ _ ___ ._ • . . . House Number— . . _ __.__._ __�___. _ _' _'_,�,.. . _._ _ � , Correct 8 Posted � " ._ ; � � -�� -.. . . . .. .. - . .�-.. .�,:�� : . _ , .., Final— . . . . . . . � 1. . ..._ ._ _ . __ - __- .___ -_ - _-_'_ . _ .__.__' _ Emer on Front � - � .• � . . . � .-. . . . . � � . � ... . .. .. . .. � �- �. ._ . . � ,n .