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HomeMy WebLinkAbout1581A WORKERS'COMPENSATION DECLARATION � � I hereby affirm that I have a certificare of consent 10 self APPLICATION���FOR BUILDING PERMIT insure,or o certificote of Workeri Compensation Insuranca, � or a certified copy thereof(Sec.3800,L 6.C.) COUNTY OF LOS ANGELES BUIIDING ANO SAFETY ol'y No Jr7���ompan � ' � Certified topy is hereby furnished. FOR APPLICANi TO FILL IN eui�ow� - ADDRFSS Certified copy is filed with the covmy building inspeo- BUILDMG �L lion deportmenyt. ADDRE55 � �p�q�iTy . ' ,/\ pQ�a�l/ NEARE57 '',. �. 9�CApplicanl ����L� C�Tv ZIP CRO55$T. . RTIFICATE OF EXEMPTIDN FROM WORKERS' NO.OF BtDGS. � n5SE5SOe � � COMPENSATION INSURANCE . SiZE OF LOT NOw ON�oi M4P BOOK � PAGE PARCEL (This section need not be completed if the permit is for one USE ZON[ nn.4P hundred dollars�E100)or less.) . TRACf BLOCK LOT NO. - NO. - - ' � TEL. ' S7ECIAL OWNER NO. CONDITIONS � I tertify that in Ihe performance of Ihe work for which this 0- pBfmi�iSISSued,I shall not employ any person in any manner - �� � ��.---- -- DiST�1 iCt GROUP TYPE FIRE PROCESSED BY a so as lo betome subject to the Workeri Compensation Lows. ADDRESS � /� CONST. ZONE �� U � � Date A licant � CITY ZIP PP STATISTICAL CLASS�FICA110N qP7, � pp, � NOTICE TO APPLICANT: I(, af�er making this Certificate of ARCHITECT OR ic�. � u 'Exemplion, you should become subjetl to the Workers' ENGwFER NO. - �- CLASSNO.,�DWEIt.UNI75 w C Compensation provisions af the La6or Code,you must forth- pDDRE55 - �� - SewER Mnv�, �' with comply with such provieions or this permit shall be TE� ,r�`^s� �� Z deemed revoked. CotaranCroQ Np��WW - BK. VG, - VAUDATIOH LICENSED CONTRACTORS DECLARATION - I hereby offirm fhol I om litensed under provisions of Chopfer 9 ADDRESS t.c.. N�� - VAWATION'. � � (commenctng with Section 7000)of Division 3 of the 8usiness and LIC. �7:fj1.� Professions Code,and my license is in full force and effett. CiTY �� CW55 S �pC(/(/ � L �-/ SO.Fi. NO.OF NO.OF CHECK liCense Number—//(a'� . �iC.C�O55 SIZE STORIE$ FAMIUES ONE , ///.���+C� /E� D LLI� NEW � s ConlraCtor pa�e�� DESCRIPTIONOFWO � LLI � ��am exampl under Sec. . �/� O /�{�QClQSS no� � B.SP.C.for this reason � S` AL1ER ❑❑ DA E� � �y /� � �r 1 b B.1 A /c-�� /,[ REPAIR Dote: . F%S7�ING BLDG.v�� !/—U/ DEMO ❑ FINAL .#r • • • • ♦� By Signature � APPLDRIMT NO � •���Q 7 5 OWNER-BUILDER DECLARATION � - I hereby aHirm that I am exempt from Iha Contrattor i License �jy o o e 3 b.7 5� Law for the following reason(Section 7031.5, Business and AODRESS i� - , . Profess�ons Cade): a r, D�i.L3 2—8 6 QBUILDING I, as owner of the properry, or my employees with ADDRE55 wages as their sole compensatian,will do the work and � � - . the structure is nof Intended or offered for saie(Section ���� 7044,Busine3s and Professions Code). MOViNG TEL. � � I,as owner of the praperty,am exdmively con�mding � MRACfOR NO. ' with licansed[oMracton fo mnstrutt Ihe projetl(Seo ADDRESS � 'tian 7044,Business and Profexsions Code). REOUIRED TOTAL SEIBAIX FROM Ex15L � � � � CONSTRUCTION LENDING AGENCY SE7 BACK YARD HWY pROP.LINF WIOTH ► 1 hereby affirm ihot there is a conslruction lending ogenty for FRONi the performance of the work for whicb this permit is Issued p.l, � ZSe[.3097�Civ.C.). SIDE � P.L . .. . . _. _ . . tender i Name � � $ P.CFeeS Pe.milFee '�`�"�`� Lender's Address '� � � 1 certify Ihat I hove read Ihis applimtion and state that}ha � Issuance Fee �.3� ' � a6ove informafian is correct.I ogrea to comply with oll Couniy Ir,�es��ga��on Fae / �y ; _ ordinances and$ta�e laws relating to bullding constroction, - �� Torol Fee ���tp• / 5� lY and here6y authorize represenfatives of lhis Counry to emar � upor"y/,/Jhe}a/bJove-mentioned p ary for inspection purposes. .. .. _ . _ � (`--�—�1�f ♦ ��. e�o2��CD�. SEE RFVERSE FOR E%MANATORY LANGUAGE � Signature of Applicanl or Agen� te � . . . . � � �� '�' � .mi i F��.SNs To p.P'rULANT < INSPFCTOA'S NOTSS • AA'h7 P.•SSli3Lt7 P p1SCL�!P.AT10\ ; ..,�1 hereby a(fv i ILai I o i exompl�frcm Me ContraUo�"s To: Rofu(ned � - . . . .. , , .litense Lmlv io' the follo��n�7�rcason..��Sec,�7031:5) 'Approved 'Frvsen.rsr u':dPrefassions C d_,<<�r.}�d(y nr en�ent��«•bieb . _:.•. _: ,,,�, . � No. -- .�� Dcta'•., --- tJ6. •..-Date- � - -- " � -.- . .. -� � � . . - . .. .--rey�iirc'r o'rc �!7n rnr..tr�ct,,nl�rr, rp;nrr,'denroJir(,. ��� =�--. � - _ nrre/�nrrcnvstraitture,(�rrortniGsrssuaxrc,afroreguiirs �._ ... .•�,. .__ . ._. . • .�. � � _�... ._ _.._. . . _ .. __ __. .__ _. ._ ' - . .... .:�.._:..i r.; ��� _ ,, �.,— .�-.. Jh�nfflirar.t for secl�prrnri:!•�fr'!e a srqrseJ statrn+ent �. .'� ,.� '�. . ,- i � .. ���.�,..� � .. . _ -__ ___....________. . . .-._ ..._.,_,. .. . . . , _ _. . . . ,.tfi.at Lc is lrccnscd f+:rsunrr!lo fbo f+rovisions of tF.c Con- � - � � ; �, _ � . � `trddnr'.rLin•riCl.l'u(CJaptcr9J(cnrirmencingtritbScn � "l tin'r.i00�J IrJDrrra)un 3 rf t1 c fJasrnesa�and}�rnfes�si6ns , . � .. . .� . � � � � - CndrJ�arti•at�l.i� s y�ltLrn/rnmarrdtl+clnsrsfvrt5c ' �'.'.. � ..�.�...� �' " � ' afiG.qeu eta•r+�h ;...l }',tdolctrm�nf Sectiorr 7031.5 by � . . Roqulrod �Dalo R�eeiwd - � � . ' � '�-'a�l affficJnt/nrc/�ernats l�th,�tl�ap(�lirartttaacivi! � _._.—!'.p�ro��e!c--- —" �.-- erAppmvvd � --- . �� . .._ .. _ . .. - /, a7y q/r.o!rrmrr tha 'f�� l.:n.c'rrJdol(urs�5500J.J: � Yo� No. � . �� � .i�+��, � t r� ..-_____-_-.. - . ._.__. .... _.. .� . .. . _ . . .�.l.l I,csov.rcrc`.IrePoperty,ormYemployooswith Woter Ct tifitate � �„�� � �'� �� . . - , � os tn�^rz s-1 ccm�ensvtion,wi I do ihe wor,and � : . . � ,, .,�. '� . .._.._. . .__ .�_1�� t�) . __�_ .�.�he s�irucrure ts noi4 I k ' . mrnded cr offered for sale(See 7044) Hc' ` • � �-• - � " '• 13usiriesr a•�d Prnfessinr.r Cnae:Tbr Contrac(or's Lrcente ollh Department �-.,._._.� '`. . _. .... . '. �. __._ - ' - . _ � - � .-.. - . ...- . -l,au dnrc nnt npply in uh ou r.rr of prnnerly u�lo fiuilds � Fire Deportment � _.__ ..::'"� :� � � _ .__ __ - '� or inMrn<�rr thcrran,rr•.t r 1 d as .rJ ru nrk bi»ite f or � � . . ..._... �, .__ . _ .._ _ _.. . �.. . � f ..__ .__. . .. � �l�ruv,ch /,i: oa•n cv�/� tc�, /�rnrrJu. f1;ct iucL ini- . Grodin� ' � . � � , _.. .. . .ro�c�uer:� crc nni int� /J r d� or sal��If, p i J j . . .... . � ��+" �;:,-.�. , ._ .� '. I /. I,ou�crcr.lFefiuildin,tnri p �f�ssoldu�itlrnonc ��'. , . • ....��.}'.11 . _ ,`� � ` ' +cil1 Larr tGc ' —__-_ . . ' � qcar �rnnfl.h - 1- �r�� . Gaoloqiccl , . .. . ` i, � ' �<� .. . .\. < <�'� 1 . dr.rd:n�n/f:r f 1f r�il rinr�,rnref�r Pedestrien Protection � � , �.thc purfose o/sa�J , . � - ,�. .. , .. . .. . ., . (Fence)(CanaPY) (� � . =�l,. � ' ��;.♦ . � - ' �1 I,oto . nf th��roprrty,om exdusively contrac- - � . . ring�•��:h ii<e. e�mntrae�nrs to construct Ihe project(Sec. Special Inspection � ���-� --- -- �� ' 701.)L � !1 r / �s> Co�i:: 7�he Corstractnr's (Conc.)(Masonry)(Welding) �. . . �.. . . ....� . 1 cn sc 1 awd r. ',r1,tu n m�ner.f frnporlY�•Gn -_. _ - '�• . .. .. .��6ur7���r.r�,:pr<�<.r!,<r��..��. d�.s;�����;,r.�«sJartacb �.__ Lot Droino�e - � � . , frajrcts i!�i11 a cnr.trncior(;J li.rnar��p+urs�_axt tn�,-1Gr � . . . . _ .. . :'�: . .C�narreu„',/.;<<,�,� L.,:�J. -- . . �:� ..• :�,,�.-_ .> . �� . : � .. � . . � . .. �� . : .� ..__ . _ ..- Parking : _.._ _ �. _. .._. . ._ . � � ...=-- � , . - . : -.. . - . .. - ❑ I am e<em,.�un�'�r S,c ,E1.8P.C.for this �, � �. ,\' ` _ .. _.. .. � _. . ... . . . ... . ., � __ _ _...._. _. ' �� -_. , .; '. .• � ,��. . 1�'. � 1 . . re�;on �. _. .... . �".",� •.� _ 1. 1.- 1 +�'' - ' _ ._. .' "_ . . , ..... i. ..- . .'�. ' .. . , . , "_'_—_ . '_. _ . ... .. Dote - �� - Owncr RPpr;+q�!s Gcf• Inepodor'�Sl�natur� . • . . . . . -�,�� . __ . lil�S'=�T�...,F!OTiS —.r— lomtion— ' , .. .____..... . ._. . . . .. . ' � . . fSetback E Yards) � � � - � Foundations � - �� :�,-.... � .. .� Slob _ . _, . . :�. .��. ' �, �--. . � , . � : . � ,.. .._ . .. -. Framn , . � .. . . . - � �. . .�. . . Encrgyinsulation ' _._.._.. __ . . _. ._ . �_____�.__ '_�___-_ ... , . . ,. .. ,�.. _ ... . , .. ., . Lalh/Drywall— , ' ' , ' .. . � ' . ... . . .. Interior '. . . . . . . .` �., :. Lalh—Exterior �. ..�-l. � . , - �:��� .. . _ . _ � - ,�� . � .... I� . . :, . . . . Housc Number— . " ' • ,� - � � " � � � - " � �� ' � � � Correct&Posiod - - - . _-. _._ _- ---- - -- �- - . I . .. . . . � . . . , . - Finol— . . .. . , . . . . . . . , � , �„. . �.. . ... �. . .. Enter on Front � � . . . . ..� ..�'` � 1� ,. _. - ��- � _ . � ..