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HomeMy WebLinkAbout1110A (5) WORKERS'COMPENSATION DECIARATION � ' � � - � '� I hereby aff,�m �hat I hove a certi(icate o��o�=e�<<o se�t . qpp��CAT10N FOR BUILDING PERMIT insure,or a tenificate of Woikers'Compensmion Insurance, � or a certit�ie+d copy thereof Sec.380D,lob.C.)�''` A COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNa/� mpany��N'�e/�1.7WI BUILDING � Certified copy�s hereby furnished. FOR APPLICANT TO FILL IN ADDRE55 3SU(� G�'�ck�-� �Yr°t� /�d � Cert�fied copy Is fited with iha ounty il i in5pec- BUILDING (7 � lion deparlmeM. � ADDRE55 S�Q �r�� �'1"RQ 1� LOCAtitt ����"�C h y' Da�e �'`�^��v APPIi[ant CIN ��Oy 'n NEAREST r+ � / [) 1L Zlv CROSS 5T. a� � C( GERTIFICATE OF EXEMPTION F M ORKERS' NO.OF BLDGS. n55e550R ' COMPENSATION IN RANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE DARCEL (This secfion need not be tompleted if ihe permil Is for one 115f ZONE MAa hundred dollars(§I00)or less.) TRACT BLOCK �or No. No. `��J i} 3.�3 t TEL. h7�� SPECIAL I certify that in the performonce of iha work for which ihis OwNER�J�Y� �BYID.cS'�J{� NO. CONDRIONS 6 permit is issued,�shali not employ any person in any monner 3 c'Yf!_ (1 �"�� D15721C� GROUP TVPE FIRE PROCESSED BY � so as to become subject to the Workers'Compensation Laws. Aookess Uvk �i`iZ'1Lcg;� C{ ' � /� CONST, r"' ZO� ��/� U � � CITY t��11^iQh :�/S� ZIP. � lv � � /v �/�N-� � Dafe ' ApP�iCOnl STATISTIU1l CLASSIFICATION APT. CONDO. F- NOTICE TO APPLICANT: If, olrer moking th�s Certifimfe'of � ARCHITECTOR� : � .TEL. � � ,,... . V �Exemp�ion, 'you ahould become�subjeu�to the 1Norken' � ENGINFER����'� NO. . �Q/1.55N0. -� DWEIL.UNITS a Compensation provisions of Iha lobor Code,yoo most forth- � � ��� � � � � � �n ADDRES$�� :� �' SEWER hMP wilh comply wifh suth provisians or.this permil shall be TE� ��t7� Z deemed revoked. CONienCTO I�frF � � NO. J v� 6K. - a'+. VAUDATION LICENSED CONTRACTORS DECLARATION J ���. I hereby affirm that I om licensed under provisions of Chapter 9 AD�RE55 �.C(J/YI1tp� CFI � NO. l VALUATION (commencing with Sedion 7000)of Division 3 of Ihe Business and ��� ] �7 Professions Code,ond my license is in full forte and effect. CITY �... C ^J S p�� ► _.ql Sq.FT. NO.OF NO.OF CHECK License Number � [.Class�3 / SIZE STORIES FAMI��ES ONE , �,,�/�}. � DESCRIFfION OF WORK NEW ❑ s Controttd2-=rLfA/s�'�'te �I am exempf under Sec � ��j� / � �n � Aoo � . AITER � FINAI B.SP.C.far this ason REPAIR � DATE I Z3 � USE OF DEMOL D tB: E%ISTINGBLDG. �(� �j� � BINA APPLICANT /� yJ TEL � Signotur VRINT � L✓C�y' /t . NO. -� - OW R-Bb1LDE RATION ' I here6y affirm t i I om exempt from the Contractor's Llcense qDDRE55 0 nfe'+OhG..C?- 9F� Law for the fol owing reason(Secfion 7031.5,Business and Professions Code): N ❑ auimiN� I, as owner of the properly, or my emp�oyees with ADDRESS �� � �.Q a wa9es as their sole compensation,wiil do the work and � the skotture is nol iMended or offered for sale(Section ��`��TY �• • • • �.� 7044,Bosiness and Vrofessions Code). pnoViNG Tct. ' � I,os owner of the property,om ezclusively confrocling � NTRACTOR NO. � • •3��5 with licensed contractors to construct the pro�ed(Sec- •3 G 7 5 lion 7044,Bustness ond Professions Code). ADDRESS . � REQUIRED TOTAI SETBAIX FROM E%IST. O�.2 O�8 G, CONSTRUCTION LENDING AGENCY SE7 6A[K YARD HNN pR�p ��N WiOTH � I hereby pl(irm thaf fhere is a constr�ttion landing a9e��Y��� fkONi the peAormanca of the work for which fhis permi�Is issued p,l. �Sec.3097,Civ.C.). SIDE v.i. Lender's Name ^ $ � C.C.Fee 5 Permii Fee +����S lender's Address � I certify tha��have raad fhis application and s�ate Ihat ihe iu�ance Fee ��+� v S obave information ia comect.I agree to comply with oll County Investiganon Fee / $ ordinances and State laws relming to building canetruction, Toiol iea -3fo. 7✓ C and hereby authorize representatives of this County to entar � upo�the obove-mentioned properry for inspection p��poses. � � SEE REVERSE FOR E%�UNATORY LANGl1AGE ^ Signolure Of Appli<anl or Agen� Dufe � � �j .. -;c:r �.�J'.7:�.., � . . ' f�lA9J5+0 RTi'LICA�7T ' . . ' � I:iSPE'TO:i'S UDiCE � . . OS�;\i:ii.�'i11LDLi:i�:;CI.AI:AT'i0?7., ' �, . . -...1 herely c�ifirc�.�the;I.cri excm�.t from fhe.Controctor's To: . .C.aturnad . , ,. . License tmu for. 1F:u f�lioviing reosorc:-.(Sec.�7031.5) Approved � I;uc;-es:sr.d 1'.��n,`w�;%r,rvv Ca:.'�•i At:v cit}�nr county�a�hicl No. .,. ____���3__..:�� No. �" � �ato �- _ .- _.� . . . . .: - . .� ,.. .�_ rey � . ,. -�.t� �i„�prore.denaolieG, - ' ----- -- nrrrfsirar.l'strs:t:�-c;Ii�un�foitsis�re)aneijaknMguires �_�� _ �� ,_ _ _ __ _ .... __ --. _._ .. ._ �;(, _.._. _. ;_ ,.._ . .. _` . ... _�.__. — _ __. . . . � .. ,i,,.,���r.�:rr fnr such pi•rnri•to filaa tr,qncd s0atcmicnt �� ' � , i�`�. �,�.. : .. . . : . , �, ,. _ . r " .. ' . �_ . . . _ ._ _- _ _ .......... . ... _ _ . _ __ . _ . _ ____ ___ _ _ , tJntLerili:cnsedfi<rsunnttatficprortcinmsaffhcCon- .. . � . . tru<1nrS�l,i:evttcLr.ic(CL���tcr9f(eoirrrnatren�;uit(>Sce- -=linx�i000J f D�rti+ib�+.�7f i!e Cusiness nnJ pmfessions . . � '. ' . , ' Cnde)nr7J,slhc'iet.il�-p;tberafrnniundtle6rsisfortle . . . . �rr t .�r� �n i r�.tsr Js��rr;on 7o3t.5 6y Rc'uir�d ,Datc Roccived . , , �� �r;:� . - t f � ' . 7 �t t� cfpfic�r.t to a ciri! _. — t,.,-r.,._1_ �� Yos, `No . �'or Apy�rovad __... . . . .. Jl,aalty nf no( r tl.c f ! -l a d d,�u�:,lssoolj: __ _ � �_j V,c;oHne�'.f Ine property,o ny employeas.w�th Water C Yfimte - � � ' I , � . . � , �A�c s t Ihr r ,s co�n-en ct�on .�vill'do the work,and ..� I � �� - -. -. .- - - - - '� , ,.`dr. �cti re is noi n r rded or b ft red for sota(Sec 9044) Hcolth.�epad:acr.l � _ -_ .__ � - �� , , lirrsr::cssr.r:r.'Prnk�sinasCndv:7l�cCmetractnr'sl,ieensc _�,__ .._ _' . i � , - �, , � �. : . . _-.-) ., � _... . _ _`r . _ _ _ . . _I,u�� � �;,i.:,:i:�an o��r.cr o/proJ�u1V wJ o Guil3s � Fire Deportment i' _ _ .. . . . . . __._ . .._ _, _ _ �r 7n;b���r et tl.er:o.,,"cr,:�! r �<d.r.�nrk�binerellor � � . �tL-ro���qh 1's d::r n,r��loyc.r, pmi.drd"JGat surG inr ._ . Gradinc� � � . . _ .. ... .__ . . ,.�/`rt+e r r �a c r .tc d �r ^ffc,-cd far,salr. !/, � , � . � � ` !o.<<rr,(1�:7 �1..,,. o �r ac,,.�ntissolJu•itbixnnc � Geo;ogi<�I- � -- . -�-- - . . � , . y�. �c . 1_ t . u ra:. u.l1 J re tle � !,a . -f./�rc, ;1..�.b �.1�1�u i,r.�rore fnr � Pedestrian Prote:fion � - . _ t6c furf•o;..cj ?rl. `.� �, '.� . , .- (Fen:e)(CanoPY) ' . ' � ��(.�f���f;moviner of tne��fro?,�.rty:am,eeclusivelyconirao- , iln7 vilC:licen:�•:. .ecic.r�I:construcl tho project(Sec. �' � 7D441 Lusir:rs::r.r.J�°'roj;uiti!:s,CeJc:7'be Contraclnr's Speciol Inspection I - - - - -- ' �--- - - --- (Conc.)(AAasonry)(Welding) � � . l.icensr I,cu�dnec r.ntn�fl��1n cn n�vx�rn/pro/rcreyw{io ' 1. _ . ..._ .. t_..�. ._.. ... .- RuRdc us inr;�r„reSYh;i:<p�;���:�d u�ho rontrr.dsJ rsucG 'r---_—� --p.nj:�rc u�;ri� � ..-r.s<n,r�:) 11r�.. �.�p:� :.cne rn%tLr Lot Droinc�c ; � { � . ' �•�� ' ,:` r.` .`. � ' •�._. �.. _ . - . .. -- -- -l'�r t rr:rcr's 1 � .:>-t.��rJ... -:�.•. ,.__� Parking . � � . .. .. .. ..,,,� ... � . � ___._.-.._ ___-,.-. �) : .-. . .-- .. . -.- -� ..�- .�._. . ..- -. " i�i la:nex ptunc�rScc ,B.RP.C.forthis � . . � . . . . ... . � .- .. � _,_ �... � � . .__'.__.._ . . ... ._. ._ . � . Doie Owner Ap�rovals Catr InepoctorcSl�ne}uro . �. V ..` . . .. � � . .. I:;:;�,�C :f:�JT�S . ' Locotion—_z -_.. __ . . _ _ . . _ . . ' �� � . . ,—, (Se bcck E,Ypr�+s). ``� ' ' ' � 1. Foundations - � �.� , .-� -"��"' . .. � . _ � � .. Slab : ��, , .i.,. , .. _�t. � . , _ • ��� Fra e�_. . . _ , � . . , ., .. � '-� � � � ' . . ._ .. _. _ ,�. S"- .l I _ „�• ._ �, Energy Imula�ion ' . �. .. � . ,��... . . .•-� � . . �� . .-�._• - Lath/Drywoll— � , . ' . Interior ' � ' � - " ''�"�' ' lath—Exterior ' ' .'-' - .��. � - . . � � � House Num.ber— ' � . .. '�=' ' � - - •.. � .' .. ' . � . � . . ... ..,�. , -,. ,. i Correcl 8 Posted -___. __. _.._..'. . _, ____. ... _ . _..- ._. . ' , ` _ ._ � �..�,. ....`, . .,-.� � . . _„r. ._.. . . � Final— . , . . ._. � � _---��—'^�. . _ .. EnteronFrcnt . - . .. � . _ , .rr��._.., _ . . �. • . _ . , � -_-_ , -—___._ . ., ..