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HomeMy WebLinkAbout1596A (9) I �'. �� -- WORKERS'COMPENSA710N�ECIARATION � � � � ' - � � .... ... _..: . . _ _. ._ . . ^t., � -. �. -..-. . I hereby aff rm the± I hove a�certifica�e of consent to self _ � ��s�re,�,a�e�f�t��a,eofwarke�s �ampen=,on��s�ra��e;a� APPIICATION F�li �UILb�NG PE�tN11T _ a certified<opy ihereof(Sec-3800,Lab.C.}�- � ��- � - - . . .. . - .. . . � � . - COUNTY OF LOS ANGELES BUILDING AND SAFETY ._. �.-� _, ...., s._� � . .,_�.,._. Policy No. Compony - -� -- - . .... BUILDING i9�� . . �� �. � Cenified copy is hereby f�r�ished. : FOR APPLICANT TO FILL IN � f (}/�i�i ADDRESS 6 � Certified copy is filed with'he county 6 r�ding inspec- gWLewG �"J�Ir ,ty '/ tiondepOYtment. � � - ADDRESS "/ C-�`�'�� 3J �7����� LOCALiTY- dP -�''/1/� -� . - -- �- - � - - NEAkEST � Date � - Applicont Qiv +�-T7(f✓-% ➢P Ceo555L � � CERTIFICATE OF-EXENIP'fTTON FROIY��N/ORKERS'� -� - �- NO.OF B�oGS. � ASSESSOR - - � - COMPENSATION INSURANCE - �SIZE DF L6� NOW ON:Oi MAr BOOK °AGE PARCEL (This section-need no'be completed if the pe m.i.�s for one � �, - /"� USEZONE NCP /!� �� hund.ed dollars(5100�ar less.) - - �RAQ e�ocK toi�O. �� � � � I certfy ihot in 9he performance of ihe�wo k far which ihis 04JNER�y/�� �/✓�����'/Le,(j hp��J-�3� � ��T CONo710NS � � pe m 1 is ssued I sholl not employ any perso any manner - -'� � D STRICT G20UP TYPE FIRE PR ESSED BV ADDRE55����Y //�'M �� �ONST. ZONE so as to beccme s b eci to the Wo�Kers'Co pen�af*O�1'Laws. �" � � -- � �^ � .���r � �� .��/,J/ CITV ET L'fl�fT J ZIP . . • �. Dafe'y ��� Appl canty�/J�A�.._A�—".�_ .. . _ . : . . STATISTICAL CLASSIfICATION APT. CONDO. �J -NOTICE TO APPLICANT: If, ofter moking rhis�Certifiwte of AR:HiTEC70R . te�. .y 1 . ;y� Exempiion, you should become s�bjecf to ihe Workers' ENGINEER NO. CLA55 NO.r�DWELL.UNITS � Compensation provisions of�he Labor Code,you must forth- ADDRE55 - ' _ .SEWER MAP"'-� � . ' � with comply wiih such provisions or this permif.shpll-be . � �� TEi `�"� '� � ��p� � � - deemed revoked . . CONTRAQOR VkLIDATION- (��. fiYr [E%�Vr1���.•NO.��EL"�+J BK. PG, LICENSED CONTRACTORS DECLARATIOI�I�- - � � �g � � � . I hereby affirm thot I am licensed under,provisions af Ch6pter 9 A�ORE55,���-Iy��/���'� NO.�'���'Y� VALUAI'ION - " � '�'�'F" ;mmmencing with Secrion 70001 of Division 3 oi ihe Business ond � � LIC. �.jp��i� +F-a m n -Professions Code,and my license�rs ir.full force and effect ;,�7v �G'4'�f��� f;q�5 �f�� $ � � ° �' - � � � ' � Sq FT-s,,�-s- ��NC.OF NO.OF - CHECK - LicenseNumber�'��Sy� Li<.Closs�/ SIZE !is' STORIES FAMILIES -- ONE .;-�- s, i,�:�f�--' �- . ` �+ . . . ❑ F _ -� - ConlracteF���'�/•�": Dafe ���r�`� DESCRIPT!ON OF WORK NE�N � - ,�- _ -- . � ' `��:-`:� � I am exempt from the licens�ng requiremenis as I-am a 1�-� � A�D - �� ¢,�� _ . licensed orchitect or o registered prefessional engineer AL7ER ❑ f:NAL -�� � � - � acting in my professiona� copauty (Sectian 7051, , . � 6ATE � �� _ Business and Professions Code?. - - �. .-- , � REPnI� - uSE�OF r � �� FINAL ' , EXISTING BLDG.7��Lt'`� �/���� �f���'�G- DEMCL B - ._„ �$�i � Lic.or Reg.No. . .. � �- �- -Date AvoRCANT� �^�� `' � , TEL Y �'�� . - . - . . - � - OWNER-BUILDER DECLARATION -�--- � �-�-��- 'FRiN7;� �� ��4l b` �{'� NO-.3S/s�E'��. - " . _ - � . I hereb affirm ihat I�am exem t from the Comracicr's License � ,r� y - � - � . . Low for the following-reosonpSec:ion 7031.5, Business and AD�RE55 7'�� 'P''�� �/y�- «��-'�� � - .- - Professions Codel: _ - PRESENT . . ._ . . . . , . . . ❑ � ��' . BUIL�ING . .� . ... . .. ... ... . �:.� .. I, os owner of rhe�prcperty, cr my emplayees wirh ' ADDRE55 wages os their sole compensation,will dc ihe work ond LOCALIry - - - �� - ' - .- the structure is-ne�inlended or offered for sale(Section _ - � � - - . , - . ` - 7044,Business pnd Professicns CodeJ. MOVING TE�. -.. . ._ _ - � - -- - ' � I,-os owneYof the propeny;am exclusively contracring CON'RACTOR � NO. .� . with li<ensed coniractors to cans'ruct rhe proiec'(Sec- _qpDRE55 � '�on 7044,8usiness and Professions Code.).- ----- ---��-�--�� �---- - - LONSTRIJCiION LENDING AGENCY REO�I�ED ��TOTAI SETBACK F2:',`s.: EX�S?. � - �SEi BACK� �ARD� HV✓Y PROP_LINE WIDTH I hereby affirm-ihat tF.ere is a construdion lending agency for FRCui"-�. � ��� - the performance of the work for�n-hich this permlt is issued v i. -� - . . lSec 3097,Civ_C.�;. SIOE � � � P.L Lender's Name - - - . ,-��� - � � � � e ce�de�s add�ess F c.,=ee s �e,,�,,r F�e �:i a I certify thor I hove read this opplication ond srate thor ihe� ce Fee U�� . � a6ove informat on is�c ec:.I ogree tc ccmply with ail Ccunty Inoes.ioarto+Fee - �ssuan . crd�nances and S�ate lo �s relat ng ro-building�constructicn, io•oi Fee (p /��. �� - - ond hereby authori -representotives of!his County to enter . � upon!h � o� nti d y for Inspection purposes. - � " - � ` < - �/f'� SEE REVERSE FOR�EXPLANATORV LANGUAGE' -� � _ � -- � . � � - � , �re o pFl:=o^.I cr Agen pa. �s , .. � :��PiAAtS 76 AP�LiEABdi -.: . � _..� . . .� .ItdSk'SCYOB'S(�,OBES . �ih'NEA-13UZLDEkI DECLlsAATION �� �.z� ��.... _ _ 6 .. ,__ _ _-�,� - 1'»ero6y affirm iha!i am exampt from the Contractor's . j fa, .. . . ��t���a� - ..� a - - - ' .... .-License Low for the.following reason. (Ser. 7031.5) Rprpravsd � : � Busizee¢ndProfesr."ose��Code:Aszyestyorcnux�mblcb q�v.� � 3`ee?e fdo.� ps�?r ._.._,�.- . .. - _ . r¢guires a pern:ff to mnstruct,dltsr.:mprove,demolisb, - � or rs�air aczy atrxctur¢,prior tn ie isscance,c'uo requirss �... � �_ . � . � - � � f .. ... .. . � . . ...�. . -- . t6e a�p7scant.fcr s±ecfi perre:it to file¢rign¢d siatemext �{{{---= - . � . , -.-., . ... , . . tb�t'r,e is dics:asedpursuant io tbeproursions ojt'ne Coa- ^ -- . ; .. �. . . . � . . .��� . �. .. trcrtor's L4csssse Law(Cbapier 31(��mencf�ag uitb Seo- � _ {— tior 7COQJ oj�x�'sioa g"of dhv73usixass and Profasszons ! � � CerteJerEGatbeisexempttbere,%romandtbebresssfarthe �....A.= .._ .-.-� �--!- .�.�. �-�.� . ... ._ . ..,` .. e?I¢gcd caesnptinr..Any vdnlatdan of Secsiox 7!�31.5 hy � � - ��uired -.� �r�esffg�•g� i .- �.n3aj�y3i:anSfarap¢rnsitsabjectsthza;7p16cantEosasavdF . . �gtp�umi �:,:. 0�v �o o ���so��d .. .. �erer)J rs maae tFan fs've hundred doliars($SQ�J}./: . ______-����--��-'�� � � - - - . - ❑ 1,as c ner oi fhs properiy,or my employ�as with .4Y6;e, eri�fu,ate _ . � - ,_ ' . _ _ wages es tne r scle cbmpensation,wifl do the work,and � � i y,��, � 9Fe siructure is nc!�iMended er offered for gale(Sec.7044) N�aMh Depanrrent . .1 .. .' � � . t - .-. : 73.�siness axd Profess{ons Code:Tn¢Contras:or's I,icense .. . .:: .. . �. � � - La.v;dae�not�p¢ly ta ara ov�tter of progerty wfio�sElda � � � � 'mrrn,�¢.=therenx,ase2�wbo�oes suth work drirxse#ar �Fire De¢3riment � . � -- - _ I . . .. . ..�. .�� r , � �" , � . -�tFi;nugb bis ow2 e-,n¢loyaes,proverled thad sucFi im-.. !urcding --- - � � . - � _ � . -.prca•e.mer.ts Gre ttot inPettdsd or offered for sale. f i � .�� � - 'oouever,tbebul�ir.goY�mproaememtissoldwidbinone G oiogica. .. - . . . . . , . .. � . . . year of comp e a u, tbe ownar nui:der tuadl b¢ve Yhe ��.r�en of pr�vang*hat he drd not 3iudTd or in=pro•�e for _ �Pe�'�?otectio�i � . . �` . . .. . -_ Zbe v^urpose oj sa e% . _ . . �e:ic=1(..anopy)- � � . � Li �,as owner of the propeny,am ezclusively mnirac � - � . -� - . --� f . t reg th I censed mntractors to cons}ruct-ihe projeci(Sec. �� j Speciai-inspection � '- . � - '04M1).$us'rses,¢nd Psofassfons-Code:.TSe Contractor's �(Conc.)(ifinsorry)(LJelding? �: � - �� -L arse-Lr�v, o-=z.�tdpp!,}•dounowmerojp-operaytilo � �� � .bx,sl�s or±mp�ove�;.herxon,a�d wbo conSrects jar such ��e4 3rairege �� - � . � .. . . � - . - � pro�c!,-wstl a eontractoryij izceos.sed p�iarsuanC to tfie ._ - - .. _ . .Caniractor's7 cexseT,uwf. . I Parking,_ - . ' an x � ... . I � . � - .. .. _. [� � .� _mpf�cu�=rSec �,B.&F.0 torihis _---�. � ; —� � . . . . . . � .�_ . . � � � � � _ . .. � - -.c-.. .._.... . . ' � � reason��- ��. � . .. .. ._ . .. - Cdte . . . . .Owner �. . - � _ .. . . . . . .. . .��. ._F.a.__ �e.__ . .-. . , . .. . _ .. _.. .._. . .:. _ ._ . . _ . R��rov�:s . �;".a42 .s,�2etc�s5�...,^,a9a?a . - . . . . � . . - . .. . - _. . . . . � , ` .� � lP9SFCCSOR'S MOYES... Locaticn— . . . � . . . . . ... . . . .. . . � � (Setback&Ycrds) � - - - �� - .Foundctions i$ c;g' � . . , � - . � .�. �.. _ . . . $Icb . . . — . . . , .__..._. ._,. .:.:_. ... ,. .,. . .. . . .. .. .. � , � ...- . . _. .. ._...._ . _ . frema f/. " �i 1 'i �„ . .. . . . . . . . . . . ..� r .. ,� _ � ... _ . . . .-,. . ,-._. . .,., _ Energy Insulation R�`�' J , . ,: �. . . . ... ... . _ j�' _^� U 1 .�� _ . . .. . . . � . . ILa9n/Drywall— r° ;'r- --..� �� �.. I .. .. . . ..,� . . . . . . .. lytericr .�,-/��i t; , . . , T+ , � ���74—rX'ETIDP. � �� 4+ i 1 � .... ... . . ... . . . . . . . . j I �'�,pr .�e..,n-i+r'..�- �.. - �4cus-s t�umbar— � i : I�.. �. .�. . .. ' . .. Correct&Pos'�d i � . . -�..� - . .. � � . �Finai— i _ .._ ,. Enier on Front � I . . '� . . � . . . �_. . . , �. . . ��_��� � . I . . � . . . �-. r,� � m.��— _ �� . . .. . _ .;... . . . _�_. . . . .. . _ '_ '._._. � .