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Home My WebLink About0553A 0554A . _ _ . ... __ _ ._ ._ _... n -WORKERS COMPENSATION 6ECLARATION P13I1 D-3 / - � � ' � �o L� I hereby aff-m that I have a cetficate of�o�=e��;o=e�f Elev. �- APPLI�C�ATI.ON- �F4R-�BUILDING PERNIIT � �� msure,or a ceriificaie of Workers Co�mpensation�nsurdnce, , .. COUNTY OF LOS ANGElES •� .,+��B � . � � :,t � .. or a cer5ified copy fhereof fSec.3800,Lab.C.) �� $3—CK-945'—I04 CPA Aetna. UILDING AND SAFETY Pohcy No � CompanY . . � � � � _�__. . .......�.:. . �. ... ''_ ❑ � � � . � BUILDING Cerr�fied mpy is hereby fu��rshed. FOR APPCICANT TO FILL IN "� ,4o�REu 'L�}36J_ D3Y'Y1Y1 DY'1V2 __._. _... _ n Cerii4ied copy is filed with the county building inspec- gUiLDiNG , , � �� fion-depariment. A�DRE55 .. __..._..... .......... __....._.._..... . . .. .. ..:..._"'..._.._._..,_""'....,_� , . . Date S�Z9�HS Applicant. �� G�� ciTv ' ZiP tDcauiY D1c7IT1011C� B8-Y . . .... . . -.. . CERTIFICATE OF�EXEMPTION"FROM NJORKERS'� � NO.OF eioGS. NEnREST - COMPENSATION�INSURANCE� . SIZE OF LOT NOW ON LOT CRO55.57. 10 & GOI.CIPI'1 S T111 (This section need not,be mmpleted if the permit is for one �-� / ASSESSOR , hundred dollars($100)or less.) . TRACT BLOCK LO LNO. / MAP BOOK PAGE PARCEL owNen THE ANDEN C�UP No 967-954I use zoNe nnnv I certify that in ihe performance of�the�work fo whieh ihis . . . . .. .. NO. " � permit is issued,I shall noi employ any perso n any manner � SPECIAL � O so as fo become subject fo fhe Workers'Compensation Laws. ADDRESSI.O�J4 PaY'�C V1eW DY1.V2 R-1 CONDITIONS _ V � CITY � � .. . 21P . . .. � Da10 - �AppliCant � � ARCHITECT OR TE�� OISTR,ICT CiROUP NPE FIftE PROCESSED BV o �`1TICE TO APPII�ANT: If, ofier making this Certificate of ENGINEER Szany & Assoc. No 445-4073 ~' .amption; you should become wbjeci fo fhe Workers' . , . . /�� CONST. ZONE � Compensation-provisions of the Lobor Code,you most forth- qDDRESS 314 N. Ist Avenue Arcadia �� ~ y winc �omply with such provisions or ihis permit shall be � -- �-- - �-: �------ �"--��-7E�` "�"-"'�""'-"" SrATISTICALclA551FlcaTioN� -�' -� " �'/� � APr. co oo. Z deemed.revoked.,,. �CONTRACTOR �e �1� No �}�e} LICENSED CONTRACTORS DECLARATION � � � �LIC. � '�- �- CLA55 NO.�'(LDWELL UNITS t I here6y a$irm ihat I om licensed under provisions of Chopter 9 AD�RE55 �•,0371580 sEv�R nwd _ .. (commencing with Sedion 7000)of Division 3 of the Business and LIC. �$ Professions�Code,and my license s_in full force and effect CiTY ClASS BK � VALIDATION -� -- ' SO.FT. ) NO.OF NO.OF.,_ - CHECN � License Number �7�5$n Lic Class R SIZE ` STORIES FAMILIES ONE . . . .� ,-.� �5��i _... .. _._... .. . . . . VALUATION '"v DESCRIPTIONOFWORK S�g� Fd�l. �25. NEW � 65 340.00 / ContrdCtor T� � ��Dafe S��HS . App ❑ S � , �s� c�-b-'�2� " �I am exempt under Sec . ...�� . �3ra e - � y �..... ......... ._�. qLTER � I a 2 C rJ.�� 8.&P.C.for this reason . REPAiR ❑ s ��- e s uSEOF � � cl,�'� � �" . . .. � ��e: � . EXISTING BLDG. ' DEMOL ..Signature . . .... . � APPLICANT � � TEI. ...._ FINAL � d � G�?,� C"�.�i OWNER-BUILDER DECLARATIDN PR�NT� . N�� DATE Cz /�D�J S' . ....,. . - �, - Cb.,LA I hereby affirm that I am ezempt from the Coniractor's License qDDRE55 FINAI , �� Law for ihe following reason(SeUion 7031.5, Business and ^ � - �Professions Code)i � . . ... . .. ..�....... BUILDING .. ... .. . BY �� v � e.� I � ' , I, as owner of ihe properiy, or my employees with ADORE55 .. . ._........ ........ ........_..... . � 3 5 Y C.(;Q . wages as iheir sole<ompensation,will do the work and �OCAtITV ihe structure is not intended or offered for sale(Section . , . . j C�,(','.Q� 7044,Business and Professions Code). - - MOVING tE�. ❑ CONTRACTOR NO. . . . . .. .... .... , . I,as owner of the properly,am ezciusively confracting �� ? G"`�.rj with licensed coniractors ta consrruct the project(Sec- qooRE55 tian 7(144,Business ond Professions Code). REQUIRED YARO HWY TOTAL SEfBACK I T. . . . � �CONSTRUCTION LENDING AGENCY � �� SET BACK 7ROP.LINE� �NIDTH . I hereby affirm ihat there is a consiruttion lending agency for FRONt ihe performonce of ihe work for whi<h�his permit is issued P.L - � (Sec 3097,Civ.C.). SIDE P.L. . . ... . .... . Lender's Name Continental Illinois . . � - LDMA Ref.k x P.C.Fee 5 '' Pe•m't Fee ' ... . ........... ........._ ' . .. . . - Lender's Address 399 Park Ave.,-N.Y. 10043 . - � i � I certify that-I have read this appliwtion and stote that ihe - � issuonce Fee �-- LDMA P/C# - � a above informati a orrect. gree to compiy with all County inves�iga�io�Fee .. ordinances an Sta laws e ting to building consiru ion, 7otal Fee � d•f/1� LDMA Perm.# � and hereby tho e repr s tar'ves of ihis County 1 en r , . a upon the a ve ntion ro rty for inspeclio p p es.� . . .. .. .. ..�.... . .�....... .........�.. •,.. ....�: , :.':. .. � .. � . . a ... , .. .... _ .. < � S SEE REYERSE FOR EXPLANATORY LANGUAGE - � ' . . . . . .. . ... . _. .�C�v`i Signar�re of ApPllca or Agent te .. . � -�-� ' . .. I � � - � ��`PlANS TO APPLICANT INSPECTOR'S NOTES OW\�flR-BUILDF.R DECLARATION . 1 hereby affirm thai f om exempt f.om the Controdor's To: � RMurned ;�� Li<ense Law for the followng reoson. (Sec. 7031.5j � � � �� Approvad . Business and�Professions Cade:1ny city or couxly u:GicFi No. Date- No. �DaTe � � reyuire.e a J�ermet to ronstruct,alter,fmf,ror�e,demolub, . .- nr repair any sMucture,prinr tn i1s issu¢nce,also reqaires . the upplicant for sucH permft tn fs'!e u signed statement � �� --��.�- tbat he is IicnnsaJpucvuant to tbe prnuxcions of 16e Caai- � , ... .. , � . � . ...,. . trareor:s Lirnnac I,ow(Cbapter 9/(cornmencin�with.Sec- . � linn 7000/qj Uix�dsion 3 nf the Uesiroesx.and Pro(essinna . � - � � - ... ... .... � . CoJeJor t/�ut bc is exempt t6ercfrom and�be basisjor tb¢ � . � � , - nlle,�ed exemption.4my+�iolalinn f Sectinn 7031.5 by ��, ��Required Date Received . an1'opPlerund for a pern:rt saz6jects Lbe applicant tn r�cic�il Approvals Yes No ar ApprOved � � - penralty of n�#mnre tfian fiva 6�.ndred dollars(5500/.): � I,as owner of the proper�y,or my employees wiih . . wages as�their sole compensation,will da the work,and Woter Certlficate � � �� the structure is not in�ended or.offered for sale,(Sec 7044) � � ��.. -� � �'�' - � �� Aussnesk anrl Profeccions C`nder�TSe�Contrnctor's I,rcense Heahh�epartment.. � J¢m does rtot applti ro un nu:aer f jiroperty u�ho builds - or en:prooes tbereeon,and xaho daes sueh¢mrk bimsell nr ��.. . . ... . Fire De artment �� . P � '-`� _. . � tbro��gb bix ou•n ernplo�ees,�procrded tiaE svcl> i-'� �� provemenFs are not ixEended or offered for sade,- Groding ' � � - . . . . {oxnc++er,lbebmildingori�nprouementissnldwitbinone - � - -'year oj completion, tbe numer-buifder�u�il1 have the � Geological � � � � .-�.- - � hurJcn of prncing thai he did na[bailJ or imfmve f r . . : . thu purptis¢-n�.cafeJ. Pedestrian Protection - � � - � � � I,as owner of ihe properly,am excfusively convao- (Fence)(Conopy)� � �ting with licensed contrac�ors to�cons,t�ct the prolecr(Sec. ��`.�..� .� .. �� 70A4j$iuinei�s und�Yrnf ssinns ('•ode:�The�Coniructnr's Special Inspeaion . . � . . . . . I.icease I.au�does nqf applv tn ax owner nJpr�,p�r:y u�ho (Conc.)(Mosonry)(Welding) � � baiJG��or irnprnvas tbermn,und u�ho cnntracls for auc! , . . -prnjecls wit6 a crmJrncinr(s�J iicensed pursuant m tba Loi Drainage .� � - � � Contrucfor'r Litense LawJ. � �� Park�ng -� � � r I am exempt under Sec � ,B.BP.C.for this ._..__._.. .._..._ _ ..,.... . . ._.. . . . reason . . . ...... .. Date Owner Approvals Date Inspeclor's SignaTure � . . INSPECTOR'S NOTES . LOCQ��OI1-- j� .. . � (Se�back&Yards) � � Foundations l�,t`.��'�/ r�l. �''`a . . .. - i ' . Slab �t:.�, � . . _ .._ .. . .. .. . . .. . .. . ,� / S , � Frame pG�g A��;�' �� . , . . . ,. . Enerqylnsulatlon :°�;�`i`ar,"ra n��.,-'�� . . .. _. . .. . . ... . ___ _ — � Lath/Drywall-- .'!7�i . . ��e,�a, <'9,:r� �.h f�.� _ � . ��, _ Lath�-�Ex�erlor �%'�.f�s,.- �.J�xf � .. . . House Number-- `I f �- � �� - � � � Correct 8 Posted � -"`— '� Final- . . .. . . .. . . ._ . � . Enfer on Frant ............._. .,.....,.... .....,,...... .__.... ..::.,.. .,