HomeMy WebLinkAbout1590A (9) - UJORKERS'COMPENSATION DECLARATION � . . -�"-. .. � . - . � I hereby ffirm thot I have a certiflcare of consent to seH e � ���' ` � �S insure,oracecificateofWarkers'Compensrionlnsaronce,or APPLIC�ATION � FOR -BUILDI�G PERMIT� . a c,,,�fe;xj4�ed c�y i�eof"{Sec.3800,Lab.C.? � GELES BUILDING AND SAFETY �,.f � Com ��rc,�s° t,�t-ti�ea,,�..,� COUNTY OF LOS AN PolityNo. Pany � 3arao'e�',, . � ._.._ . _..:.. ._., � _:,�_ . ... .a,:. , .s.�,. . ,.:;.. ., ..::,� ;�: Cerritied copy is he�eby furnished. FOR APPLICANT TO FILL IN nooeess f •�c,� 'l �C9� � Cenlfied mpy�s filed with Ihe coun,y bu�lding inspec- gU1LpWG /'/1� o/. j),.c� �� T1 tG� �` tion department. AODRE55 CG��` /� ��""" LOCALI7v .1.,J t� MEAREST (' �' �ate Applicani CITY f//�}/�$(I�i�� /� ZIF CROSS ST. �Fj����. �',� Ya n �CER7IFICA7E OF EXEMPTION FROi41�V✓ORKERS'-�-������ ������ h0 OF e�o�s. ASsesSok � COMPENSATION INSURANCE - �� SiZE OF LOJ NO`N ON i0i �tn.4P e'JOe P/>GE . PARCEL (This section need not be completed iF ihe permit is?or one �j 9 �. . USE ONE MAF _ �j hundred dollors($1001 cr fess.) 'RACT»(J3-: .� BLOCK LC7\O. �T NQ .�� :l T.J' } . � Tet. f AG .•? SPECIAL y I<erfif thaf in!he erformance�f the work for whlch thls OwNER �G�"/ c Ii���� /=�� No.;,J���/J� �Q ��UDI71pN5 � � � DIST2ICT GROJP TYPE FIRE PROCESSED dY permit is issued,I sholl not employ any persCn in any monner /p,� � l, � sb as to become subjec'to rhe Workers'Compensaiion Laws. A��RE55 (,P•IJx ��✓��I� ��^ CO.�Sr3,� ZONE {� 1 C5 �' Y r i k�-o� o ome ApPncam cirv �,�/liioaCr".;) ��� z'P � ARCNITECT OR TEL. STATISTICqL C1A551FICATION APT. CONDO. (J NOTICE YO APPLICANTi I(, ofier making th-�s Certiiicate of. ENGWEER 1'C. CLa55 No.�DWELL UNiTS � Exemption, you shou�d bemme su6ject !o Ihe Workers� Compensotion pro�isions of rhe La6or Code,you musl forth- NDDRE55 SEWER MAP - � �. � � with comply with such pro�isions or ihis perm�it shali be y^TE� �'.ONTRAC?OR f.�r..i�Q �ZES-fJG�i N0. (+�.:�H JG•�y " gK.� �. �— VALIDATION deemed revoked. � � � LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm thqt I om licensed under provisions of Chopie�9 A��RESS �����+'.-�'�k�/f�- N0��14�'/3 VAWATION � (commencing�.�vith Seclion 70001 of�iv�sion 3 of rhe Business ond / .,;� y� ' Prafessions Code,and my license is in full force and e.({ect GTy /�76:y�7^'C<�/�/i� CLA55 C.� S /(�) �L�C� �� �S SQ.FT NC.OF ) NO.OF CHECK uce�se rv��„be�—�/7l 7 3 u�:cioss �`�z��� size .�3-.'� sToaies ` FAMAlIES � orve ,y�y �/./� S COntractor 1%I'/-L-���/���''p�e�C� � � DESCR'�.PTIDN OF WORK (y �LS�yy� �VEW � ' � .❑.. . �� AD7 .. I am exempt from the licensing requiremenis as I om o licensed ar<hi�eU or o registered professiancl engmeer ALTE4 � FINAL /� p ochog in rey professional capacity (Section 7C51, � REPAI2 � OATE (p l��..- Q,�!� Business and Professions Code). USE OF � ,.��,� " FINAL�.�_! - ' EXISTING6LDG. ��%y���"t'�- �EMpI � = . Lic.or Reg.Na. � Date APPL'�CANT TEL B�y.'�rv�,�� �rRirvr;� �• , /'�i.c/%� No(v.1'/—�0.:3'� ` / q �Cz.c,�,,,� �OWNER-BUILDER DECLARATION � / ,J p L / �°� I hereby affivm;hot I am exempr from the Con!ractor's License � L� .. �F/y>'� �C.7tl� 6�'��� y Low for rhe follcwing reason (Section 7031.5, Business pnd ADD4E55 �� �� �5����RG� . .. ..... ..... . .. Professions Code): �RESE�T ., . . � I S�.C,n ❑ 3JILDIVG . . . a .. I, as owner of 1he property, or my employe=s wirh ADDRESS '};m a • � wages as�heir sole compensation,will do ihe work and , ihe strudure is not intended or offered for sale(Secticn LOCA'.�TY _.. . . ( e t �{, .rJ O 7044,Bosiness ond Professlons Codei. �'AOVI'JG � 'E� � � ❑ � � CONTRACTOR �ti'C. � � ,2 I,as owner of the property,am exclusively coniracting � � !�E..r"�.(i c� wiih licensed conlrociors to cons'ruct the proje<t(Sec- p�DRE55 , ��on 7044,Business and Prcfessions Code)- � --��"" ���� �"���� �" '"" ��,1 L,-�'�,G. RECLI�ED vp,RD 4WY' TOTAL ScTBACr FRON FXIST CONSTRUCiiON LENDWG AGENCv ser enca reoe uNe Niorr _, ... � -. ... . � I hereby af�irm tho'rhere is a construction!ending agenry for GRCNT� � fhe performonce of the work for which'his permi��s issued f5ec.3097.G�.C.). SiDE --� Lender's Name � _ � ie�der:add�ess a c vN�s PP�m,�=ee `/.3. �' _ I certify that I have reod�his opplicalien ond stare ihat ihe I=_suo ce Fee ,+�1�t� obove informolicn is corcect.I ogree te comply w:!h oil Ceunry mesr�gatlon Fee / � . ordinances and State Icuis relotinq to build�ing constru<ticn, ioial Gee � ,+.� and'nereby oWhorize represenro+ives of ih�is Ccunry te enter upon;e ove-mentio ed p��r�operto fo inspenion purpcses. . � - c'��'� � YFG'�E.4 eX � �� SEE REVERSE FOR EXPIANATORY IANGUAGE S�g^,olure of Acpl'�cc�l or Aoer.r �a•e . , �5 . . .. ., . � . ... ,.,.x:'y _,:..�..,.�-�.,c� . '. .� '��...,�. . ..-: . . .. . . . ,�.,� .-�_._.._. .....e..>�H. ._-.,�...:,._. � ' a..... ,.._........�......_. _�_ -�..�...�.W...�.,_ CDYs'IVriZ-BUILf7F.I2IDECLAF.ATION P4AfV5 YC3 4e�PL CdIMY � S�SPPCTOR'S HOTFS � ��� - � ; , _.. - . ...-�--�,..._.,,,,...,�,�.�_„-�..---'_..-,.-..,g,..,.._... , . _ .:,e....��,.s.,, i Fereby affarm?hat I am exempF from the Cantractor's 2 io: I €�Crssrre� w L cen��e'16u� for }he followirtg reason (Sec. 7931.5) i P<pprs:xd . - � 9uanessandPrn,fessionsCode:fing�ciEyorcounaywHicb f Pto� �o4e i 6Ne. Dai� . � . ° . . � requ ra:a perneit Lo construct,a.ter,improre,��+x+aluFi, r=--�------�� � — —+- - . - ov re0ciratty structtere,}hrior to iu issrcan:e,uGo requires `i :Ge ap�ildcaset for su.ch ps:mi€to file a s±gned statemenr �-� �- . . .. . Ehc4 hn i.a Idcerased pursu.zr.t to tTie proaiisions of Pbe Cart I�� � Y- _ --� - sractor'.�License b.ew(CSapter:�J(comsxencing cuetFi Sec- � �� � . � . _ - - , _ . tdrs�{%O�OJ af Davisinn 3 0�tl e 9usAxess¢nd ProFessiotu ! � �� � . - � � �� � � CodeJ or ahat be is exe�E tberefrom nxd Ebe basis ne tlse � 4 . - — nIP,�d exemption.Any'viol¢tron of Szdior.7£131.5 bq ..._._....,. _,,....�.,_.....,.�__,.._ _....,_..__.._ . _ . . . . ���� .� .. . . � Rcyuirz �&�� �t�N�,�� . . ...... � � un�aq�<icarEf�:upe:mitsa6jecxctXs¢aQ�dicext6r,acivi! 1 . �'�Pe����=' � 6,r�p;s.�y,e� . — b..wadty cf not mare afiar.fsve humdred dollars I�SL��I•1: � ��__ -- � ��� � �� � � - � _ I,cs owr,er cf the p'operty,or my employees wiPh N!cter Cerii'ri:at� I . . wages as ineir sole compensciion,will do the work,and � � � �� V� � -� � . ihe s•rucrure s not intended or offered for sale(Sec.7044J _.—�.'—_ . . . Hea ih Daper4me7t- �„ I . r�y � - . - Business ar,u!P:nfessior.s Code:The Coe�dracacr's s,$cesua �L� --------i � � ' . La..0�n¢s sr.�;:a�+pl,�En ar oktter�?f'apGrty suho 5raflds Fire D�,.artment � --- .. a^saprooes f5ermnra:end who cloc-sa�.c.y euark 6ss�ssFf or .� -� ��� � - - �� tbrr.uyb his ou�n zmpio�ee.e, a3r�osded tt at sucb im- ��,6��rg � , � �--- . � provemere:, are zot isafended �r offererS,�or sate. df, I } _,___� - � ' - - � � bowex�er,Ebe bueddeng or i+r.prno¢mer.&issold waPbin cxe �Geologicci �I � � � � . . . ycsr of cosn�letdo�, the oa�see�busfder wi11 have tbe �. ._._�,__..�._ I __1_�_.._� ._ . .5ardena o.f pravinv td at be dir�nraa build nr ir.�aj�rove for ���edes9rian ProtecPio� I . . .. ... ._. _ — th�¢u;Pasu nj salaJ. !�rcnce)(Canoay) � i _� �_ � I,as owner of ihe properfy,am ezclusively coniror tt I � ting with licznsed mntracfors to tonstruct ihe project(Sec. Specl��Q��rspPt��pn�� � - 7C44)F3usiness¢x�Frnj¢SSLOSt5 Cod�:The L'axtracaor's �(Conc){Masonri�(VJ�Idir.g)� � I � I,:mns^L¢u dn s nnt cnply ao ar.oa�aa�.r ofK'rr.[>zPty u�bn �,_�_ � `___J ,_ . . . . buel�ls rr irepm�es tbcreor.,¢nrt w/o eontracts for sueh �Lot D�ainage �� - � projects wst5¢conLractar(sJ litensed pursumnt Eo fbo _� . � •. - �� . Contrecaor's Lirense LawJ. Parkirg i , � � � � � �-: . . . I am exempt under Sec ,B.&P.C.for this i'_.�..-_ i__ _�_J_____—_ ' . , . , , . ,�:...,. .. . . _. reason � _..._._.�._...� I i . . . . . .. Dah Owner__,___.�-,_ � . � � . . . ... �� � , � .. .—. ���.��_.��_i J arr;a,�.�-.,..-.... a,� .v�:s ; n��^ e:;���.�e:Y s�;:aay:� (� --- ' � t:�S�etT��'S wos�s _____�—_. __ � �__�. _ —._,_—=---------s-- �._..,.,�..�..a,. Loi—cc o . ,. o . . :�.., ...: . ........... �,.... . , �.:_ . �(Se�acb«Yards)� --A-- . � . . . . � founuations � ��.�i�` . _.�_�,�..__.�-_� . _,...._. . . _ ... .. . .. . s�a5 � � � — —,, . ,_.. , ---- � ;Frame i ..... .... ....... -- . _._..�--�� q , _� _ _ L�E�ylnsulation l.�,r_6�(s-� � ✓U'l .______. ___ Lc�h/Dryt�ia;l- .. �;�-,.3;�-_,5-� .�___.____�__. i �. :ci�rio: �V ��, ", � j—�-_—_— �.`��='�-'=j�------ — i Flousa Numbar- . � - :Correct&Posted�_ � 41__M�M^�^�__,�,.p.,,,,.�,�_,�^�__�� � Final .... . . . . ,. """"^'-'� - Enter n�Fren} �.����.TM. ��_�� ..�.�.,.��I_...._._..F.s,t,__�.�.. . ......__...,_,...� . f �- -.. _ ,--------I------�__ — — —�-- -- ----- — _ -- : _ �.��.�...a.,�.�...__r.��..����.�.1_.—��,_���_._�� _�.,rt== — — -- --�.