HomeMy WebLinkAbout0794A 0796A 2183A 2201A _ .a . . .mr...__
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WORKERS'COMPENSATION DECIARATION �
� he,ebY°"�,m th°, � h°°e°�e��,`��°,e o`�o�se°f ro se�` qppLICAT101V FOR B�JILDING PERMIT
Insure,ar a<er!ifiwte of Workers'Compenstion Insurance,ar
a cenifed�o thereof Sec.3800,lab.C.! COUNTY OF LOS ANGELES BUILDING AND SA�
PalicyNo. � Companv�{(.�{�-�-�/(���,f`7 . . �,�y
� Cernfied copy is hereby 4umished. FOR APPLICANT TO FILL IN �' "�"° Aooeess �� �I�C.��mArtr ��✓+'
'�CertiFied copy is filed with:h co�n!y ilding inspeo BUILDING A ��,1��.������aaa ,J�
�ion deportmenf. qGORE55 S U � ��. (��Y �� LOCALITY A7'�'�M .�L{,.�' I
.� NEAREST (�
Do�e '� %�-Applicant � . ., ' CICv' ZIP CROSSST. (
CERTIFICATE OF EXEMPTI FR M N/ORKER� NO.OF BLDGS. a55E5SCR
COMPENSATION I ANCE 52E OF lOT NOVI OPJ LO7 MAP BOOK PAGE PARCEL
(This section need not be campleted if the permit Is for one TRACT •��✓ 6LOCK LOT NO� �,j� USE ZONE PMP
hundred dollars($100)or less.) No
TEL Cr�-��/ SPECIAL y� �
1 certify thai in the performonce of the work for which this �WnER NO. f CONDI710NS �� -���+ 9'�— �/-�U�
permit is issued,I sholl nof employ any person in any manner - . DISTRICT GftOUP TYPE FIRE PROCESSED BY �
so os ho 6emme sub�ect to ihe Workers'Compensa;ion Laws. A��RE55 � N CONST. ZO�EI J�(y ,}J/ �
I.W S, � �+J J'� G� I.++Gi.4lXj �
Date AppliCant - CITY Z'P STAT'S?ICALCLASSFICATION 'APT, CONDO. �
NOTICE TO APPLICANT: If, ofter making this Certificate of NGNIEERT R NO.G� " '�1� �_ �
Exempfion, you should bemme subjecl to ihe Workers' � � ' C1A55 NO, � �WELL UNi75_ �
. / �p_ .., . .. .. ...>.,. �
Compensotlon provisions of the Labor Code,you must forih- qDDRe55 �TJ iy�S GrI�7L� ^ SEWER MA?" ' - ' ' -' ,Z
wirh mmply �th such provlsions or �h��s perm�t shall be yqLIDATION
deemed revoked. CONTRACTOR �O. BK PG,
LICENSED CONTRACTORS DKLARATIOIJ ����
I herehy affirm that I om licensed under provisions of Chopter 9 P,pDUE55 NO. VALUATION � `-�` ���'4�'
(mmmencing w-uh Seclion 7000j of Drvision 3 04;he Business and �i`
Professions Code,and my Ilcense is in full force and effec'. div CLASS S �� � ��'0 ' ° "L::
/ �y SQ F NO.OF NO.OF CH`e�K
��CenSe NUmber_�`f���1.,�LiC.Class ��✓ �IZ: . �' STORIES FAMILIES �NE � � ��� � 4�.���(j
y� a 7 ) OESCR!PTICN Of WORK S �� �EW ❑ � }° ,/ -�-
Conrractod+'.f�F7/'✓11�7L�Da.te_��y���� ,J C`f �'�l :. -y.J'.�!:c�
� I am ezempt from rhe licensing requiremenis os I am a '� ADD ❑ . 3" j ,[ Y/,``v ,
licensed architect or a registered professionol engineer ALTER � FWAL �� n ? .��
qcling in my profesSiOnal capaciry (Section 7051, REPAIR � DATE
Business and Professions Code). USE OP - � � -
EX��SiING BiDG. � F1NAL �
oenno. � .
Lic.or Reg.No.� Date APFLICANi� {7�ti �� c°"P; TEL 1l f "��}1 gY / � �:i����:i�',
OWNER-BUILDERDECLARAiION ' (PR�N71 "ti¢'i �L .i��A,�-� NO.�;�'��'�, ,y! Rj�`J`ti'y (,
I hereby affirm IhaY I am exempt from ihe Contractor's License f� qh � '/�/�(�/�^' `� �j , ,� �F<_,,�5 " g`"
Low for the follcwing reoson(5=dlon 7031.5. Business ond ADJ2ESS �'t+� !��� W^l�(1^�Z�� `'�y���^'�'����a' �fg' � a
i,
Professions Ccde): � PRESENT .. ...- -.. .. . -,.•. • .: .,yyyf„�,�"�'`��J-ci.�'�i,r.{ E C,• �
BUILDING
� I, as owner of the property, or my employees with aDDRE55 �X � Q �'� � � - � :�7 V u
�:.,r'.�..,':: 6�,E., `.',k'°irr'... m . . :
woges as fhelr sole compensa�lon,will do the work ond � �t
rhe struc��re Is no�intended or o44ered for sole(Se<tlon .OfA',iv � � j���� ' �I ; �(;�.
7044,Business and Prcfessions Codej. !�nevi�G � - - T�_ �T.'��„�. F�'�' �i
� I,os awner of the property,am exdusively mmrau�mg CONTRA�TCR NO. �f�� •
with licensed conYracters to consiruct ihe project(Seo qoDaE55 -
bon 7044,Business and Professions Codel. �
REQUIRED 'OTApSETBAC�C FROM EXISi. ' �
CONSiRUCTiON LE�DING AGENCV sei sncK vneo :�mrv Rca.uNe - wioTH
�hereby affirm ihat�6ere�s a coos�ruction lending agency for =RONT
he per{ormance oi+he w�ork Far wh�ch this permli is issued v.L ��G� �,,3�1
(Sec 3097,Civ.C';. Sioe .
a.�.
Le�der's Name , � . }}e o e m 2�
� �e�ders add�ess P.c Fez s ���l^,i c=�m r Fee T ,�''. C4� � —� � �!� ( o � 6 5,6 0
I certlfy thoi I have read thls applicniion ond state tha;ihe '-�` ��"��'�`�'� iss e Fee +i� � .V v e N a e � �'�f�i��
� above�m£ormation is mrrect I gre=b comply wrth all County in�.esr�goimn'ee Ve^c / ~ F � %'� � O
ord�nan es and State lows relating�o�nullding mnstructior., ro�al Fee 1 � �ly���>� `x% ��'• � —' � ���� G'�%
m and he eb au�h � r esen!otives of 7his Gounry io en!er �
w �� ��, V � p
" u onl e bo -m n;lenedpropertyfc�'inspect'ionpurposes. � "'�'-'°"`�� ��'���>--���.��.�:�����!�:� -" � ^
p .�, .... . , .. ,_ ' .
�,� � SEE REVERSE FOR EXPLANATORY LANGIIAGE
� 5 nolure c'App��ca �Agen' Da'e , �6
C.^�.���� PLANS TG A�PLSCRMT��Y.+a��._P»Y.�R�If�SAECYOR'S NOYES --..�`�� O�"i�tiR.IIU1I.DER IILCLARATIQIR
. ��.,.�� 1 h=raby affi�m thct I cm exempt from the Contracfor's
��, � �Egj«��� 3 , � �� � � � Licensa Law for the followirtg reason. (Sec. 703i.5)
A��rsaed 1-� � �, ' - BusEnessandPrqjessinrsCnde:AsiyciPyorcouxtywhicFi
��Dafo P7o_ E1a?¢ .� .� �„, � reyss{res a�ersrrit fo=onstruct,aftcr,imprcve,denrofuh,
�— � or repairany s.racture,prior so iu issxaxce,al o requires
� � }S tbe�ylicEvaa for such permit Eo file a signed statesnent
r---� i -I tl ut be srldcensed pmrsaant fo tneprovisians osthe Con-
� � zracror's Lrcesue Lew(C7.>apter 9J(camasencdng wiEli Sec-
�-- iioa 7000J nf Bivistoro 3 nf tbe Busifuess and Professions
Ii ' Coe�e%ar fhat he ia erempe tberefrcm and tbe baars jor tfie
�_,.,,�,.,_ f ,.,.,_,„__ _,,,,_j„_�,,,,-� at!egeu'exemption,Amy niolatinn of SocEion 7031.5 by
.� � Roquir�c;;���. Ga9cRaaa:•a��! � . , an.y�p[ic�xdf ra(er»siasubjectsth¢applrcanttoaciedd
,4�prmvcia � 5 i ��a a:Ana;ovad � � yer.c!ty of nos'r.xo;s t�an fia,e bundred dol7ers(85D0/,J:
� -�--( � I,as owner cf iha properiy,or my emplcyees with
f���� weges as their sole tompensation,will do 1he�wrk,and
Vv'o�zr Cur;ificaie ! I �� . �
�_„_,__,_,_ .,�i_ I , . , ihz structure is not intertded cr o4fered for sale(Sec.704b)
� I He-Hh DeparPmern � � - I , ^ Bzesinnss amsl ProFessio,s Codz:T'he Corztrartnr's License
��____�___�� � . � . . Law c'oes r,�t a,r,�ly to ae�:c:rer�f y�rc�arty w3o buikls
f-ire L'^pcsrtment � �� ���-" ., , . or i,r.�rcves therer.re,ar.d wHc does raccb u.�mk bim..:e f c-
�J tfrou�h his nwx enrpZoyees,yrovrded efi¢t s�ti�i»�
�V�.a?��� � � � } , . , , ., prnx�aments ure rot intended or u9Jcred far saJe. If,
�__� - hamever,Fhe buifding o.-in:proven:cnP is sold w6tbsx ofee
�G�nlo ical �� � -M 3'emr oj comp6e#ion, EJo awfaet�builder wsll Aaoe the
� � __,�_,.___.__,___, � Ea�^slen?f f�+"osiroR tbat fie did faot huild or 1»;,/rrove for
��-�-��_ �� � tbe�urpose of sadeJ.
�Fedes�rion Frof=ciion
(ie:�ce](Canopy) I -. . � �.� �,as ownsr of the properiy,om exclusively wnfrao-
tirg wi9h licensed contractors ro consfrucf ihe projed(Sec.
S�Q!Inspection ' ' 7044).Ssssixess and Professxnns Cade:The Conlractor's
(:onc.J(Mosonry)f14'c•Iding?� — Licrnse i,Gu�does xot ap�hr'y tn a:a owner of prnperty who
J !uilas or inrprooer tberenn,enl mhn con;racts fcr sucl
g ! � i � ' .... � ' :. ' .. �- . � _ ContcBs witb a cantractor(sJ licensed pursu¢nt ta zhe
Lo:�Jroinoge p �r¢ctor's Lisense Law1.
Parkin i . -! I am ex=mpt under5�c ,B.BP.C.forthis
;'—_ '____i _ —_____.
recson
� �m_!�`��� . --- - bafe Owne;
�� :TdSPECe'O@'S F3f3TE5
w".�pr.avaEc 3Efe I :rssp�asCes�'s;' S:,-c� •�."•'-..^-"•`��^"
s... '
—_ _. .'i— _—��_ � —
4000PIOn-- : ' _�___.._.. ._..
(Se9back 8 Ycrds) � � ��,� � .
�Fcundations `�' �� j/f ,. . .. � .. ... . � -
. �`I b �` �� .
"rrame �.��' /i��.�S ^
�Energy Insulation � I - . . ,_
Lpfh/Dryu�oll-- j��9 ��' i
Infericr ��\J`1�i��'�C''��' J�`.��F. '�-- � I .
�tcth.-Ex�. -E . �
j Hause Number---��—� �
�Co�rect 3�7osiec'
__._ �. ._._.._�.
�Fincl- i
Enter on Fron9 i :,..,-,....,..rs�.:..-.,,...a:.� . .._. .. . , ..
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