HomeMy WebLinkAbout1783A 1994A 1995A ' WORKERS'COMPENSATION DECLARATION � �
� I hereby offirm thot I hove o certificaie of�onsent�o self qpp�ICAtION FOR BUILDING PERNIIT
insure,or a certifica!e of Workers'Compenstion Insurarce,or
a cernf�ed�opy thereaf(Se�.3600,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po.icyNo. Company
.. ,._.. _... . .
� Certified ccpy is hereby f�m+shed. FOR APPLICANT TO FILL IN acoaess �G'-C-7 .�1� �-rw._✓7�:eL'- ,r-�-
� Certified<cpy is fiied wiih the county building irepeo- gURDiNv ,�/� p�
non department. ADDRE55 �W )-i LCCALitY _Q,,.r�-,.�� .�,L/
�1 . � NEAREST
Date Appllconi CITv 6 • (�dL�P l/"'�.� CRO55 51.
CERTIFICATE OF EXEMPTION FROM��UORKERS"� h0.OF 5LDG5. ASSESSOR
COMPENSATION INSURANCE SIZE O'LOT �'OW ON LO? MAP BOOK PAGE PARCE!
(This section need not be completed if the permit is forone USE ZONE MAP
hundfed dollars($100)oY less.) TRAci B�OCK �OT NO. NO. y
TEL r2 SPKIAL �
I certify�hat in rhe performance of ihe work for which this ONJNER �,I NO. �'/' CONDITiONS Q
permif is i55Ved.I shall not employ any persan in any manner D'STRICT GROUP 7VPE FIRE PROCESSED BV (�
so as to become w6lecf�o ihe Worke Cempensation Lo✓�s. ADDRE55 CON57. ZONE �
o � �� ,^ .�'�=� '1�
Dpte , a a Applimnt �' '4� CITv Z�P SiATISTIC/+L CLASSiFI TION AP7. CONDO. �
ARCH�TECT OR TEL.
NOTICE TO APPLICANT: If, aft kmg this rY i te of �
Exemption, you 5houl J beCome 5ubjeCf IC f e OfkerS' ENGINEER '�D. CLA55 NO. :-=`.�1 DWCLL.UNITS �
Compensalion provisions of the Labor Code,ycu must forth- �
with ccmply with such provisions or ihis permii shall be '��DRE55 SEWER MAP �
deemed revoked. �^ T��� BK. FG, YALIDATION
coNrRncro� 'N l, No �{y ^�f?7�
IICENSED CONTRACTORS DECLARAiION L'�C.
hereby affvm Ihot I am licensed under provisions of Chap!er9 AnDRESS � ���(J�ILp NO VALUATION
commencing wnh Section 70001 of Dwision 3 of'he Business and �/, �IC. c� 7�3 p
'rofessio�s Code,ond my license Is in full force and effect. CITV rv6Q/U�� CI.A55 G"4�5 S �
SO.F? � NO.CF NO.CF CHECK �o a o q.'��
icense Numbe������ Lic.Closs ��S � SIZE��.3 STORiES FAMILIES ONE ��
o�rra��or l�FUK 5lEN Ca pate�� oesceicT�oN oF woRK ue'� ❑ � ���30�-k- ( a � 1 �4 0
] I om exempt from the licensing requiremenis os I om a (,�JJ�,L� � AD9 � � = ���I v.�-'l�c=i
licensed archi�ect or a regisfered professienol enaineer aLiER � FINAL
acling In my professional mpacihy (Sedion 7051, qEPA,R � DATE (1 J`.C��/`�2
Business and Professions Gode). USE OF j
E%IST.ING BLDG. . D`����� ❑ By � ( q, ,
c.orReg.No. Date AoPL'CANT , . '�`r� "�n� ':EL�. �j
OWNER-BUILDER DECLARATION iPRINi; ' r.�J.! �:�J yi.��� n10. f'f�'�C �
hereby affirm!hai I om exempt from�he Coniroctor's License L' +K.�E� N* 4� ! -S
w for the following reason (Secticn 7031.5, Business ond ADDRE55 �,
�ofessions Codel: PRESENT
�19i4A.
7 9UIL'JING m
I, as owner of the properry, o my employees with q.�ORE55 �� � +2 3
woges as their sole compensption,wlll dc ihe work and
rhe structure is nct intended or offered fo•sale(Secticn LOCALiTv ,� ° ° � �,�G
70d4,8usiness ond Professians Cade?. a4CV:NG ?%L .
] I,as owner of 7ne property,om exdusively controcting �`��UTRACTOR NO. m a a � [;./+('j�
wi�h li<ensed controctors�e construct the proje<t jSec- qD�RE55
tion 7044,Busness and Professions Codel. �.').�9"��
RE�:11RE� TOTAL'JE'BACK FROPA 'XIST.
CONSTRUCTION!ENDING AGENCV cET gp�� "%�RD H�NY pqOP L�NE `A�IDTH
iereby affirm Ihar there is a<onsrcuchon lending ogency for =RCN� �� �9'��
e performonce oi rhe work for which rnls perm�r is�ssuetl .�.
ec.3097,Civ.C��. SiDE �a e e e o �
PL
nder's Name � � ° �G 9.5 Q
nder"s Address F C.�=b / � Perme Fac- �,�`? e e u[F CJ�O�
eriify ihot I hove reod'his aoplim:ion and stata tho•the � �(.�Z] ce Fee p�r � �,').L C/--��
ov tien is cerre<t.!agree fo comply with all Cour.ly I�..es-laailen Fee �ss�a,
s a Siare laws relating'o bW Iding mns�rurion. io ol Fee .�V �
d hereby a ihorize repr entati es of+his Co�nty lo eNer
- pro y'ar Inspection purposes.
� F SEE REVERSE FOR EXPLANATORY LANGUAGE
a�
�namre of Apo�im or A n� Dare �
/
. PLAi�S Ts'A APP�lCdaMY i MH���.a�� Is�S4�ECTOR'S h�OTEB �� <14Vi�F.H2-IS:;ii.T�EA 3ECLt#RA7"ION
i hersyy affirm tFat!am exemps from the Cor.tractor's
��, �eqv,z,�4 ��aR���� �T�T���V�� liceose Law for ihe following reason. (Sec. 7031.5)
�.��A—u w.JA".1..�����tl���-A,�psa�Wd �'�es4wesscr.rdProfessiensCode:Asaycdtyarcaur.Pywbiefi
��,,� ��9q� _� �Q� �yq'� _ �zquims a yernxst to cnsutruct,ad.'er,ixeprove,r6ernodisd, �
� �= , orrep¢ircnyslructure,grlorto4tr:ssuanm,clsoreyuires
; � � � ! cd e a/>f�Tirent.for sucb perrxit to f'le a sigre.d ststcment
1-i ��----- — L'sat hn is tire:s�d pursuant to tba paxevisions of 3he Con-
I irccaor's 3_.Ecersa-L¢eu(C.':�Qpter�J(eon:menei�g�dtk S¢o
+_�_—._T_ �.__ r.'a:s 7G:i0i�i����sic.3 of t7ie Eusivaass ar„d Professio+cs
� i! �—� ---� Cr,�leJnrt{iatd�e:;exena�n:zi�erefron�axrlt'aebas:sfovtl�e
i�.:f..l,�,.o.,.,.,._...._..,�.,_ ___.,r. - ,._.,!..,�,..._.,__.._-......,.�---- ct!^2ed nxemptfon.A^y violatior:of Sectinn 7C31.5 by
_��vM� �r.rsy'-��; .�� � .. asa;r;h�laca«:joreperrmit aubpects sl e applicant to a ciuzl
&• ovcl�. y-- CSa4�Si�:aivo3
��'" a;.:ti�o;�a��Nr:�' } `er•¢.'�'y of.nt saxore than ji»tiuxdred dollar�s/§SGQ}.,JD
,i I � §!.x �_ ,al}--�
•�-'.—___—_—_'___��_..��._�,-_....._�._.-- :_� I,as ovvne:of Phe propery,or my emp(oyees wi9h
I Y'ic4cr Certi¢icc4e ��— � �veg�s cs their so!e compansa4ion,will do the work,and
jf�-��-���� __.�___^___j the structure is noP ir,tended or oifered for scle(Set.7044)
'Yie6Nh�7f9orfinen4 i � � "`- -� Lzusl�eascn�Prefessdons Codc:TL•e Cor.t:a�aor'sLuense
� � 7�iw sdo%?t nat�3�1.y 4o ar owmer�f�r��2ra3:wFaa buidds
� irs Ce ariment � �-��A�._�-y.l� _"-'-""'�'-"'-" —.` or zs7a�•oves EF.eeec�t,an�+s�hrz�ncs sasch.work�%�aesr!{o«
r P .�..�.�r.__
t��_�.�� I � tbrnugb 1 is nu�xi employees,f rocfded YhaE such in:-
- �Grcdin� g � � ,firovemz�ts ara not d�stended cr ffvreJ{or saJe. If,
Y_� ��__J, � haweuer,tbebu:ldingnrrmhrovement:ssaldwithlno�ce
�Gpolcgital I � • . +�car oj com+�deEiox, ibs ourner-bufdder will h•ave tfie
.___�_______„___.�_�._. .�,__L__�._�..�_.�..._.�.�.� ?�ur,{�x of pra+;ing t.5ct bc d{d ret buidd or irnprooe Jnr
a:destrian Frotection - c1�e purpna�a�`saFeJ.
� ' �� �C� � I,as owner of Ihe
i(ren )( cnepyl �I I property,amezciusivelycon!rao-
�__ �_, ``� tir.g with licensed coniraaors to consiruci the project(Sec.
_ �Specinl inspec9ion 1 , 704?1 Bus�ne=s cs�d P�qfessions Code:TFie�or.Eractara
I�=.anc.j(Tr.d-onry)(N'eloing)! i �,•cs:.sc I..�u•Joes noi ophTv tn<r:�u•nc•r�propert:'w10
' " _�_�___ ____ � 5uil�:or i.»�.,nrovn.s?i�erenn,nnd u•hc rnntracts for such
�Lot D:oinage �J ' . (�rojects u:it�n r.anSra:tor(sJ deeensed+�ursuant to the
� Co:xt�rrtt.or's.L:'CaMre Lewf.
�Parking � � �
y _ � L__^I__ ❑ !om cxemot und2r Sec. ,3.8P.0 for this
� � i — --_ —..- � ._.
reason
� L �.�
� Da4e Own2�
�,.�..._.�d..,�.��mml__�___�,_.eryx.�.�._ ____---
I �3t �C$v? I �T�Ei.�:deOY�.�'ui«::�G:>•,;T2�� _ .
'_—A 3POV�SS ( ' ��v/��� B{V9PECTQR�dNOT�S
Location—� —�—_ — .—� _ . , .. , . _ _.,a».�
(Setb�ords)
I�OVIIGCilORS ' i .
!
Slcb � ' . �r..� — _._.�._
Frame { 1 !` . . ..� { .
I d i
eryy Insulction i .. . . �
E�a�enio�yU�u—_ � — "
�in+�=,ar —_- --- --- �--
LcPi.—Eztcrior . � �
Housc!Vumber—. I � ��� ' �
CorreU��B Posted f � ��� '
Finul—�^ � . — . . .. .
En;er on Frcnt � Tn,�d_���__� ' _
�.'_'__�'_ �__'— _1 _
� _ —._. _' , . ,
. � �-�.s— �._�...t',�—�_—.,���.-��_�—,�_ a.�—�,»�a' _ _ _ _,