HomeMy WebLinkAbout1712A 2263A 2264A (10) _ _. . _
_.__ _ �..____.__.--____ __ .x_.__,_„v.
WORKERS"COMPENSATION DECLARATION
� he�ebY°ff��m }h°, � h°�e° �e�,�{��°,e°f�°°=e�r 1° Se�` APPLICATION FOR BUILDING PERMIT ��
insure,or a certificate of Workers'Compenstion Insurance,or
a wrlified copy thereoF(S <.3800,Lab C.1
n /,� t �� �_ COUNTY QF LOS ANGELES BUILDING AND SAFETY
��Y N�J/ /.JJ.'�C�`�ompany 2'°"`'"'pr . ..., BUILD!NG G3 j
Certffled copy Is hereby f�mished. FOR APPUCANT TO FILL IN qo�sess f � /�� v1'�`"""`�'s'�` .-�''�'�� f
� Certifled copy is flled with the county b�ilding inspec- gUiL�ING } - !
fion deparlment. AODRE55 j��� ;v �,-.t3 ;7{ � �N LOCALITv I�.Z-y-, �f.��
NEAREST
Date Applicani C'�TY +.� �. Z!P CR055 Si. t_ i.t'..N'
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. ASSESSOa �
COMPENSATION INSURANCE S2E OF LO7 NOW ON!OT A4AP BOOK PAGE ARCEL
(This section need not be completed if the permit is fo�one iRaCi 1 USE ZONE MAP
h��dred doila�s,Sioo)o�iess.l ��`i�'�W 3 B�aK ier No. / no. .�3 - v'�-5 y
TEL • u 'b SPECIAL
I certify thot in the perYormance of the work fer whi<h this OVINER � �iV �/'/4 �� NO���f "D�"� �J� COI:�ITIONS �
ermit is issued,I shall not em lo an erson In an monner '! DISTRICT GROUP TYPE FIRE PROCESSED BY v
p p Y Y p Y A�ORE55 � /� l ,I/J CONST ZONE ,7 �
sc as to bemme svbject to ihe Workers'Compensation Laws. f� n .� r'� ,ii���� �
�ry �1 4
7
C'�TV /6 'iy:-• ;y� ,� ZIP s"' F �
�Dote Applicont STAT!S7ICALCLASSIFICATION APT. CONDO. u
ARCHITECTOR .— EL
NOTICE TO APPLICANL If, after making fhis Certifimte of ' � 7 !' Z, �
Exemption, you should become subject to the Workers' ENGINEER .) ,�/ G'. � NO.� ��1 CLASS NO. � �WELL UNITS_ �,
Campensqiion provisions o4}he LaboY Co(�e,yoJ mu5f Farih- qDDRE55 E'yjJ /.y.yt�✓ (;��'�0.,Hs � $EWERMAP �
with comply with such provisions or �h��s permil shall be
deemed revoked. � ThL // .���� g� PG, VALIDATION
CONTRaCTOR [i." W'c'/ �:�C'iVy"/+ NO Jr7G'—
LICENSED CONTRACTORS�ECLARATION ���
I hereby affirm that I om licensed under prov�sions of Chopter 9 aoDRESS�L/c�� T Y NO.LJL'37') yq�UATION
fcommencing with SecGon 7000)of Division 3 of�he Buslness and uC �� �J-�"�� z 1 7 1.2 A
Professions Code,and my Ilcense is in fuil force ond effed. CITv ,J�N�� CLnSS ^� �
SG `T.. �O.OF NC.OF CHECK � m a e s a�3
u�e�:e N�mee� `2-.5���f:i u�.c�ass "� �'zE.+�;C C� s�oRies Fa:v,iues oNE s � 1�''���< " I • 1 0
T ? ^ESCRIPTION CF WORK �J2Y���9� yy� ' NEW � � r ��,R O
Contractar CL'���✓' C'p:.��I- Date Qi `�S�' f ,
� I am exemp�from the licensing requirements as I om a L`� '� /v .'4c ADD • � � U l''��'�'
licensed orchitect or o registered professional engineer ., aLTER � FINAL � �%�pa J
acting in my professionpl capacity (Se<lion 7051, R�PA�q � DATE a � ,�(+8�
Business ond Professions Code). USE OF
EXISTING BLDG. ��� '�u 5 ��!}L �EMOL � FINAL
B
lic.or Reg.No.— Date APPLiCANT �El
OWNER-BUILDER DECLARATION �PR�NTI �O. �
I hereby aRirm tha�I am exempt from rhe C�cntraUcr's License
Low for fhe following reasan(Section 7031.5, Business ond �DD4E55 •
Prafessions Code;: cRESENT
� 1, as owner of Ihe y, y P Y �U.L�ING z C[E,. �j��
propert or m em �o ees wilh ACDR"t5S
wages as iheir scle mmpensation,will da the work and �u� � e
the struc�ure is not intended or affered for sale(Sectian .00aLliv ., °��
7044,Business and Professions Code?. MOVWG TEL
� I,as owner of the property,om exduslvely contwcting CONTRAQOR NO ` � �' "�4.�i�1
wilh Ilcensed cen!roctors to consiruct the proied(Sec- �
tion 7044,Business and Professions Codel. AD7RE55 e � �>��; �1 c�
REC(11RED TOTAL SET3AIX FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BaCe �ARD �'Wv pROR LWE wiDTh' � O�:G O"'rb C
I hereby affirm thor:he�e is a cons�ruction lending agency 4or FRCVT
the performonce o'+he work far wh�ch this oerriit is�ssuec v L
�se� sa9z a�.c.� s oe �2 2 6.4 A
��.
Lenaer's Name q_���,�..y #y e �; o e e 1
�.:, Fee F <—+f--='"'9'> Perm�l�ce � �`�
Lender's Address � �„ � 0 2� G,S(1
1 cer+ify�hat I hove read this cppilmtlan and stale'hat the C�1'� �fj iss., .e Fe= �..J �f
above i�formation is correct.I agree�o mmply w»h ail County :esrgai�on=ee .�i � � �f� ,✓t) ° °L i „���v
ordinances and Stale iows relonng te building consiruction, i�'Y"C'�- ?orcl Fee h' `r v
ond hereby ourhonze represen•atives of'his County to eNer �ti,c'Q—c4,�
upcn�he�ov M:oned propeky�c��:nspe<tion,ourposes.
��/!6'`.w- � „3'—L., SEE REVERSE FOR E%PLANATORV LANGUAGE
�yjgrihvre oi Acpl:a� c��ce Jate ��
�,
. _r. ...oa...e,a.m,�a�....,..:^>r-.,._m....�..�.,.t=.:.--.,:,:�-,�-�-_--...--�.,�.,�-...a—,�.....>.__.__P_.�...._...,.....e....e.-a�,.o-.���...-.y----._.._..._"'._._'�'____..... _ ' �..
�..�._._..�..�.._,.m.,� PiPmP35 i'G AP6�LICqNY,g•.�.�T....�...�..i-.,��.814� _���-- IE�EPSCYO�'S fd07E3 OWNEA•3UdLI�EA I)ECLAR.AT'IOti
�.�a_ . ... .. 4 ' . .. .... ..-�-,..---.-Y-.�-..�� I hereby affirm th��!cm exempf from ine Conhactor's
'r�•e ���`�n�� iicertse La��rv for }he 4oflowing reason. ($ec. 7035.5)
N
J�_T,_ J 6pg:re.r=_8! -- 1SfiSY��S36Y[IPPnfxss4ostsCode:Anyr,'CyarcountywAich
.?.+o.I 6aPc P€�. Jate i � raqzires aQernaai to cnnsisuct,alter,irrrprove,demolssG,
�=I'-'—' - �— o:.rpGirany.esructure,prJortoits''ssaamce,clsorzguire:
� abe appP:cant jor such permit to fsTe a sigr�ed seatement
--�------- �—�— -I---� .hct Ge 6s licafrscd pazssuan>to the provisions of tbe Con-
' � � !Aw.cto:'sLdcansaT.¢:✓(C'r_cfi3er9J(ccmntsncing:ulthSec-
F !ion 7�OCJ of D:vis:on 3 of the Eusi�t3ss and Professsons
� E ! j Code)or tbat be:s cx2sr.pa thernfrom aa`Z the 8asis fnr tbe
,,..�.�_..,....�.,.._,r.e,.._.,.,......._e_�..__...�_.�._.s._-��e.�� c!legn'a.rcnaf.teosr.r3say vioT¢tion of,Ssrlsr,r.703f.5 by
Rs�as3:�:�W � �'n��¢�_:e,� ' av:_yx�plican.tfOT..^.pCH'IHSECdLF1'3C�5COCC�pIZLQ48SSPbLiLRE
'� A��savts4���-----� QP����,a,,.�� � . _ _ . yer.alt��nf v:oi r.rn:e tl�e;n flcve fiur.dre¢'dindi¢rs($SOOJ.p:
�r�.,: 6do
L_�—� � � �,os o�vn_r cf ih��ropert„or my emplovees•a•i16
U:'cter Cer;;`im!a weges 6s their sole compenso9ion,will do ihe work,ond
'�i' � ine siructure is no!in9ended or offered for sale(Sac.7044)
� � _ _���.__�...���_; . •
�Haclih Deparimertf �� � I . d3azsimess cxd Pe�essiorss Ccde:T'fie Cematractnr`s Licesase
�.,___. ._._..l_._. .,� Lcw docs:?ot c�51 u tn¢;s nwner nf praper•y u�aa 7suslds
or i:K�^.reves tL<_�^;cn,r�::d w.bo�ces such wor8 bSmse cr
�Fira�eportm�n4 ^� ` . . �
thrnngh ris n:un eneplo_yues, �r�c�ided thm±srscb inc-
9"�eding� � �I � �rnuemer,ts are rar,t inter.dea or ojfered for aa1e. If,
4 � _ � bou�evc-r,thabuiltlirzgcrexa2hrovesrantBssoldwithinorze
�G=..olnqital � � � .� � . ye2r qf com¢detfox., 3$z owzer-buadder wiF1 fiave dbe
L•urae�qf�trovir�g that 5e rdr`d'teoE Gsaelsl or iyy�.$rnae for
�destrian Protection I�"-""' — Phz�;ur�oc:ofsal¢,�.
ch<e)(Canepy) I � �� �_ I,as owner of the property,am exclusively conira:
��y _I I tirg with licensed contraciors to consiroct the project(Sec.
�SFecin!Inspzcrion � � 7944)Business and.(':of�ssinnx Cade:TGe Caxtrnckoz's
�..onc.)(6Rosonry}(lAJeidir.o) � i.fc3wsn Lau�does not apQi,y fo an ou.�aer of�Pnf�eYty wl�o
� _ __ _ . . . Es�ild.s of iwcprna•es thereom,anu�¢�1 rs oon.trwctx for sucl�
�o��rcinage 'I � � �proiecEs ri�lah a rontracaor(sJ licensad purs�nnt to tbe
� . Cvntractor's I,Srn.mse I.auyi.
�7arkinq- : . !I `�� .r�.__.�_. .
��—�- � � C. I am exemot under5ac. ,B.&N.0`orihis
� i ---M � recson _
�!—^ ~^ � Date��. Owner
�s�.._.a._..�,. .a,l��_m.-._�_...��-...,,�-.e-...._� �
d4�;aruvsis ' ,ryc".� I :����,�axi3r'f�5d�nrc"::�>6
� � � s���-��i@dSPE'd'PC�R'S Wp?ES
location-�, � _..__ ....,.�,.,...�.4'.,�,,.-._ _ '.�,.""""'""'
�:Seioack U+.Yards) �`--^__..�.�_�_._� ...
Founda9ions I
Sia6 ��
�Frame 1/�3�
�---��-- /dl i
i Energ� 'y!'�su�affon � . �
Ld' h/�ryvrcll— � I
� in��rior r7��G �`'p� � /� L.t� �
�La:l�.__Ezterior CI j .
� I
��iouse Nurnber-� I
�cbr:�_ct 2 nost2��_1__.___. I �
�na!— �_7_,,.e__� I . _ .. .
enier on F:onf
i � � I —
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