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HomeMy WebLinkAbout1304A WORKERS'COMPENSATION DECLARATION J'� �I hereby affirm tha�1 hove o�e�,,,,�o,e of�o�se�„o sa�� � APPLICATION! �FOR BUiLDiNG PERMIT � insure,or o ceriifitate of Workers'Compensation Insurante, or o certified copy thereof(Sec.3600,Lab.C.) - ' COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � 2 � Ce�r�fied copy is he�eby fomished. FOR APPUCANT TO FILL IN ADDRE55 �� ���. 1 �,)�+�� �/ � Cerlified copy is filed with 1he counly building inspec• gUil�tNG /� � (�� / A� lion departmeM. A�DRE55 ri �� vrv �ate Appliton� Crt� O iP �Ocqurv . � CERTIFICATE OF EXEMPTION FROM WORKER$' NO.OF BlDGS. taE.4RE5T d COMPENSATION INSURANCE 52E OF LOT NOW Onl LOi [ROSS ST. (�R..7�D� - � �This section need not be completed if the permit is for one � . !uEu�R hundred dollars(E100)or lesi) TRACT BLOC �LOT NO. MqP BOOK PAGE PARCEL ,E�.86a�3 � NE �P I ttrtify lhot�in the performonce of ihe wark for whith this O�NNER - � NO. ��3 ,,p. _33 permit is i u ,I shall nof employ any person in any monner /�, � SPECIAL �. so ai to b co ubject to the r rs' pensation LawS. ADDRE55 . �i��"I� �• �Oc� 0 CONDITIONS A V Date Appli n � CITY D Y ZIP � � - � NOT�CE T APPIICANT: If, a ler moking t is Certificafe of ARCHITECT OR TEt. OISTRICT GROUP TYPE f FIRE PkOCE55ED BY O Exemption, you sho�ld become ]ubja[f to ihe Worken' . ENGINEER NO. �pryST.f, ZONE _`_/� � U Compansa�ion provisians of Ihe Labor Code,yo�must forfh• qDDRE55 �� V� \�l _ W whh mmply with such provisions or Ihis permit shall be � ' n. deemed revoked. TE�• �f STA7iSTICAt ClAS FICATION APi. CONDO. (n CONTRAC70R � NO. 7 Z LICENSED CONTRACTORS DECLP,RATION ���, C1A55 NO. ' ` DWELL.UNiTS I hereby affirm Iha�I am licensed�nder provisiona of Chapter 9 ADORE55 . NO. ( 7/ (commencing with Seclion 7000)of pivision 3 of the Business and ��� ^ ��R�P ', Professions Code,and my license fs in full force and eHect. CiTY � MSS �t-'��� VALIOATION I�1� (� Sa.FT. NO.OF NO.OF CNECK BK' �'� LI[ens8Num6er � �� LI[.Clais "`T � SIZE �� STORIES FAMILIES ONE „�__L ���� ✓� g? VALUATION Con�roctor-��Y� D41B DESCRIPTION OF WORK NEW s SU� ADD ,❑�am exempt under Set. � ARfR �1 3 Q 4 A 8.67.C.for this reason REPAIR s � � � � � Dafe: USE OF #• • � • • � EXISTING BIDG. � 1� EMOL Signafuro � APPIICANT TE fINAI � +.� •`3 6'7 5 OWNER•BUILDER OECIARATION velNi ( NO. '� DATE �— —�JQ � •,� .�(�'�5� 1 haraby offirm Ihal I am eaempi from 1he Contratlor's Licenee � �Z� A, ,� ��a�,rf� low for thn fol�owing reason(Section 7031.5,Busineis and AODae55 ��'U FINAL :�q.�2•-$'] Professions Code�: � - aY BUIIDING '� I, as owner of the property, or my employees with AODRESS . wagea os their sole compensotion,will do�he work ond i�1TY� � � � - tha structure la nof intended or offered for sole(Section � � 7044,Businesa and Professions Code). MOVING � TEI. � � � � � I,es owner of Ihe property,om ezclusively controcting COMRACTOR NO. with licensed comracrors to cons�ruct the projett(Sec- qDoaESS � �� � � � ' � tion 7044,Buiiness and Professions Cade). CONSTRUCTION IENDING AGENCY - sE�ancK YAR� Hwv TOTApRbTV LINE WIDTH � � ' I hereby affirm that there is a tonstruction lending agency(or� FRON7 . ihe performance oi the work for which this permit is issued v.l . (Set.3097,Civ.C.). SIDE P.L lender's Name � n�. L r� IDMA Ref.M ' m Lender's Address F.C.Fee S 7ermii Fee •f J . , � I ceqify that I hava reod ihis opplication ond state that the . .. insaonce Fea /�-'s� LDMA P/C N ' ebove informa�ion is correcl.I agree to comply with all CouMy Invesnqauon Fee y < �. $ ' es and 51ote laws relaling to bulld�ng construction, . To�al Fee ��/ J IDMA Perm.N - ' � �� R ond her y Quthon represenfatives of ihfs Coun�y to eMer � upon the bave� tioJn(�ed,�propany fo_r inspaetion purpo�jses. , ^ �CW/�-�' �� C" p� SEF REVERSE FOR EXHANAiORY IANGUAGE . ' Signorure of APPlicam or Apen� porv . � . .. PLANS TO APPIICANT INSPECTOR'S NOTES . U�11\F.H-Illlll.11l�.lt 1)ECLARA�110\ - 1 hrx.cF:y<�fi�.n�tl,�r I�m c. �.,p�Irun,ihc fo.,r�o_�!or's To� ' � . Rvlwn�d� . . , Li:en<r lmv Inr the !oli ng rnnson i5c:. 70]1$i• .� ' APPrOvad � 1lnciuexsnnJ.!'rnlrsdonSLodr:.�ns��it��nr:uunh'�rl,ia! No Dafe No. ' .�o}e `. . � ' .... • ' � . = r�•yur e prr eitlu�unsiru�t.dltrr,en:pr�� �.drrm�li�/�, ti - .. , n/mrun�crroctun�./�rinrh��tcicv�enu.dltnri�� ' c _ � __ _ . . . . . � �% .�'`� � � � - � �' ��Y tltah � Hlfl n� !r R Yr �1 Sl�! ynl � ._ Li.�t `'l� i-�S r,j , t! r%��6.��,r/ SI /�'> �1+ c �! - _. ._ . _ ` �u �!< s�n:�- ,u ��.�r n���.� ,�r�� r l d�- ... . r� �. ,...,. �-'�j�-S �' ��..,.� t':�; ... . tru.ior'.l i�.a����f.✓i�(Cl�ap�rs'>l(n, ir�.t u�irl,1cc- _ . . _ . _ , ' . .. . n, � ... . ." . _ .. .. . �ion ?00l1 If�sin� /Ir�J�s�i�,n� ., ... _ .. )r�/!)rr•i�„�n 3 r,J th�, �,. . � -- _ t. - � . ._ -''i� ' ,tS•.l��T�:'�•..) - . _C,�J�•Jnrtf�a�l�eiat•zrmptrlerrJr,�mu dU�h rl.�,rr/.e .. . .. ___. . . _ . . . � .. . _ , aRr.qad cxrmp�i.rn.Anv�•ruluti��n.r/.1er�inre 7b31.5 Fr _ _.._ ._. __. _ .�8aquir'ed'.'�' t '` . .. � . _ _�� �..`:��.� . . . .. .. '._�. . mn�uPPh.�+n1/ur��prrnrileuhjr�l.��be.�f,plrcan�m✓u�il � oafe aeeeirad • APProvals o.qoproved _�:penuln�d nnt n�nre thm�/n r/��,�Jr.-d Julluro(Ssr101J: �� Yes No .---- - - . .-. - -. - . . ( � 1,as owne,o!�he o .t� o•m � ob�:c�z wirh _—�— ! --__ - -. .. c 1r�-. . •,�.-.. _ p�ry yem� _ - ` . '�� pr .� !. � � � ��' �vd,c�:th�..orb.nnd lbo•��.Cr.�fico�e -� �� � �•� _- - "` � �� �.. � wngr.s as�hc��r solc cnmpensonon .... . - � .\.e � i..� ,!I; �t ` . `'�- . ihe rructu�e is nor�niended o•n�fereJ fo a I_(Se�< 70a.; . F�eol�ni7eva.vnen� .. _._ ._. __.�• � � _ � _ �. _� � - . .J. _ - . ...�y _ . . .. liasi 7�1 s< <. rC�i + , esc unJ s 'inc C.arl��7'h t K.t l .7 .. . l ..ii i.. �ile.•,...., .:� �.�__�uJ _ nu�fPlti����r1'o r /f��� �h'�,(.,�F�r(J� � F�.e Ge�pa,i���nr . _.. . _._ ..... . ... . ' :'.' . . ur i�r��,� �and�! d�..�.v ro/�f 1<<�ili.n.-!/nr .. . , ' ,. tlruu,�L.6is'nu•n empli�vr.'e�. prurrd�rJ.f1�dY surb i - , r.r � C:rndin9.. -. I .1., .. � ._ • � �.•.� _ �frn��rrnen�r'arr n.rt irtf�•xded u. rr//�reJ/i�r su1.-. /1. ' . � . � !nu ei�rr.tLr Arsillm,q nr rnrprne en�rn�iv xr�(d�rrt/br nnr Geoloq,cnl�- � - _ .. . . � . ' .�,� � . � . �� - - � yeur n��rnnr��leti��n, 1Lr�neeiier.Frn/Jrr�ril1 bnr�- t!� . `.�"t 4ey i ._. '_'�' _.• ... ✓j'�/. . �- . 1�urJi•n o/fror hr,�,�hur hr Jid nnr hue11 nr nrryrro���/ur 7edestrian Proteuion - - -� .. ��t 1 i � tJ�p rJ r i�/ !J � .��. . ��F�nccl(Ca�oPY1 � .. .. . . . � - � \`•. _ � � '.� , .( i-. .•. _.. . . � � �! I.u:o�+. rr of�hir propcary,nm c .I.,�s�cly rnnvn-. � �. �� ._ . , . tin9 w-ith hcensed co�+trauors io cons�rucr thr pro�ec+jSec� .. • �' .. � �. Spe•c�cl i sp:u�on �. . .. _'.. . . . - .._ . r..; ._.0 .._- . • �'�, . 'N /�.c. � s f Jrr '!br Co»rr„�h,rs 70ea rsr-ss �d 1 S� �Con<I(MnsonrYl(V✓elJ�ng) �� �. ��. . . �.._�_... . � . . .. ' . 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