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HomeMy WebLinkAbout1527A (8) WORKERS'COMPENSATION DECIARATION � - !I/hereby offirm �ha�I hove a certifimte a,�o�;e�,,o self APPLICATION FOR BUILDING PERMIT . �insu�e,or o cerGficote of Wo�kers'Compensotion Insurance, �. �r a ce�t�fied copy thereof�Sec.3soo,1a6.C.) COUNTY OF LOS ANGELES BUILDING ANO SAFETY C\ � .�ilicy No. Company � Cenifed wpy is hereby fumished. FOR APPLICANT TO FILL IN BUILDING . � �`\ ADDRESS � , � Certified copy is(iled with Ihe tounty 6uilding inspec• BUito1NG • ' �ion departmeM. nooae55 0 -r U � 1 ..Q,h1 P_ • ♦ ' Dale Applicant CITY �Qm� I � 21V ��� tOCALITY r Q�� � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. . NFnRESi COMPENSAT�ON INSURANCE SIZE OF LOT NO'N ON l07 CRO55 SL � (This settion nead nol be completed if the permit is for one n55E550R hundred dollors(SI00)or less.) TRAR BLOCK lOT NO. � Mqp BOOK �AGE PARCEI TEL.7/f OWNER (1 ?r �':' � INO. �^, � USE ZONE OP � I cartify ihot in tha periormance of ihe work for which Ihis �r _ �„ permit Is I�sued,I sholl nol employ any person in any manner qDORE55 Ot � 1 !IJ L�a�J e. SPECIAI p_; so as to become subject to�he Workers'Compensati Low. '� U CONDITIONS � 1�Date Applicon CITY �u t�n�-J� .�' LP ( I��� NOTIC TO_�T: If, olfer making�this Certificate of ARCHITECTOR TEL."7 `/ DISiRICT GROUP TY7E � FIRE PROCESSEDBY O ENGINEER P NO. �p/�fJT,—� 20NE F— Exemp�ion, you should bacome wb�ect to the Workers' � V Compensation provisions of the Labor Code,you must forth- qDDRESS � '� �� ti ��A 0. with comply with such provisions o� this pe�mi�shail be � TEL. ,,,,,, STATISTICAL CLASSIFI TION AM. CONDO. tn deemed revoked. . CONTRACTOH NO. . Z IICENSED CONTRACTORS DECIARATION iiC.- C1A55 NO. DWELL.UNITS � I hereby offirm ihot I am licensed under provisions of Chapier 9 ADDaESS � '�� NO. "f (commencing with Sec�ion 7000)of Division 3 of the Business ond ���, `"�R�''�'P . Professions Code,and my license i:in full forca and eNect. UTv ` M55 '� . BK � YALIDATION 5p.FT. NO.OF NO.OF CNECK � . Li[ensa Number LiC.Class SIZE ��O STORIES FAMILIES ONE � VAIUATION • DESCRIPTION OF WORK N� C❑ontrottor Date ADp � s 3 Q�d � , I om ezempt undar Sec. � ALTER B.BP,C.for ihis reason REPAIR s � � Do18: USE OF � DEMOL EXISTING BLDG. �Signature APPLICANT 7EL. , FINAL I � �� . OWNER-BUII�ER DECLARATION vRiNt No. DATE � I hereby affirm thpt I am exempt from tha Contmcror's License - � � Law ior ihe following reoson(Section 7031.5,Business and aDORE55 FINAL Pro(essions Code): � � R N � gY � � BUIIDING . I, as owner o(ihe property, or my employees with A�DRE55 �� S�L I A wages os their sole compensotion,witl do the work ond � � , � . �ha struUure is not iniended or affered for sale(Setlion ��'�n� �{• . • e • � 704a,Business ond Professions Code). enOvwG TE�. . � I,os owner of the property,om exclusively contracting CONTRAROR NO. . � • •4�p� � _witb licensed controUors to construtl the)project(Sec- � - . -0 4�O O U tion 7044,Business and Profassions Code. nDDxESS w a = REOUIRED TOTAlSETBA K CONSTRUCTION LENDING AGENCY � s�i gA�K YARD HWY PROP.LINE - WIDTFI ' �9, �_8 8 I hereby affirm that there is a construction lending ogency for FRON� � , the performance of the work for which this permit is issued . P.l. (Sec.3097,Civ.C.). SIDE I ' P.L lender'a Name � - � � � L�MA Ref.M 1' . . P.C.Fee�S Permit Fee � � ' Lender's Addross � i; � I certify thaf I have read this applitation and stata ihat 1he � lesuance Fee �� � IDMA P/C N . obove infarmalion is corrett.I agree to comply with all County Investiya�io�Fee $ ordinonees and Stote laws rala�ing lo building coneuuctlon, � Toral Fee LDMA Perm.M �� R and hereby auihorixe representatives of this County to enter � vp�t�abov�onqd proper y for inspection pur Z s �. � S� —�7�0 SEE REVERSE FOR EX►LANAiORY LANGUAGE n J �S�pnafure of ApPlicam or Agen� Date � � � \ PIANS TO APPIICANT � INSPFCTOR'S NOTES (7�1i\�I:K-BUII.DIiH llF.C1,ANA'1101 , I he.eby o�fi.m,IF�oI I am exempl 4ron,ihe Controac�"s To: . � � � ReWrnod . � � . . � �- .� . , , �Licr.nse�la�x• ,fer ,the following reoyor (Sec. 70]I.Sj � Approved . . . .. . I3usir�racnnJPrnJesdnnrCode:Ant'citt�nr.nunty�rl.ic! No. ❑me ' No. � 'Dmc . .. � . . -, rcyuires o perruit 1u rnrcafrvrL�ltrr.Lrrj,r�� •.denn,liaG. - �_ -�— �(. . . . . � refuirunYsrr�ehere.�r �t t. s��mrt«.ahnrry��ins " �_,. . . . �6e upp(i:J�u/nr svrb�p�rnvt tn filr u�sr,qr�eJ st�te:newt . , ;.: . . ,.. . � ... � - . .:`--• . . . _ . . .. .. t . . ..� � IGJI IJC((GCCk3('J��uuu�nt n��be prn�isinns o/1br C.rn. . . � '. ' )>.-: � �) i`�I���� ,.-1 �� t tru:lnr'al.r�rasrfair/CL,upter')1(unnn�earinCx��itLSe�- � .. ... . . . .. � . � . ..- . .... .. : '.�� . �. ;.•: ,e �..-'' .,. , .�. � . - _-_ : • �`.1- . 'rj�t�j _� �\:.•;llJ��i.�� � .. CoJeJr�r1tlatLefislexcnrpt-%fu�rJrf�nrun�dt/�F cr,JorN�� ' � . .. .. . . . �7Jcc�J exrrip�inn.An��rinlation rf Jc<tim� iO3L5 G�� . . ;. . . . _ . . 8equired . ..DaloBaceived � . .-... . . � . :.. . . . ...�-��� - -. .. ' �ns'spplicuntlnrnj�rrnri[ruljrclrlLeappliu�ntlnurirrl Apprevals - ar ApProved ��r: J,enaltY oJ nnt nrnre!1 an fir a bundrrC/tnllnrt/�SOOJ.)� . Yos No — . _ .. . . ���. . . �. � . ___ _ (_� I,as cwner o}�he p�ope�ly,o�my employees with .. •;�� .. . .,. �'. � �.� '_ � \1'av�r Cernhcore-.. _ �. . '� . • ��� �� ' -�� �-� � � -•- -- . -�`�'oges os iheir sole mmpensonon,wHl do Ihe wo.k,and ,t- ...�.1 �. ` � 1 '� ' � �--��..�- � the strucrore is no+intended or ofiered for pale(Sec.704.1 i Hral�h�eParrmen+ ._ . __ _.. . . - �.... .. . . . . ._ � e rn/ .0 . �C nt en � I � 1j I .`, ..J ,. �l �' ' Icph• r f'sar%er '( '_'. � � � �• �_:�..�_ ,l.ai�Jn.an�t ����unnuner ti�«1�/.l+urJ� F�re Depvrtmcnt.. . . .-- . - _ . . - �. . . . . , 'i�tii'r irprr.ir s 7L ��ott.and u•bo dne �u?�u u D'/,i.�ue!/.rr, - ' � 'r`'( �. .�l ' '_il;.l'� � � fhrnv,�f� bis nn�n rmplqpres..prr,riJeJ tLai su:b i�.�- Grod - � . � rrar�emvxft aro nut in�rnded or n//rrrd Jur snle. 1/. '. . _. ,, • ;. . , �9� _ �.� d ,'� . . .. .._ ;-i .:.j:, - Lrnu•ex•er;lLrhuilJin,ynrineprnnenrrntitsnlJu�[Lin.�nr Geolegicot .�_ ____ �� Yrur n(rnm/�frtrnn, t/e nu�ner:Fuilder u•il!larr thc . _ . . � . _ .. . . . . . __ hurden nI pror�in,q ihnr he d�d mn!•:.;W o.l�nprore f r Pedestrla�nProlea�on' . � " '-' . . tiepur�,ore'alan/.•J. � . . . (Fence)ICanoPY) .. . . . . .. .. .. . .. .. . .... .�.1 I.as owner of the pwpeny,am eaduslvely cen!rar� ; -ling w�th Gcensed contracton w consvurr the pio�ect�Sec. Spec�oi I sGec�ion - - '� .. . -... . . .. .. ._.� ��. 70d4)!)usirsess und Prrr/rsrrnrrs CoJe: 1 Le Cnufr�rtnr's IConc.J(1+^.�sonry)(Weld;ng) .. � . . - -' . . .. . . .. _ . . l.ic e I..eu�does no1 ap)�f�'In un nu�nrr r/rropertr ud•n � - huilJs or iu�pror•rs lbrrron,an,f u•hn n,ntrucu Jor surb Lo�Dro�noge � . . . . . .- .. -- . -. . . ... _ J+ lert� u tl�n �nnlr�c[ r/J/.a ccJ pars�.ant tn lfr�� . .^:.'.. , _... _ •n � ... . ' � , '. � G�nba.tor's I.icrrs�e f,uaJ. . . . -. . Fnrking � . � ___ ._ . . - . ❑ I nm e•empt ander Sec. ,0.8P.0 for ihrs � . �� reason . _. _. . . � .... . _._ . ._. . ._. .. __ - � Date Owner Approvals Dola Inspedor's Signafure . � � . . , _ . . � � - INSPECTOR'S NOTES � Locoi�on— -. . .. . .. ISetback 8 Yords) � . . .- . . _.- . ..- . . _ __ ._._. . . . . ' . . .� . ,,: Poundations � , � � � � � � � - Slab ' � � . _ . . . . __ . . . .. . .._. Frame� � � . . . . . � . . . . . Energy Insulalian . - � ".. .. .. . . . ...... . .. . .. � . � � . � .. .. . � � . La+h:Drywall__ . ._ . . . . . . . . . . . . . - . In�e��o� � Lath—Ex�enor . . .. _ . . . . .. _ .._ �__ __ '. . . _ �. . . �� . �� House Numbc._ .: � '. .,, �_. .. _ . _ . . . .. _._.�_. .. . _ _.. . . . . Correc�8 Posled � � � Enr:er on froni � - �i : . . . � . .. .. . . . ,. .� ' . ... � . . ., . .,. 2 .� . .. . _ '. ... . � C`\_.\ ' \ ',l / � :�-i�..- �_.