Loading...
HomeMy WebLinkAbout1439A WORKERS'COMPENSATION DECLAR.4TION � � I hereby offirm fhat I hove a carfificofe of�o�=e�„o,a�, . qpp��CATION���FOR-�BUII.DING �PERMIT inwre,or o certifimte of Workers'Compensation Insu�ante, � � or a cenified copy thereof(Sec.3800,lab.C.� COUNTY OP LOS ANGELES . BUILDIN AND SAFETY PolityNa. - Compony BURDiNG � � Cert7fied copy is hereby fumished. FOR APPLICANT TO FILL IN nooaess�Z>J7���a Yt /C� � � Certified copy is filed with fhe covnty buiiding inspeo- BUIIAING' / fion department � qDDkE55 3�33 . � '� lOCAuiv 4t�-ir� -aG�( /�Y NEAREST 7 D01e Applicant � CITY� Ca. ilP CRO555T. � (�P � �(J CERiIFICATE OF EXEMPiION FROM WORKERS'_ NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE � SIZE OF LOT NOW ON LOT MAP BOOK PAGE 7ARCEL (This secfion need not be completed if�he permit is for one G q hundrad dollars(f100)or less.) � . iRAn 3? BIOCK LOT NO. 2 ��N� NpP / ��aJ '. ' � ' TEL.. . `. -. p . SPECIAI 1 certify ihat in�he performanca of the work for which this �WNER � � NO. /daO CONDIilONS � 6. permit is issued,I sholl not employ any person in any monner - - � ��-- 11 oiSikiCi GROUP TYPE FIRE 7RO�E SSED BY 0 . so as to become subjecf to Ihe Workers'Compensatfon laws. ADDRESS 2 7 3 CG ...,1 ,1/ �p CONST, 2 ,U V . . . . . ��j-y.�� ��, - �- ��Z a Dote Applicam � ��TM «'- � "- r Z�P � STATISTICAL CWSSIFICATION APi, DO, O NOTICE TO APPIIGANT: If,alter�making ihis Cerrificata�of ` /+aCtirteCi o T 1 -1 TEt / � ��, V . Exempfion, you should bacome subjecf fo fhe Warkers' ' ENGWEER L�- C3'C -fc�f '� ND. (p "�6/ ��q55N0.�� DWELLUNITS_ a Compensalion provisions of the labor Code,yov musl forfh- in �� ADOftE55 ��r - � � U ��(� SEWERMAP �. � wifh comply wifb suth provisions or �his permit sholl 6e /� � Z deemed revoked . � � � CONTRACfOR � N099�'3 '`BK.'�PG,' VAIIDATION � � IICENSED�ONTRACTORS DECIARATION ;� i ��G���'�. ' 1 hereby affirm thot 1 am licensed onder provtsions of Chopter9 q�DRE55 Z.ZL/el} l�c'..v�\ �NO. VAWATION--� - � �i (commenc(ng wiih Sadion 7000)of Division 3 of iha Business and LiC. � Professtons Code,and my license is in full(orca and efiect. Ciiv � Cu55 � S� d-'�'`a � ' �/�/��� �� � � � SO.FT.! I� NO.OF J NO.OF CNECK , . ' License Number HH/ Lic.Class SIZE �f STORIES f FAMIUES ONE ConlroctOr��'���(���f pa�e'� .. DESCRIDTIONOFW02K . . . � .._.. ...... . .�.� NEW.. .� _ '. �. .` . .. ADD. � . �I am axempt under 5ec. � 6��L ! x ��Z'" p�7FR � FINAL �, � 8.8P.C.for this reoson - �'���"L�^""L-�-� �� "-" �- REvaIR � DATE � ,� ��� � � � ' � � ' USE OF / �� Dote: EXIS7ING BLDG. . . _. .. . ....__. DEAAOL ❑ FINAL.�-n` � , . . -. - � � APPUCAM 7EL. BY \�� . Signafura .. PRINT �lG`� �1�!'U V ND '�('O� . - .. . .. OWNER•BUILDER DECLARATION , I hereby affirm�hat 1 nm exemp�from tha Contmcror'a ltcanse ' Law far the following reason(Section 703L5,Buslness and � ADDRESS - - � Professions Code): � � . ... . . , , ❑ 9UILOING �I, as owner af�he property, or my employees with ADDRESS ' wagea az their sola compensation,will do�he work and � e�, � � ; fhe structure is not intended or offered for sote(Section ����TY . •-��� , • .� �+� f+i js . , 7044,8usiness and Professions Code). MOVING TEI. ��.:� �d��'ti;:. '�,����..} � � I,as owner of Ihe properry,om exclusively contracfing . C NTRaCTOR NO. ._. _ . ,� .. ' ' , �� /S�9 a wilh licensed contracfors fo mnstruu fhe projec�(Sac- nDo&e55� �tion 7044,Business and Professions Code�. . ��"� � � �.� � REOUIRED 7QTAL SETBACK FROM E%15T. CONSTRURION LENDING AGENCY seT BnCK �ARD HW1' PROP.LIN WIDTH ' � I here6y affi�m thot There is o consiruc�ion lending 6gency for � fRONt '/ - � � � .- � • •J�i 7 Jr � the performancebf tha work.lor which this permil id issoed ' v.L� � � � �Y' . - �� . . �Sec.3097,Civ.C.)... �.� . . . � ' . �.SiDE � � • • e J�t 7 J�� . . . . . ._ . . . . .P.l. '-� " ' ' � ' 1 . � - ' � '.. ' % � . lender's Nama �_"_'�__ '. . � i :� . ' ;/. � 'i� 7 2 0 8—8 4 ;r- P.�.F«t oa.m;;Fae a�.a .,� , ,;:: ° lender's Address_ . ,,, �/ : �'�' I rertify thal I have reod Ihis application and sta�e Ihat the � � Issu ro Fee� /d'-c7. � '� � . � � above informotlon' orrecf.1 ogree tomply wifh all Coonty � Invesuqarion Fee -.. -. �•���. H � ' ordinontea a te la reloti o building constructian, .� � � Tmal Fee ��• /� � � end hare orize rosen rves of this County to entar,-.��\.� _ �� " . � �upOn t v`e-m oned perty for Ins ' urposes.�. ..�j� . . . . . .. . . ... . -. • � - , . �... %` . .._ . .. .�� � S � � � � SEE�EVERSE FOR E%PLANAiONY LANGUAGE � ���� ��jti��� � t (�J�` � �����'1 . Signorura oE pliconr orAgenr .pa�s . � . �� 1� � .m+ � �� � PlANS 70 APFLICAHi . . . 4 � � '�INSPECTOR'S NOTES� ._ .,-1.Qj�"VFI?�:?UILDrP DECI.ARATION Y . �, '. , � .-I horc6y alf�m Ihal 1�pm oxempt from 1he,Controqor's To: ..Returt7ed . . , Ucense LcW far�tho��follovring�recson.-(Sea�703L5) ��Approved '� Ausiarss ar.d Pmfecsrn>is fnJr:Ar.�rity or cnvn0y�wbicb '� ��. t.� ,,.:: . ,. . No.-:-.��--�--Dato...- ,� � Nc. -Dofo. . ..�'-' . . . . .. . .. . - .. `�.. . . . . . `�reg�dra+t«perr4it tn cor,tn�ct aL•rr_ir�rrmrr,d alixl, � or rrpair¢nqslrCrle.re;J�norlo itS essu¢r.cc,also reguires '- . -' _-- . . :_...- �---. ._- --- ._ .. - --- -- r_-. __ - - -- -. ._ .. r e� s%nrd [atcrrient � , -- . �"t>>�prrr�<a,:��nr�sercl permir!o f'1 a g s '__- _ ._-._ .... ____. . _.. . ._ ___.... _ . . . . .'. ._.. ..___ . !/a0 kc is licrnscd f:rrs�mrsl ta lfia f�rorisYnns of tGc Con= -- , �'�. ��-� -_-��-�-��.�`. �. � tractnr'sl.irrnscl,aec(CGoptcr9J(tonm�cncingu�itlr5e�- - - - � � '� � '� --tion 70001�r�nr�rs��,r 3�I rr����ti,,.�rne<=a,��r��Jessiona � ' ; � � ' �- CodcJor�Guth c�.FrniptlJrrefronidndtJeL2sisfortbc I � � afle,qed exrn�ptiar.:vlr,}•S�inlulfon�o/Scctimn 7031.$by i ` ���Reqvired." �� � ' �� �. - . ��� ' .... ��. � . ' ar.�'a/�licnr f�raf�crl+irdc[jccrs�Neaf Trc6nt#oa�trce! '-�---Apprevels�..-. ---, . •Rsea(vod.: ' _.... __ : ..._.. .�... ; �. ` ' :•.-prnallY�f nnt i..nr_th..r�fire 1 an�red d�flars�SSOOf.J: - `o�rApp�owd Yes No � . .�.__'_.._. ... .:..... .. ._ .._ :..., -, -.�". �. • !. �_� .., �_.J. l,az owner cf the proper7Y,or mY employees with ;� - . ; , ;. --�.� � � �. , ,�r�woqes a3 their,sole�com ensarion;'�will do tho work,��and � WaterCartificate � ._" ' . . �.; �.. �, , ^ .. ...! ' ��,�.'.. ..! �.�_. .._�.'1.... ._ ___�_c_ .. ...�ties+rociu.eisnottntendcdorofferedforsole�Set.7044) � -�� �.• �,�. � -� �� � .. � ' • �. �., Uusmcss cr�d prc(v.vsions Codc T-bc Controctor'sLicensc Health DePorlment _:.__... .�._... _. ..� __. . .._ . � . :.. , . . �..; . � �� . , . .. . ..� .__. --._.. .�.--.. ._.--._� _ .____.. --- ..I.aw docs.uot applv to air ourci of.pm/�erly wl n build.c .. , � , ._. . . .� .�- . : . ' '. r i vJ �r:tJ en»�.�r.xd u!o'r.bes satb�cork bin�sclf or ,-� FiroDeparlment , _ . .; .�: :� ..._..�. . ......� ... - . . __ �'.�,..� . ' .-...'.. . ' .- . . :�._; . .. ,. lir g! !r o+-r.'rinpl�t , rrn dcd�fLalsricl�im- , � Grading � , _. . . _ .._ __... _ _ .... . _. l.� /n��oncir,s urc.,r f�ri t��ct d nr�./f raJ fnr ial: If, ' houcrcr,t1 c brnlJirc,�nr n ipro+�cm�++t u sold sn:tbrn ona .__.__ ... � '; . .. ,• . .... ��. - �` : ,.' . . tiear o 1 t t e.o:rnrrfu Ide : . �• f,rnn� t -� t rff Rc�c fbr Gaologiml --- -�-- - .. . .. ,. �. .• , . . . . h rr.'an.nf./: n .�t.....L--c':.�rot hu:71 r irrpmne fnr _ . `'.ti��,�ros��� �ri:,;: Pedesirian Prmection ' � ' • ' ' - � � (fenco)(CanoPY) ,�: •. � " � . . . � ' �-. . ' .'� �J�.�I:�aso+.neraith�property,amexdusrvelyconlmo- : .. �' . ; i ` � -- �- " � , -� � t;3 �h I:censed conlmnorzb con:truct 7he roject(Sec. S e;ial Inspection ���-- --�'-� —� � - � --75144�'b'as�ncrc crUPscfrssrv-s C de:,Tho Contracrori p ���- -�......�'� �.. . . , l.iccnsc I.aro doc:r.at af plti,fn nr oncr oJ/�ro/rcrl.l'u�10 . (Conc.)(MasonrY)(Weldingj . .� . �� . . ... , ,. . . , � � 'Fuildr'n.r�n�>nre•fh�rrn.�,nr.n,erGo mnfrafts/nr�sud� . ,__ .. _...._... .__._ ___ �_. . Lo1 Drain❑ .... ' . , �.. . . . . � Qrnjrcts a i!�a c rac�ar(aJ!i d frursu. `_ ge � � , . � �, ''____ �._'_._'_ _.._ ._ .. " ...__._'. ��'.. .—_Cnvtrset,r:a7,i<..i.erif,ai..�f.�- cens ant to,7Ga �. Parking �,_ _..___ _-�..._ _ ._�.�� ... � : . .��.. ._____ ..�.=_....:_'-_ ______._�_..:_, _.__-u�-"I am �pf und Se .,. ,6.dP.C.iorthin . ' ' �. .I �,.� � ' __' _.__._�. _ .,___' .._.._. .___..__ • �.. .. ._ ._ ._. .._.�..____.___. .'__....._,. _.. .-� .. reasen , . • . _....._._ .____... .. . . �. ( : ._ .._.___'_. .______. . .. �.� .. � � �Dalc �.�.' � .Owner , � � , _ . . -. . , , ... . ,.I � Approvds ^� Dats Infp�Ner'�S{gnatur� � . . .. . . . � . . , . . . .t'!.T'{TO`:'S P70TE5� ;---� Localion— --�-- ---..._ _ . _..__.. .__.___._ . ..-- . (Se�Eack G Yards) 1��� . �, ...� .- .. . . � Foundations - , ., . ...� ��„ . �.-. _. . .�... , i � Slob . ' � � ,��� .. :. ....._ Fmme � . . � � . . � . � ' . � .. _... - i �� Energytnsolalion - � '_'.':�.. ._._...__.�'___. t___..� __'...'._ .t.' : . :r..,.,��..; .. . .. , ._ . + __ Lath/Drywall— � � ... .._ .. . .M � . . ' _ . .'� .: . ... _. ." .--. . � Interior . �--� � , . - .____ .___ _. ._ _.�• .. ,.,� Lath—Exterior � �����l���A' GAGGS._'�'2D��---� . . _ . -_.. . _.__. .:,�.r.;�. • . ' � House Number— • / ���� . .". Conect 8 Pos�ed '��G:._•.-�,��.�C���f��L -.SL, S . �. . . ..t���,_. ,. . . . Final—�' '. .. . .. . ,.,- � .,. ..� a r,"� . �:��.��. , , . �t.. , .- . . . . . . .�:i_ Enter on Front � �.._ Vl'J`� ' _'____ � .. . .. . .__"' . . .