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HomeMy WebLinkAbout1440A WORKERS'COMPENSATION DEQARATION ' � � �insureboracer�ifo'teofWarken'��omPe�o�o�°��s�,a��e` �� . . APPLICATION FOR �BUILDING PERMIT or a certified copy thereof(Sec.3800,lab.C.) �� ' � � � . � COUNTY OF LOS ANGELES BUILDING AND SAFETY P❑ollcyNo. Company ' , ^ Certif�ed aopy i:hereby furnisbed. FOR APPLICANT TO FILL IN ADDRESS z 3 3 �l�r /C l� � Certified copy is filed with the covniy building inspec- BUILDING,.., 7 tiOn deparlmeM. . . ADDRES$ Z? Cl/7 /C � �.� IOCAIITY �'C.y�^�-��T�Cl �r�� NEAREST i� Date � Applicant CITY L" �'�l !' Zta CROSS SL�1/I'K =cr� 7I CERTIFICATE OF EXEMPTION fROM WORKERS' NO.oF BioGS. assessoe � COMPENSATION INSURANCE SIZE OF lOT NOW ON lOT Na�BOOK PAGE PARCEI (This section need not 6e comple�ed if the permi�is for one c� uSe zONE Na� ��� _ 33 7 hundred dollars(E100)or Iess.J � TRnCr3Z 7 siocK ior No.l� � TEI. ��— ! SPECIAI Y I certify Ihot in ihe performance of ihe work for which ihis OWNER • � Q_. '�'C� NO. � 1 coNDITIONS C Gtmit is issuetl,I Sho��nol em �O an tnOn In On Tannef � j� OISTRIC[ GROUV iVPE FIRE PROCESSED BY � P P Y YP Y ADDRESS Z� ��C��J J� F�'(=K� CONSi. 20�JE V eo as to become sub'ed to the Worke�s'Com ensaHon Laws. ���,� � . �( • . . . I � . .�. .. � P � CiTY lt%!7?t' �' 6.xV ZIP. .� I� , LLt . O D01e ' � AppIiCOM - � ' , SiATISTICAI C1A551FICATION APT. CONDO, i� - ARGHITECf OR� �.:TEI,� ..... . . V NOTICE SO APPUCANT: If,�nfter making�tltis Certi{iCo19'of ENGiNEER� G'f}f��� NO. I ��vl �QA55 NO. ` � �WEU.LNIT$ � W �Exemp�ion, �you�should-become��subject��7o ihe Workers' �� . . ? ,�/Y �r� - 6. Compensation provisions oi the Lobor Code,you mvst forth- ADDRESS� �0>�� � ,7�1•3'b��.1AZ'��VST'� � SEWER MAP y with comply wi�h such�provisions or this permit shall be TE4� - ' �z CONTRACTOR �S 'C� �NO ��"�7��� � - � VAIIDATION deemed revoked. � � � ,(�`( . BK. PG. . UCENSED CONTRACTORS DECLARATION ,/� )q�. ,i 1 1 hereby affirm that I am licensed under provisions of Chopter 9 ADDRESS�� /[/!�r`-`��`� f�t�o. ��S jJ VAIUATION� � (tommencing with Setlion 7000)of Diviaion 3 of ihe Business and ���. � Professions Code,and my licanse ia in full force and effea. CiTY :�f''A CLa55 S � ���• , - �� � ''� SQ.FT. • NO.OF NO.OF CkECK LiG0n58 Nulnber � .� LIC.CIa55� $2E STORIES FAMIllfS ONE ''� `/f/I��Z/�� 7�7� ' DESCRIPIION OF WORK _.__ NEV/ � S �, . Contractor � .f Date — ` j� v �qoo � � �I om axempt under Sec. � � �"ZUGd Q�`.-`�C`�- 55U � - AtTER � FINAI , B.BP.C.for this reOson �� - � � REPA�R � DATE � ' - - � USE OF FINAL - Da10: . E%ISTING BIDG. . DEMOL � BY , . . . �Slgnoture � APPL�CANT �G� r�� TEL.Q C^� � , . . PRINT �� NO. I Z _�`( .� 4�O� -OWNER-BUILDER DECLARATION � 1 p , � � � � 1 hereby affirm iha�1 om exempl from the Coniropor'siicense qD�RE55_ZZ� � ��`��' ,7 rz� . , e . • law for Ihe following�eason(Seclion 7031.5,Business and � JL-/ �• • • •'2 3 Profeosions Code�: � � � a �J�' ' BUILDING � � I, as owner of ihe property, or my employees with qoDRE55 � � � �� � ��• •2 7.6 3 � wages as Iheir sole compensation,will do tha work ond � �� � . _ Ihe structure is not intended or offered for sale(Saction ��`��TY � � :�:o e 2 Z 6 3�� 7044,Business and Prafesslons Code). MOVING iEl. , � I,es owner of fha properry,am exdusively coMraUing C NivaCTOR No. . �"� _ . p 2 p 8—8.4 � wifh litensed controcfors�o canstruU the project(Sec- ADORESs � tion 7044,Business and Pro(esaions�Code). .. � � ' " REOUIRED TO1Al5ETBACK FROM E%IST. � CONSTRUCTION LENDING AGENCY � SEr BnCK YaRo HWY pgOP.UN wiotH , 1 hereby alfirm thor tbore is a conshuciion lending agency for pgoNi � � � ; � � , the performence of fhe work for whkh this permit is issued �a.L ' tSec.3Q97,Civ.C.). � . � SIDE �. � - - �P.t. , . , lender's Name ' a -- v.e.Fee s �7 lo ve�mu cee lender's Addross � � I aertify ihat 1 hove read fhis opplicofion and slate ihat iha Iss� ce Fee '. � above informotion is corraU.I agree to comply with all Counry ����setgof�on iee , _ . , ; ordinances and$tafa laws relating to huild�ng comtruction, � Torai Fee f ond here6y aufhorize representofives of fhis Counfy to enrer . } - upon the obove-mentloned property for{nspeciion pvrpme3. � � � ' � � � ' - - � � £ SEE RFVERSE FOR E7[PUNATORY IANGUAGE � . .. Signorure oi Applicam or Agenr � -Daro � � � '� '�a .. .. _....... . ...... . _'_..__ ...__. .� .. . � _ . . . ... I « , . - _ , � �,_ o}S�:vr r tiu�t "z .,, � ,�� . . FLf,itS TQ FJ':'IICt.HT. � ' .� .. ' ' . :� I ' . .. IC:SP�L70P.'S!{OTE:1. � . . . .D'-'R Di:C�.ARATTON`,�..... � _--;I�I erchy,afFrci�i ct I qm 5x^mpl frcm Ihe,Gontrattor's Ta � .Fclurned .. ... License Law furJ lhe followinp�remoa.�Sot.���7031:5) . ` .. . '�AADrov:d P,u . ..',Pr<��.:rinrcCala:Ar:ycitl'orrnantytrGicG . . .��,� . , � .. .__._ . ..._ � ... __'_ _-._� .___ . .__.... . No. -... Deto----, No. -Dat¢ .- ., � .. . . '. ' . . .. . � . . . �� - '-"t.��.r:s..�:r�- t. �.��str�cl �.t�r.lnj,roi�t.Jcr�o/icl�, ' or repair cr.}•str:io.'�src,�ti or 10�its'ise�lnnie,also rega"eres __,_._ ... _ . ._- .. _ ,.._ _._. .. _ . . .__. .. __..._'_._"'____. >' _ '___' __ . ._ _ __ _ . _. , ��,.: �- , . .� , '-?1 e p/rp1Yc.^.t.f rs�cG'rrrnril in filr.a�igrzed statcnicnt ,._ ._ ___.._ . .._. __ ..... _.____._. . _ _ , __... .. _ �. _.. .�.�._._ . _�.... . _ ..� . ...__.__ tl tl .ulica aJjr:r.ucntlnfGepri rsirin.s-oftbeCon- �, � ' , � trcrtor'sl,i:euel.au�(Cl.t/�lcr9J(tont�nerteircgu�itbSce- .� . ..... ', . . . � ' ' :.. .,.` �. ..:.: �. -..._.don�700'J/fUiedsion3oJYLeBusinessundPrnfetsions - � � , . . . CodrJdr�Gatl��iscicn+plilcrfron�andtJcLiuisforlbe . � � - � - - ��� rtllr,qcd e.ie�rr t. �71 1'[ 1 t o;i of Seelion 7031.5 dy �, �,f;eSvlrod � or e Rocrtirod `-,. � - ��' . . . .. � ��.��� �•t/r a n��i �1� cr 11 arjrlicdnf to a'cix�i! i_.----A�^.pravafs-----_ ._ Dot, �. -__- -- ��_... �'- '__. _-.- r.ale) not r r n t?�..n� �.Lund�ed driflars 5500.: � ve: ��o. A�,P�o�aa � I I� ( 1J , , . .. - -. _� � _� _� ... ......____-� ._.._... .. .�_�.. .." ..... _ ..._ . � ❑. I.aso�ener.eF;lhopropnrty,ormyemployeaswith ' ' -' ' � � � � - '�� ` � . �wcg�is cs�ihe r s �i�c^m;�en:arionj will'da ihe work;�-and � Water Cartifica�e � ,-. � . . ; �.., . . . .� . . � .,� �- �: . � " �- � "�"-� -��- - - - �-- -----�' ,- --�--' � � �.Ihe'sfr�ci�r�ts nbt n cn9c�d or cffercd for;ate�Se2.�7C44) . HcoLh DeportmeN.�_._�� � ` . � , � . � � � �-. , . .., � Bei.cinees er.d Prr��e.csrnrr f.ndr:T'he Contractor's Licensc . __ ....-- . _.. .. ._� _.. .. . . • � � ' � � --- � - - -- ^ - - , - -l.au•dncs r.nt pp [o cn o.cvcr nJ j.roncrly uGo Guilds Fire De nrt. � � p r�en1 , , �. . ... .... . , ,. . ` ... � � irr�r��t%:c! �, ese f�r .:�; i•�aarl�fi�nr,E 1 in nr m. ;2�r.J��ln : .. . .. . . .�.. . . . . . . . ,. � -�---- �.'�tGro,�h �is oii:�eir:r(o}:es. fvor(ded thaf'sucl�'ini- ' � � � � � � _._ .���fr'circr.is,¢rq na[ frtci:dcd ar nffcrcd for',sale:1� . Groding . ' .._.__. . .__ ..... _� . .._ �...._ . . . . . . . .._..._. .... ', . -�. .... , � . b�n�zcrrr,tbel�r7.l:r.,qii:ir,;rrcear.c..Susolltritl�innnc _'...._ _ _ :".". :,•, ' -. . -' �.. .. �. , . ; . , Goological i� . .. "...�. ... � , �- . . . .. ^ ! , 1t c�o L�u�L.'cr i ye J rri, '� rr i� r- .triR�b��e tl e . . h 'J ja r ,.,-S.:_1 f: c.::��.nr Z�uri1 nr in:p nne fnr Pedes!rien Protection . . . .. _ ,�•tbe f�r:r��asr of-¢IrJ. .�.. ., � .. . . ' (Fence)(ConoPY) ...: � ��-. .� �.. ' ��� ' .' : _ .... - �'.:.; " ❑:.��I,�aso� �nf Ihe nropmrty;a. ondusive'ycontrac' _._ __ .... . _. nnr �n � ' � ... � tin�a��.hfcerseicontro_tor�brhvstn,�cttheproject(Sec. Speciol Inspeclion . - -. --... -.-..- . . . . . ._. . _ . .-JD44;�;::tmrci ec,f I'rojessiuna.�Co1i:�ILd�rCoanactor's i � (Cone.)(MasonrY)(Weldin9) V. � �. .. -- - --' -:-. . . . . . � ..� . I.itcnsrl.a�i�dnvs rot mp/:l1 m nn ofe.meT of f�ro/�crty wbo . . . .. • . .- .-. - �. . ...{�vr/eCe nr_i'•.pruns IL+rrC.R�.�n:l u•lro mr.traets fnr�rutb Lot Drainac�c - � . p I 1 �f . � !nr'sJ l:c��r:, d� . ,cnt.tq(!1 f . . , --... . .... _... -- - . _ . _ . . . , --�-�c-,r,...e;,.,i ���,..atu:.). � L ,. __..._ . ___ __i . '� . _.___ .._. _ . ._. ... .._. _ ___ _..___.❑ .�..am_exemp'undcrSec r.,;.._.. . ...�, ,����. Parking ----- .� . - � � .. ,E.SP.Gforthis - --._...----- - ....------_---.-_�_--- . :� .. . . ._ ._.._ . .__._ .._.... __... _ ..��_-_._ _, � � n -- -' --- - - � , . . ,. --Date----- . ----- �- .�pymer:, . . . � , , . � , . . . _.. , _ - . .�.. , r � . , . . � „-. -. ,. � . � ��: . , . kpprovcli I Date -Incgcdor's Signalurc . . . . . .. .. . — � - . .... —�'— I�" �.,TJ;,o PiOTCS Lacation— . I _,J , . _ ...._. __ _ _ _ . _ _. _. _ :' , _ •'- (Setback 6 Ycrds) �� � - �- " � � Foundotions 1,� . � .r .. ,.� .. � . . ... . -- Slab ' .,..:,.,_...��.., ... ..,... ,..�;.. . -�-� . ,.. ._.,.- , . ' _ _. _ .. . �..�� �' �� ..1., l� -,_ .. . - � Frame . � , . . . I .. �. .. ' .-. ., � .. �U., ... ... � . . . ..,.� . . .... Energy Insulotion `. , i , .� � � . � �-.�i. . -_�-I��: �� ��� ,. .._ �. „�. Lath/Drywall— . ' � ...-..... �....� ,, . Interior " � � -. '�. .. .� . '_ . � _.. - ...,�r .. , Lalh—Exterior . ... .'... : � � .� � ..���� �. House NumScr— I . . .. . ..�� ��� . �. . ...� . , Correct&Posted . .- _--____ _ _ .....__ .._.__....__'___. ._ . ___. . . . ... " ,.. �., I „ i. .. i ..i , . . Finol— . . ' �..' . . ' : Enter on Front ' ' .. . .�' . ' ..�, ... ... _.� _ _ '� . ,. _ . . . I _._. _.... -._- ,.. . .,. . - . . .