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HomeMy WebLinkAbout1727A 3116A 1728 - . WORKERS'COMPENSATION�ECIARATION � A P P L I CA T I O N F V R B U I L • ,� I hereby affirm that I have a cer�ifimre of corsent.to=e�f . . .. DI NG-�-PERMIT- insure,or a certifico�e of Workers'Compensrion Insurance,or o cer�ifed cop rhereof�Sec.3800,tab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy ryo95/�—`7� Company 57�T��tlnl0 , � Ce�rfied copy'is he�eby furNshed. • FOR APPLICAN7 TO FILL IN AD�RE55 �D' c. � , U 0 r CerGfied copy is filed wirh the counry buiid�n�inspec- BUaDwG / J '/ / � 1i n eportment. � ' ��.is . [rt• C, ADDRE55��C��/' ��� �"r�N� ��• LOC,4LITY Dafe_�A licant . . .. CITY- MO�Q BR� � NEAREST� . pp -ZiP cRo55 SL ' �'C' � ERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF B�DGS. ASSESSOR ��-� � ' - �� COMPENSATION INSURANCE - � $IZE OF LOT NOW ON l0T O MAP BDOK � -- PA E . vARCEI � (This section need not be completed if the permil is for one �` u5E ZptiE MAP �7 'L ' hundred dollars(5100�or less.). - TRACT 3�7 g�p�K LOT NO. �J - �1 NO. �S J T � : � ) TEL p ,,` SPECIAL • 0. I cerlify that in ihe performance of the work(or which�his �'r/NER r�0 1�,5 N NO.-l��� ���V CON�I710N5 Q P.LJ• ��f' ZZ� DISTRICT GROUP iYPE FIRE PRoC�gseD8V permit is issued,I shall no1 employ any per5on in any monner � �� .- � CONST ZO E V sa as to become subject fo�he Workers'Compensa�ioq Laws.� no�ae55 �� �, � ^_ 1\Q� O �iL7\� . . CITY .�„io�sr,a� � �` � =�P' rZ G � . Dale Applicanf ' STATISIICALClA55ifICATION � - APt. CONDO. � ��NOTICE TO APPLICAN7:'If, affer making this Cerfificote o�- '"�`*�'�N��K� Sb�IN �NO.Zy�'2'� W Exemption, you sllau�d betOme S�bje[t to Ihe WOrkerS' ENGINEER ClAS$NO. � / DWELL.UNITS f� . n. Campensation provisions of the lobor Code,'yau must iortb• �� - - � � - �' 1 with mmply with such provisions or tfiis permit shall be /+�DRE55 A SEWER MaF �. - Z deemedrevoked. � � CONTRACTOR(,Q GON`�Jr td0./rS�ryy�Z � BK. �FG, � , VALIDATION � '� � � LICENSED CONTRACTORS DECLARATION � /J LIC. �j � I her¢by affirm iho�I om licensed under pro�isions of Chap�er 9 . _ . ADDRE55 , 63 /�/�.UG�IV/Z- �No.7�l�b? VpIUATION (commenc7ng with Sect�on 7000)of Drvision 3 of rhe Business and �--_� , . . Pro(essions Code,ond my license is in full force and e(fect. Q7Y .y��Q[l!�%/Q C1A55 S '��7 OQ Q � ' ���FJ� -dj I SQ.EFT.�I(J�`D STORIpES � AMIL�IES I CO EK - �� 7 2 7 A ' License Number �a Class t � � � � � � e;�,� � - NE,,, � §a��, ,��fo �#. ... . .,, Coor�ac+or R.d�IL�i.��� o•?NG oo�e� DESCRICTION OF WORK Aoo � ''I.•SD Q 5 0 � �I am exempt from the licensing requirements as 1 am a S{a pytl }b (.,, � . . ��litensed orchi�ect or a regisfered professional engineer . . a.ITER � FINAL •a�Q 5 fl� -acting in my professional capacily (Section 7051,� � � � DATE �i�.t.l�/I(fj/ ' Business and Professions Code). � � USE OF � � REPAIR , ' ' ��� �. E%ISTING BLDG. - • . ' DEMOL ❑ g NA� ���� - . ���3�—8',�L I Lit.or Reg.No. Dofe APPUCANi TEL Y . . . � � � OWNER-BUILOER�ECLARATION- � ���PR�NT� R �to���i�t.,rrnb.k�o.96B-���lit- . j I hereby cffirm that I om exempt from the Controctor's License �j�) �yyb� � �. � , �S: ��, , �_. , . � � Law for Ihe following ieoson(Section 7031.5.Bus�ness ond no�aes5 n � - � Professions Code): �� � � vei eNr ,� 3 �` � :3 1�1.6 A � � . ❑ . ' . . . . . ' BUILDING . .. .. _ .. . - . � . I, as owner of 1he properly, or my employees with� AD�RESS wages os Iheir sole compensa�ion,will do�he work and � � '! ' ,:�� � #=• • •2�J �� � 7he shucture is no�Infended or offered for sale(Section� �«A��T�- �y-a''��' . � � . �. . 7044,BuSinesi ontl Profe55ion5 Code). MOVING � TEI. �'. � \�' � - � •4 9 G�'� � I,os awner af the property,am ezdusively controcting CONTRAC70R NO. S.y' � wifh licensed confractors lo constroct the ro'eci Sec- ��3� � P I ( ADDRESS . . •G.�J 2�H O i.i .� tion 7044,Business ond Professfons Code). - - � � � � - �� - - - FE�UIRED TOTAL SFTBACK FROM EXfST. i ' � CONSTRUCTION IENDING AGENCY SET BACK YnRD HWY ppp0.�INE wiDTH �9��9`�'.G � - I hereby oifirm Ihal there is a construclion lend�ng ogency for� -� FeONr � � � � � - ` ' � the performance of the work for which�his permi�is issued a.� � �/�OY' .LU��� st,oT b�. CA��+YCd I . (Sec.3097.{iv.C.).'. . . . . _ . SIDE ... . ... - .. . . r� Y..,�l� - � . P.l. � dfl,�}�S �c111C��fL� -iC� ` �. Lender's Name ' C�rt�.eA�RS upPrO`�9 i (� p urZ,Ti I' Rou��'l: --�-� �.g • P.C.Fee S �J. O Permi�Fee � lender i Address �/Z U� }^�r,�, �c A,R 1 V�'1l by,r`�� ��y� ,.. I certify that I have read.�his applicotion ond srare rhoi ihe f- I+�U. 9U iss�ance Fee O �.5�� Q C� LJ � � above informolion is correct.I ogree ro comply wilh all Covnty Inveviga+ion Fee... . . . p � /���;�_-� '3//g� . � ordinonces and Staie laws rela�ing to buildmg constrvction, To�ol Fee a ��•� ����1� � � and hereby au�horize representahves f this County to enfer - •., upo e abeue-men/ty'p�e.�dJf�J op ty Far inspection p ses. - , � � ���_.4�w�"/i�^�^ / I G�'� . . . . .. �SEE REVERSE FOR E%PtANA10RY LANGUAGE.. • � ' .j � . . . � . � , . . � � � � • S�gnai�re af Appl�can�o�Agenr Da�e . -.e . . . . . ' . � . ' . . ' �� � , . .. .. . ... .. .... .. . .. . .. . . . . . .." .. .�... � ., ... . . . . . : � � �.PLANS TO APPLICANT � � � INSPECTOR'S NOTES ' � OWNER-DUILDER DLCLAKATION '1 hereby affirm Ihat 1 om exempt from Ihe Confractar's � Ta: � � Returnod - � � � � � - � � � Lttonse Law.for the following reason. (Sec. 7031.5) - � � " Approvad . . , $esinessandProJessionsCode:AnyeityorcountywhicG � � ko. - -- �-0afc - Na. � Dofe � -� � � . .regurres a penniC!o eonstroct,altcr,improve,dcmo7rsb, � � _ , , ,. . . , orrrp¢irartystruciaro,priorsoietusuonce,o&orequires.� � � - �� ' �� � � � - - . � � �- - _ 1Gc applrcant Jor sucb permit to fiJe a signed statement ' tGat Ge is licensed punaani to tbeproouions�of tbe Con- � � -� - - .� � � � � . � � - �� � �� iractor'sLicenseLaw(Cbayter9J(comm¢ncingwitbSec- _, , ,.,,, tion 7000f of Dicrsion j ojtl e Businru ond Prafcssions �. � � � ��� � � . �� � - . CodeJoreGatGeisexemptfGerrJromandtbebasisfortbc , alleged exemption.Any riolation of Seciion 7031.5 by � Raqvtrad DoteRecaived � - $ - � anyapplicantforapern�itsubjectstLeapplicantioacxviJ " _.Approvpls � � �`�� CC � �'- cnalt o nat more t6an rce bundreddo!!an S$OOJ. ' . . .Yas Ido orAPProvod . . . 1' 9 J 1�' � �� � . , �,�J r,��.. �-�.,�; . . ❑ I,as owner of the pwpery,or my employees with - �^Jater Certifi�ate , � � � � . . . wo9es as their sole compensation,will do the work,and , � � - ' � - ihe strucWre is not iNended or offerad for sole(Sac.7044), � Heal�h Daportmont ' ' • � , . , Bariness and ProJesaions Code:Tbe Contractor's License .. .. _ .. ._..... ','�. ._. , . , . . ._ . . . . . , � Larv dacs aot apply to an oa�ner ojproperiy wbo bailds ' . Firo�Deporiment � . , -,y ����,_ +;,:_,;,� ,���. , or improves tbereort,and a�bo do¢s sucb mork bims¢%or �. � �� � �� :.througb Gu ou^n cmployecs,�provided t5at sutG im- ' Groding � - � . �- provcrxentr arc no! intended.or offered fos sale. If, �--------------- - � - - � � � bowever,tbebuiklin,qorimproven�entisaoldwithinone ��� ear o ronr letion, tGe ownenLuilder wi!!Gave ibe , Geological -. . . . c ' � . .._ ._� � ..,.. . . . . . . 9 f P , - � �, i - _ �\ i� _ burden oJQvoving tbat he drd not duild or improveJor Pedestrian ProteUion � � �- � . � tbe purpar¢of saleJ.� � �� � ' ' (Fenee)(Canopy) � � � � � C \i s,��,_�,(',�.;� ❑ I,asowner of the praperry,om exclusively coniroc- � �- ��• � � , _` li�g with licensed controctors to mnstrud the project(Sec. . � Spetial Inspec�ion . , � � � � � "'1' 7044)Buriness and Profeuions�Codc:Tbe Cantradors : (Cdne'.)(Mosonry)(Welding) - . . _LiccnscLawdoeinnlapp7ytocwbwaerofpraQertywbo � � =�-j-��f i f��i,� (i i p..,'l � ' . . � buiWs or imQroves[ber'eon,and u�ha eantracts for sueb Lot�r6ino�o� ° � � � � � , �. � - projects witb a tantr¢ctorjsJ licensed f�ursuaat to tLe � 9 � � }�T._.� _ i�C"� . .! .�.1,.','..,���' . Contractor'sLicenseLnuJ. � � _ iParking' ' . ' 'Y.� _.' ''''�,�-'7 -l.aj!•,ij��":�I'�: .. ._ �1�._;.'_�. '� ❑ IamexemPtunder5et. ',6.8P.C.forlhis � ', __-� � _� - ' "�;�� „,t - . .. _ . . . - reason � . . . . ' . .. -- ...... . .. ._ _ . -..._ _ Dato � . . . ..�. . Ownor , . . . .tni:' •.a��`..t � . . , ' . . . i ;Approva�s Dete Inapectors57naturo , �;'Jj; ''. ..,. i : .i� �,. . � . -�. .. . , INSPECTOR'S NOTES � lomtion— .. . �✓ . . . .. .. . . .. _ - . , . . . , . �Setback'&Yards) f} • � � - � � . Foundations - ���'e . ���� .. . .�. . . . .. . . . _ . -. � i� Slob . ... .. . . ... . . . . . � . . . . .. .. . � . . . . , � Framc- � _ ., , � .� . . . . . . . . . , Enerpy Insulation . � � . . . , . � � Lath/Drywoll— . . � . . - .. . .... . � �'�Interior , . . _ . . . . . � Lath-Exterior � .. . � - � ' . . � � House Numher— � � . ' � , � . . � Correct&Posted � � - - �� � � � i Finol— � . . . .. _ . . � . . . �. � Enter on Fronl � � � - � � � � - " �1�r,uG 5��� tirP��"r��-p.�G. `r` ��uSP�or�Pou� �.�c.P � ,;�. .�\i = .` \,, �. . , . {��iG GCO.t7 L S' PF-/ENS�GR9D/n!G i.c1.SP � a �,9 �. •� � -. --. r� . , . '