Loading...
HomeMy WebLinkAbout0977A (5) _ . _� _ _ _ _.— .___ .._ _. _.. .. , _.. _ _ WORKERS'COMPENSATION DECLARATION �,�, � �f I hereby affirm that 1 have a certificcre of�o�,e�„o,e�, qpp��CqT10N�:� FOR BUILDING PE� RM1T v5sore or a certificate of Workers'Compensotion Insuronca,• • � .� or a ceru5ed copy thereof(Sec.3eoo,�ob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY . Policy No. Company . . . . �. . _. . Certified co is hareb fumished. BUItDWG � � n - ❑ PY Y FOR APPLICANT TO FILL IN ; - ao�aess � �CS 2 d-U-rCp,�. �u*� 1�(Z. � � Certifiad copy is filed with the mvnty building inspec- BURDiNG ,..I�) �) J�' / �r .af� �n p . �tion deporlment . , , . A�DRE55 L�107 '/" L LQ�V �- �L[..J �� LOCAUTV lN L.Q��...—S�i.-�X . . � �7 f'��)�Y �Jl'!« S i NEAREST . , Date Applitant � CITY 21F CRo55 S7. ,� CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OP BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON l0T MAP BOOK PAGE PARCEL Qbis aection need nol be compleled if 1he permit is for ane � � USE ZONE hua hundred dollars(SI00)or less.) - T��T BIOCK �oT N -.i . No. — N 5 - (� c rei. 2� s�aai y I Certi(y that in ihe performance of Ihe work for whith lhis �WNER �^ - NO d CONDITIONS ' ' p, . permit is issuad,I sholl nof employ any rson in any ner - �^ f �n� p . STRiCT GROUP TYPE FIRE PROCESSED BY � so as lo bec�cf b fhe Work s' ompens on . E55 � � t- I...W(��.. . � �!C... CONST. 20NE U Dote A limnt � Z 'CIiY ' ZIP 7GS � �" '�' �-�' o PP . STATISTICAL CLASSIFICATION APT. CONDp, F- NOTICE TO APPLICANT: If, after ma ing this Gertificate of . ARCNiTECf ,- ;1EL. ; - V �Eaemption, you should 6ecome subject lo �he Worken' ENGMEER �,NO.- CLA55 NO. DWELL.UNIiS �W Compensation provisians of the Lobor Code,you must forth- ' � � ' with comply wi�h :uch provisians or this permit shall be ADDRESS - SEwER ht4P . . z . deemed revoked. � � � , coNtRACTOR � �Pfd I'lJB. :. BK. -PG, � . VALIDATION � � — � � LICENSED COMRACTORS DECLARATION '- � LIC. � � I hereby effirm�hat I am licensed under provisions of Chapter 9 ADDRES � NlcJNO. ��VALVATION � � - (commencing with Section 7000)of Division 3 of ihe Business and ^ ��� � . Professions Code,and my license Is in full forca and effect. CI � �t/ l" 'CLnSS ' S Dd��� ' � � ' � .FT. ' NO. � N0.OF�� CHEIX Litanse Number lit.Clasi SRE ST021E5 FAMILIES ONE � Contrpcto/ Dafa OESC IFTION OF WORK � � N� ❑ E - �I am exempt under Sec. ' G�� AD� � � B.BP.C.for this recson . . _. . . _.. . . . . ALTER ❑❑ . .DATEL � � �0 9 Z 7 A� RFPAIR ,�� � Dafe: . EXST�INGBLDG. - ... . . . DEhtOL ❑ FINAL' �: : •.e e.� .. . ey Signofure A7RiCANT �TFL. OWNER•BUILDER DECLAR.4TION � PRiNi 'Np. � I � o L C.S O I hareb affirm that I am exem 1 from the Cont�actors Lfcense � Law for Ihe following�eason(Section 7031,5,Business and ADDRE55 � . ,��� 9�. . • a °G L,S G�. Professions Code): - . R N _ ��2 Q—E C 9UILAING �I, as owner af the property, or my employees with noDae55 - - � woges as their sole compensation,wiil do 1he work and . � . � � � �ha structvre is nof Intended or offered for sale(Section tOCnlirv _ � 7044,Business ond Professions Code). MOVING �.TE�. . � I,as owner of the property,am exclusively cantracting . MRACTOR �NO. ��: with licensed mmractors to construct the projed(Sec• ADDRE55 ' � � tion 7044,Business and Professions Code). , REQUBED TOTAL SETBACK FROM E%IST. � � �� - - � CONSTRUCTION LENDING AGENCY � SE7 eacx YARD HWV CROP.LW Wioiti � � - I hereby affirm ihat Ihere is a conatrotlion lending agency for .FRON7 � . , tha performence of ihe work for which this permtt Is issued p.t. �Sec.3097.Civ.C.). . SiDE - . _ . . . . . P.L. . . . . . . . . _ Lende/s Name � � Lendera Address 7.C.Fee E Pe�mn Fee 1.2.� . � � I cerfify that I have read this applicotion and stata�har the - � � - issoor,�e Fes Q'� � . � � a a6ove information Is eorrect.I ree to eomply with all Caunry Invea+iganon Fee � � ordinan State at� g to 6uild�ng construction, � � --- -- r- -� �� � - � � �-- -- - -� Tmal Fee Ci 6n reby aut r re atives of ihis Coumy ro enter � ' � on 1ha o io property for inspec�pur�se� - � --- -- .� - �- �-- -� � � � -. _ _ - . � / SEF REVERSE FOR E%PUNATORY IANGUAGE� gn ure of Appticanf or Apenf Date . - ''� .�� � � �Flt�f7E TO AP£UCANT � � � �� INSPECTOA'S NDTES ' � �_ .�� 04�'.1T'F F,UII.D^F DI:CI.ARATION, �� . .-I hereby ofLm�Ihct 1�prq�exempi frcm the,Convoyors To: � � ..P.ofurnad. . - . License Law for'tho�follov+in�reoson:-�See.',703L5) - . . 'Approv�d BrrsinczcandP�cfessiur.sCnJr:A>:yeiryorroun,tywbitG ..__� . _...._ . _.__... ...._... .. ... , � N6.--'-�.-�-�-Data-�,�� Na. � bato ... . . � . . �� :-.. . . ..:. � .... . .. .. -;�-"rrqurres a]�eri t!!to rn>istnicl,'at�ar-i r�rrnt e:de�blre�lq i_ c ____-___ ___.._._ _. _.._-. _� • . .. _ . . _ _ . . ;.__ .. . _r.,- .. _ ._ -_-. . thcA�rlrrant rrsr<cl' rrnr.�!�io 1�aptCrt�rt�t�nlent � r �� r t� - •..,,_.; rr t r f' .4 .; . . . :.,��., . ,, , �. `. : ' "_'...._._,_ .________,____ _.._.__ ._._. .. _ . .. .. .. �.._._ . ._.. _� .. , � ,� lGatGrislicensedpursuanttnt/eJ.mnrsinnsoflheCan- I � . . �� � _ . �'.i��' �� i.�:\��: tractar's Licrnsc Luu(CI aptrr 9I(cunrnrcncirsg u�ilf.,Sec- " - �-tinn�IODOJ nf Die�icinn 3�f thr Uresines.v nrrd Prolvssioas . , �.. . � , , . . . . � ; . . � - .. '. Code)nr'tE!n1 G isizen;pt l5�r fr�m narl tba bn�is for tbe � � ,� � . .. . � . � .- . � . . • c!le�eJ excmftro�.-An1'[r.�lr.hm:b/Secliva 7031.5 by . .. .� � � �,, .�'Requlrod � � � . �'��mp'epf'licrtvif/ c f err iu r'T� ct fbe eff�licent Jo a nri( Dafa Recetv�d ' 4___._.�FPrccals. . •__ � :_� . �-�-�- ..__ � � ' " pena171 o/noln r t�a f��lu�r.drrG,!�rt�>��rs5obj.J.� I Yes No "or Approv�d : � 1 :� _ . ... •,1 �. . ...•:1.,, --'.-j _ . ... ..L I,a;owne cf Ine praperry,or my emplOyeos with . _ Water Cerfificate � -� I . � . � J _ ��� ���K'a^es veihe r sc�n+cm;ensotion;will dolhe work,�and _ - �-� - - "-,ti� � thestruUurt3lsnof�'M•ndr,dcra`.feredfcrsale�(SeC.70G4) HealthDap�itmont ' --_ � � ��' . '.I ( � . . . .._ .: .1'.�...' ���_., . �IJaemri�ar�dPrOJ:'if9tlSCClIP:IFCCVXI):ICIOTSLffCftSC � _.._ .__._._..__ ._.__ _. '� - '. .'�� �, ; . ...!_':.7,au ducs noE a(�1;Iv.t�,mi our.�r f prnperly whn bsild,v �� . �. .� : �.. ,.. . .• ,.. _.... ..__.._ ._.. _. __ _ . 'or rmfr os thnreni�.er�r' / <.o. a tli�i•hrk b arsc f or Fire�epartmont' :___' . .. � -. . . �� . :" . , __.. . . . .. _.. ' .. �. �,r_.-. . ._�.. . _..__ __..-- .____... . �'�;1Lrn.,��h�Lic aum�-ev:/•(rlor.,.�'roa:d_l�ibst'sucG ino- �� Grading�. .. �r � . _ .. ...:: . ,:.. __...____ _._._ _ .- ,�,�h .a e af rc riot�,inl i �eJ nr ffrr•d for salc.,If� . ` l : - � - � - loucrcr,�tl�cbuildix,qnr��r/+rnrc>•re�t�s��oJdu•rfl�'n;ona � '. __ � :. year oj,cwrpletpr t6c o � � �-rf( ��� !1),arr'.f/c , Geoloflcol..___.. . . , . . . ' _ . . ,\ 1.' \ . � .. hur��.r�nffro: lo�c!!� i.,...ntP �� �. � orcfnr � PedeelrianProtection . ' � •` �.�thrfuTosra/cqlef,,:.��. .. ..,�.,. . . ����� ..;.: ' (Fence)(CanoPY) ..�� ..''� : '"-�.\ . ',� .� �.- ' �. �� ... _� I,as esmer oi the property,am excl�uvely coniroc . � � � ' - - . . tirtg with liceosed�cntrocters to consiru<I Ihe projeci(Sec. Spe[ial�nspecfion � -��- --� � ��- �-�- -- -�� - - � --7945)L'usir.e. d 1 rcfesairtr.s Co. .T'ne f,ontrucrork (Conc.)(hlasonrY)(Welding) ; ` ; �. �- } a .• 1 ic r l,n«d . 1 Rn��li tu m,nu nJpmpertp�e8n . ' :_._._ t.._ .'��.`-' '� . ._ _'�.J. � .�;. . ..__bur7�/snri•�thn�cztbcr. ..u"Jr,! _c:ntCactsfnrr��cb lot Drainego .;: �-.� . ... �. .� . . �,� '___.. _.��••�.l._. �'J._. ..�..�)i.. _ .�� ...__(rinlr�cfur�s,l.r.:c�=rt���t/n. . i . _ � . ... . �,1�� J_l�crr. d jrrrrs�mrrt ro i Parking .; _... • � -.�.:` .� ,.� - _..____-__....__. ___._ __.—_'..'_. . _._. '-___�-_I am axem�t un� Se<.c . . .�L.EP.C.for Ihis � - .. , . .. .'_ ._ ._"" . _ _____..__'.__...._ _._.___.'__ . , ,. , � . .. ._ ._ _________. -__ _ .__ .- '- reaao� � ,�- �� . _'_Dat - '__ _' .- - �O,vn � � ., ,'.� ,, ,.� . - , � -. � t , r�: . . FP I . .'� P 9 . . � ..: .. . � �f_.. ��.,_ � I;^r=�TO;�AO : u., ...,; A rovcls Cafa � Ins oct�r's St nHur� � - � - . qi � Locafion- .... .._. ... .. ._ . (Setback E Yards) � , - �� � � Foundmions . ' .. ,., � �. �. . . � � r- stab , -- . Frame . , . . _ , . � . . ., ; . : -�;�. . �:i�.� � I .. . ... . _._.. _.. .. ..__ ._� __ , . �. . - , . ..... .. , Energy Insulation � . ,__. i. :� . -,, ..!�..,, . . r'.,.�.t r..... ..:.t ,,. ... Lath/Drywall- � . .. .. . .I. . : � . �. . .. ... ..... .y intarior �l . . . -. :. .- . . ,.,�.:^,z'r_..-.J - Lath-Ezterior � ���•.• � � .�.'-- , ..,.. . . � - _.__ . . . . �._. ..... ... . ... .:_: � .. . �.r,.:�:�..,..� House Number- . :i ; .'; i ..-t , . ,.. ... .. . .� . . . . . ,.:., c. .� . ._:,. .. ... . . . ....__ . . .. ...,_.._..._...__.. ..._.__ -___ .., �� .. �. : Correct&Posled - . . . , ' .".. v . �I � , .�.� .. , � � Finol- ,. �� , ... . � ' �. ` Enter on Front � ' ' � � � - 7, . �� t���' .. _ . � 1, , _ , .. �, ,