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HomeMy WebLinkAbout1653A APPLICATION FOR BUILDIN WORKERS'COMPENSATIDN DECIARATION '' � � � � affirm tho�1 hove o cenilimte of consenf to,e�f � �� � G P E RMIT - � ,or a certiiicare of Workeri Compensa�ion Insurance, _i�certifie mpy ihe�eof(Sec 3800�yab.C.p��_ - COUNTY OF LOS ANGELES BUILDING AND SAFETY �� PolicyNo ��� Compony . � Certified copy is hereby fvrnished. FOR APPUCANT TO Flll IN BUiLDWG aooRess �� Q �� �Cerfified copy ie filed wiih the oonry bvild�n inspec gUaow� ,' + Ilon deparfmant. ADD SS � � 1 W � � Dote�Appliconf . . Ciiv � iv IO�qL�TY \ ��.S�C� Q`� ^ C TIFICATE OF EXEMPTIO FROM WORKE ' � � NO.OF BlOGS. NFAREST I d��,�� SIZE OF l0T NOW ON LOT . CROSS ST. 1 ��COMPENSATION INSURANCE !1 (This setli n need nol be completed if the permit is for one - TRACf . BLOCK l0T NO. � d� �ESSOR � hundred dollars(5100)or less.) 1vV1P BOOK VAGE FARCEL �,� 7E�. ba USE ZONE � Q I certify thal in the performonce af the work for which this OwNER N . NO. ��-��� 3 y permit is iss�ed,I shall not amploy any person in any manner , qDDRE55 � �, � � SPECIAI , . . O so ae to 6ecome subjecllo fhe Workers'Compensali0n Lows. CONDITIONS aTr t1Q.nnOtJD " Dote ApplimrN �' �P ' [Y ARCHITECT OR TEL. NOTICE TO APPLICANT: If, afler making�this Cerlifica�e of oiSTRieT GROUP NPE fIRE aROCFsseoev O Eaemption, you shauld became sub�ect to�the Warkeri ENGINEER NO. CpNSI.�� �Z-Or�NE U Compensation provisione of the Labor Code,you most forth• qDDaESS (� � � L� �`� 4� w wl�h comply wi�h �uch provls�ons or Ihis permll shall be ��,�,r2 "� O. deemedrovoked. COMRACTOR �'7t--Np�, STA7ISTICAICIASSIFICATION � APT. CONDp. Z LICENSED GONTRACTORS DECLARATION � . r 'l�,' '����, � � CLASS NO. � �� DWELL UNITS I hereby offirm Ihat I am licensed under provlsions of Chaptar 9 ADDRE55� a—V�'� NO. (commencing with Section 7000)of Divieion 3 of the 8usiness and ��� 3��R ME+P Professions Code,and my Ikanse Is In(ull force a d effed. Crtr � � cuss BK �� ' VALIDATION c( O '��' SpEFT.� S ORI�ES - F MILOIES � O EK. license Nvm er�f I� ( lic.Class � VAWATIOr�N1v� CoMraCtor Datec:��?�� . DESCRIPTIONOFWORK �1 N�' � ❑ s`\ �W—�� , �� AD� �I am exempt vnder Sec. �`1' O AITf R B.BP.C.far Ihis reason _ RE7AIR � s � Date: USE OF �^�.t�L DEMOL EXISTING BL �1 7�f�`-' Sign0lufB " � � /•FFLICANT TEL. /_�][)..� FINAL ,�/�/ OWNER-BUIIDER DECLARATION GRINT . NO. CA'S DATE / % `� ' . I hereby oifirm that I am exempt from the Contractar's Llcense (p.�i� � Law for�he following reason(Section 7031.5,8usinees and ADDRE55 � �'�'�'J� FINAL � Profes3ions Code)� - � 6y ❑ BUIIDING ' I, os owner of ihe properly, or my employeea wlfh aDDRESS _ wages as�heir sole compensation,will do the work and � ' . '" �— � Ihe sirocture is not imended or offered for aole(Section �OC/�liiY � . � 7044,Business and Professions Code). MOviNG - - - TE�. - � � � I,as awner of Ihe ro erl am exdusivel coMractin CONiRACTOR NO. '�. C P r, r s z1653A with licensed contractors to construU the project(Sec- - � qDokess � � � - � ' -�'�- � lion 70dd,Business and Professions Code). J--"'�'--r;. �`.;I`c�.1 �y• • • e . � REQUIRED TOTALSETBACK '� -� CONSTRUCTION IENDING AGENCY �T gq�g YARD HWV GROP.UNE Wi07ii � I • •�J�J.O O 1 hereby affirm that there is a construction landing ogency(or fROM ' �-. tha per(ormance of ihe work fo�which this permi�is issoed - - v.�. � ��, - (Sec.3097,Civ.C.). moe • •�9 3 0 G� c.�. � . Lender's Name ' 0 9,� 9—$8 C?n . � LDAL4 Ref.M '� ' . � n Lender i Address P.C.Fee f Fermi�Pee Z�t/ , . - � I cenify fhat I have rea this opplicaiion ond sta�e that the isn�o�ce Fee lQ. � �DMn v/C N � � � above information is cor ct.I agree Io comply with all County In.esrga�ion Fea ('� � 8 ordinantes and$�ata s relating lo building conslrutlion, io�ni Fee �•�V IDMA Perm.M R an r y avthoriz prasentatives of this County to enter � up obove- i ned property for i�spection purposes. � � m I�7^�� SFE REVERSE FOR EXPtANATORY LANGUAGE � Signoture of Ap coM or AgeN Dote - -. - ' � l PLANS TO APPLICANT� � � INSPECTOR'S NOTES � ,�OR'n'1{BdlU1LDHR U!i(;I.ARA7T0� � I hr.rehy affum thai 1 am�xempi from ihe C� . To: �_ ,,. ... . Retuined � � - , . .. , - License Law for ihe.followmg r ason. (Sec. . ' , ' �:. :: . � ' _: � � :, . . , e APProvad D��sinrsn anJ PrnJesciorst Codc:Art v citl'�r:nunh'�o...`. No. Oate � Na. ' �.Datc� � . ' • - ., . . �reyurrr.a¢fcrniif!n innstrucf.aftrr.rimpru�v.�Jrmnlish, % � _ . . �� orr/�rr'anvsirucl�i�re,friurh�rtciuuance.'afsnrryuirrs , }.� r. /,�_ �-`! . i� ., . , � I!e upn!'�unt f�r svth perniit tn filr a ai,�nrd stuternenl - � - - �- .:r�r n�is uc��:�Jp„rsN�„�r„rt��•p.�, :,J r�.�c,r�: l..� �- . . . .... _� ��...'., �t..'�f'� ��i J � � lru:fnr's f.itrnsr f,Aii�.(CbaP -"I. ; . - ' - - ' - - j 'l1 re! __ . . � __ ....i-. �:_•... ..� . .��.� .!� • � � ._..� ' . ._. _ _._ . --_��. � _ �'.� r^:�'i � , . _--C.rJeJ orl tlrut I.F n es�i/�t tGereJr nir�and rl�h�sic f ir�d c� � ' � a!l�gr�uxen�ftian.Any��inLrtiors�/Srrh��n 70;1,5 ht. i � Yes9uireMo. .'DafePPteived ;-'',, - urtYu/'/' ,_. . ' � � .. ' � � 'lie�ent/oraprrnrittuhf•ettlLrapffreunftnutiri!• � ' ..__. ', . , . . _.:. . __'_____ - . Approvalt . ' • ertaltv n{nnt ntnrr tb�n �c.AundrnJd�,lt�.s'cSool J: � �� or A roved 1' 1 �- � ---�� � - -- ' (� I,�s owner oi rhe p operiy.or my rmployces wuh � ' t� ' ' �' '� � �� �� �� wa es as�he��sole com ensor�on,wdl do the wo�k,and :..' Woter Certd�cote- _ :. '. : . � ,�I�. .1:,' l% ,':. . .. . . ... ...'. �� � es truci�re is not intended or offe�ed{or sole(Sec.70-04J . _ th Heolth DePanmenl -. ..- — � ' "`- � � '-- .. - . . -_ ._: .. . ..' ... ._ , Qusn�r.cs and PrnJr�sio is CnJe•7h rrbarf ir's I icense c Cn r ( '. �t ;r� .�; l.mn Jnrs not op !v fnr�n n�rnrr�f frnperty r<�/��huilJs .^ , •" ..�= � .. Fire�epartment - ' or en:rrnnca tl crr��n,anJudi��Aoes sr�<'�u�url:Limsaljor ..... .. .. .. .._..___ ' '. ' . .. ' _ _ ' � - . �- !(rrnu,Q/-bis..oun emhf�{t'ces. Jrnrided tl✓1 surh i Grodm4 .' .:. . ..::.. • ` ��' �.. (i• ,�.., � . � p�nrrrn�ts�are.nnt infanJrd ur �jJrred.Jnr.mle.,ff, ' .•�/�i,: `� •• ..�..Gnee•evrr,tbe bnifding nr irnyrnvemrtnl is rold�e•itGinnnc .� ., _ . . ... , r, �. . � . . . .. . . ... . .. ._ ... __. ._ . . , .._ . f / b '!J 7!! h Geolog�cal '• � , . . � �� �'Yror o 'ro,n/rfefinn, t�e nunerv vi rr ui >aov !_e � _ . __ � . .' __,_ _ '� . _ _ FurJrn nf prn�in,�fFaf/�r did nnt fimilJ nr rircpror�fnr Pedesinon Protechon ' . .. .. . �.��.;� . +'•. . y.I', Ibc purrnse o/so/rl. ' ' '"�',' . �'; (Fence)(Conopy) . � � . � � - � � -- - -t � �- � , �.� t,asowneroifheproperty,'amex<los�ve�yEOniror � . . .. . '• '�,.':.i'.'.., .. g w' . P� I ( . , , �in lh licenaed con!racto�i to�<anvtr�u ibe o en Sec. .. . .� �044)•Ourinesc Snd Pr Jeatinn:G�dr. 1l�c Cnnlrurtnr's Specia)I ,peciion . : ... ' : '; .. ' -' � -.. . '_ . '1 . . (Canc.l(MasonrY)(Weldm9) . � ' _. ,. _ . __ 3_ . . . ., -. . l.itrnse.J,aiv durs nn�up},1ti!n'an oie•iier/frnprrtv u•hn � . . ' � .. -:, ..... . -bu fJs r im rnrrs O�em ni un�l u�!>n a.,nlracts Jnr ssscb n toi Droina9e . .. O,".. . !,/` : , . .. � _ _ , � pr�er1t_aFi3L a tnnirc�t r(aJ!rencrd.purzu,�nt fo 1hc %. . - -i' . �Cnntr��luri"I.irerisr l.auJ. .. . . Pa.king . . _ .. . _' ._ . . _ _ _. _ _ . .._ . . , � �❑ I am exempi underSec. ,B.BP.C.�Fo�lh�s . --. ._. ...__... . .. ... ....._ . "r, �. . .... � � reason , .,, F. i ,.. .. ._ . ._ ; � � - --- . .. _.. .._ - ..- - -- - � . �.�1'�.. -�. , ._-_ '; � } '.. ' - '.'- -_ n ' , -_ . . . , ____Da�e .. _ ..Ow er ..,. . ... .. , , . Approvals Octo �Inspecfor's Signatvr� . :`� r ' 'J�'•.��J l..! `„ - :,)j � '_ . . , . . � 1 . � � • - � '� INSPECTOR'S NOTES locanon- � . -'_- , ` . - . - ISetbod 8 Yords) � ���. . . . ' . .. .. '� - • . Foundotions ' , _" . ... . . . .. .. ... _. .,_ - .' _ " - . . Siab . ; �� . . � - frome" . . . . 0 . . . . . . ... . . ... . .,. Energy Insulation , O� /il�-� . _'__ .. _._._ �_.. � __._ �._ ._..� . _.� .._ . , . , —� . . .. i '�. � ' ... i. Lath;DryWall._ . � . .__ _ ._ ..._ _._ _ .. . _ . ,, . . __ ___ . Imerior .._ . �...__..... � ,, � . ', . . laih-Exterior � � . . . . • . � . '_ _ . _.. . _ ... _. _ . � . -__ _ _. . ' r. HouseNombe._ � . . , . -- ..- - . _ . ._ . _ . _ _._. __ ... . . - . . Cor.ec�&Pos�ed . . -., ". ;-�� . , -__ . ___ __ . . ___._.._. - � . . , _ , . . ... .,_ ..._.,�. .. .. finol- . . _ . _ -.._... . ._ ._ . Enrer on Front � . � , . .. . . �� � . .. �-. � � . � . . � . , • .. ,, . . . . . � c� � � � ... '_t � " - . . .