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HomeMy WebLinkAbout1593A (9) �V��`�ORKERS'COMPENSATION DECIARATION � � ,�, a,�„m «a�I have a�e�,,�,�a,e of�o�se�„o se�f APPLICATION FOR BUILDI NG. PERMIT � msure,o�a cenlfica�e of Worke�s'Compensauan Insurance, or o certiiied wpy ihereof(Sec 3800,lob.C.) COUNTY OF LOS ANGELES - � BUILDING AND SAFETY Policy No. Company � � Cenified wpy is here6y furnished. � FOR APPLICANT TO FILL IN BUIL�ING /� � O ��vE�� � ADORESS (�/ � Cerlified copy is filed wilh Ihe caunty bu�lding inspec� BWL G I �, ' tiondeparrment. . ADDRES _ Q�e Dme Applimnt . . .. CiTv 'YI /� La /� LOCALITY LJMON � CERTIFICATE OF EXEMPTION FROM WORKERS' �� . No.OF eto�5. Nenee57 �� . COMPENSATION INSURANCE ' S¢E OF LOi� 9O y IO NOW ON LOT CROSS ST. (This Secfion need not be complefed if fhe permit is for one iRACT - - BtOCK � � lOT NO. MAF 900K ' PAGE iARCEL hundred dollars(E100)or less.) . / TEL. � ONE �P �� I certify that i Ihe performance of th work fo w Ihis OWNErt C7/1 .0 3G� NO. i " p�p, �" � rJ � / SPECIAI , . O permit is issued,I sholl not employ g, erson i a 'a�� qpDRE55 / / CONDITIONS so as ro become wbiet to the Wor� i Comp ns ii La � V ' utv �4 C . zir 9 � � Date � �� A plicant � � ARCHRFCTOR TEL. O NOTICE TO APPIICANT If, aft moking thi e ificate of ENGINEEfi OWi✓�� NO. DISTRICT GROUG TYPE FIRE 7RO�SSEDBY � Exemption, you shou d bec e svbject to 1 e Workeri . . . /J /] , . /!.� j �OHSL � ZOrIE ��'�y W Compensation provisi ns of a Labor Code,.you musr forth• ADDRE55 G/7�f7rT✓ �l J d' , wilh aomply w'th sv h visions or �his permit shall be , _ , _ �,' . . . . . 7Et. �� �� S7ATISTICAL CLASSIFICATION APT. C�ND�. Z tJeemeCJ revOkfA. �ONTRACiOR NO. � UCENSED CONTRACTORS DECLARA110N UC. , CLA55 NO. DWEII.UNI75 � 1 hereby affirm thot I om I�censed under provisions of Chapter 9 �� nD�ae55 � /� - NO. (commencing wirh Section 7000)of Division 3 of the Business ond pC. '��R�P� ' �rofessions Code,ond my license is in full force and effecr. - Crtv ' �� C1A55 eK � , - VALIOATION . . . SQ.FT. NO.OF NO.OF CMECK Litense Number lic Closs SIZE STORIES- FAMNES �- ONE � VALyATION DESCRIDTIpN OF WORK N�. �- �. Canlroctor Dale . . � ADD s C(J � , �I am ezempl under Sec. � q��g � - B.BP.C.for fhls reason ✓P �O REPAIR -s .� � � - - Dafe: - USE OF' e DEMOI � � Ex15TING BLDG. / �� /�C Signature .. .. A7PlI�ANT - TEL7 FINAL ' OWNER-BUILDER DECLARATION FRINT �A✓1G� � Mt NO. OATEp2—�J _g,Q � _ _ . , I hereby offi�rtt Ihol I om exempt from the CoNraUo+'s License "-�" qpDRE55 � 2I /W✓�'� 9/� FINAL Law for the following reason(Setlion 703I.5,Business�and ' Prof ions Code): . . . . a N . . . - SY , BUILDING �I, os owner of fhe property, or my employees with ADDRE55 � � . . �'� ' wages as ihoir sole compensation,will do the work and � � - � , �1 5 9,3 A the structure is not intended or o(fered tor sale(Section �O�'��iY ' � � 7044,Business and Professions Code). ._. MOVING . . . . - - TE�� � ��. {r�� � e � I,as owner of ihe property,am exclusively contracling CONTRAClOR � NO. M • � wi7h licemed controctors la tonsMocl ihe projecf(SeC- - qDDRESS �� � -�- - � � � � • +6 1,7 5 tion 7044,Business and Professions Code�. . ', REOUIRED YARD HWY TOTAL SETBA K •6�,'I v V� CONSTRUCTION LENDING AGENCY SET BACK �ROP,�WE WiDiH , - + � .I here6y affirm thaf thera is a construction lending agency(or fRONT ihe periormonce a(the work for which�his permit is issued P.L. - � - O�,� �l—S H �(Sec.3097,Civ.C.).� � SIDE v.i. Lender i Name - � � . I�� IDAM Ref.M m _ _ P.G Fee S Pe�mit Fee , , Lender's Addrezs �� � I certify thot I have read this applimtion and sfole that fhe issuance Fee LOnM 7/C k abo inlorm lion is correcL I ogree to mmpiy with oll County Invesugation Fee / ordi nc nd Stote lo relating to building conslruction, To�ol Fe V L�MA Perm.M � . Q and hare authorize esentai�ves of this Couniy to enter � on� above-me d pro ny for inspection purposes. � �� SEEREVERSEfORE%PLANATORYLANGWGE Siynature of A$ol�cam or Aqent . . po�e .. _ _ . . . . . . � � , � PtANS TO APPLICANT INSPECTOR'S NOTES -OK'NF,K-HUfLUI{R UF:(t1.AHA'�i7C�"r��.-.��: I herchy a!hrm tha'.I,am eaempi trum d�aL 's=�� - � � � � ' � . License lnw lor.�he followmtJ.renton (Sec ,.,fl.$� To: _ . . � . . Rafurned ., �.. , . . ` ,. _ � . . � � APProved , . . , JlusinrssondYr.�JesSiunsCnJe:.9nvcih�r�r:.�unl��reLirl� No. Data No. ' Oale.. . . . .. . .. ., rryaires u fi�r vit!n rnmlrurt.ult�r,impru •.Jernolis/r, " - — -- �nrrep�iirnnyxlru�terr.prinr0uit�is��mncr,ral.vnrryuirrc � , - � � � - ' .. �f. �. . Ibr apf�li:�uit Jnr tuah frrnrit(n filr u si,GnrJ se�tivuen� ` '. ; �' , � ' . _. _ . ` '' _`. _ . . _ _ ___ __ _ _ . f_._-.- ' _ - ---� �- _.._.. _--._._ . - -_-.- .__ . . ' :'-�: '_• - �-'.'..'. _.. . - ..-lbdt br isli:enseJ pur�uant tu rhe pr�y i�i.�ni nJlRr(:.�n. � ;, • . ....; �, . �'_ . � �r •(CG�pn�r')1(rom��r�rin¢'u�irl�.5cr- -. _.. � ' �... � .�.. . �I4Cli 5 f.%fa'nti��wi�1 ___ __._—.._._._' "_". ___."__ ._'__'__ . '_ . . _ . . . �- . .. . . . tiop?bOflJn/Uiri�i�in 3 Jtbe[3utinrssunJ!'ruJrsainn� , . , �.�,.. . .., .' ,.,, •.'`" . . t���,.:c.� _ . ._ ' , � _.__ . ___ .�.`r.. . _ � . �'.. .LoJrf nr tb�t be n rxrinpt 1LerrJrnm unJ tlrr hnai�/.�r/Gr �_._ _. . __ _ ._ . . _ .,. . -- --� " u/Irgrd exrsmrtinn.Anv rinlulinn./Srrtinn 1U31.9 h�� ','--�--- =- � ---'- -Raquiied� - p6fa R�celv�d -� `' -��- ' - � -. � - - . . . �ny up/�Iicanf/ a pe i(rubjeds 1hr uffb�ors(!o u i iril I APp.�ais , . , . . :..-----__ ._.__ � 1'� ulev��/n�rr� n.�tFan/incLu�JrrJd!laric'/SSOOJJ: ,'. : 4cs_ ..No. or Approvsd�� � . . . _� ._. _._ __._ '_ . " .. ' ,__'_ " _ . _. .... .... - _-< _ ' , � � �_�!� I,os ow�e of�he proprrty,or my empinyees wirf� _._. , ' V;u!e�...'.ernt�cate__. � �.� . - � �. ,.� , � � �- '" �. `.. � - -�- - .��wayes oz'�rheir'sole cempensnbon,will do,the worl;ond � � - - , � ��the siruclure is mt.iMended or oflered 4or sale(Sec.7�4d} � � MeoPF Depanmem---�-- - �--" - -.. '.-._:'-.' •�.. ... . - , , ` ,�� • ;, • � ; �'Uutinrst anJ PrnlesSiuns G�fe:97re Cnnha<'dir's l,irrnte � . ' , �'l.uu�Jnrs nnf ar/�fy In un�iuyrrr r f rrup�,r:�'irhn huilJc I ... , __„"_ _ __ __ _ _. ._ ._ . _. ._: . . ..,: .. ..� � . � .. orimfrovi•sfh� n:unQu•Indocss hu��.kii���,rf/nr Fi.r Dep..rtment . � . . � . . , .. , � ..: . -� . . .. , , . . . ... , � ' llrnu,Qlr l�ir nun'ridplulere, /�mraJc(I thuf iu:h un- � . Grnrimg��� � � ' ' • , ' . ' _ -_- '- - - . inorrrxrntr'arr�nnt.infeniled ar�r//crrJ fnr salF. !f. - ...:. -�. �, � .. _, 1 � , • . ..--.� ' _' � .__ _ _'_' '_'__.. .._ -.., :_.`.' , _.._ . ._. , '�Gnu•erer,tGe breif�tin,y rir inipme eroen!is snJd rc rthrn pn'e �Yeol��cnl�i � I � .�� :' .� � � . ' ___ __._. . . , )'rar nf rnmhletinn, !be nd��rrbuildrr uif!bu"�IJir � -__-.__..__ . .._.. . _..... -.__.. '' burden.n/prnvirt,y IGuo.l+r diJ nnt F�+i1J or'mpr �e/n � l . I-'-- . -'-.-�-. , � ;- - --_'- . . . _------ 1be/rurfroteo/salel. ' -' rt- n� . ,., . Pedesn'on Protecr or+ . . � .. � ..-._...._.. -�--- .;: .�...... .. . �"� � ��,ng wi h aw sed convacron o c rFe��ceitConbPY) - . � p P Y maxclusivelY�ovwa ._.. onsrruu�ho pro�e<e(SeC. _" . . . . ._. .. _.. . .._,. ._. ._ _ _ _ - r �'r a� 'nJr•T/ C�nlru<!nr i - a ..- � . 7044)13vtiners unJ Pr fes�+ C . SPe:of Insnechon :. . _..- _- ._ __ ; .. � . . rc � iConc�IMosonryl(Weldmg) � � .-. _ ___..... _ - ._ . _ . . .�_ . . __I.icensel.tu•dnernnlapJ�fYloanomnernJprupArl1'u•Ln � }� �� \. _ burlJs nr impm��er(berrnrt,und u�hn cnn�radt/ar s�<d� �.o�O�a�no9� . � ' . . � -_-pmjrtts.u�ith�u ran(ructnr(s/firenserl purtuunt to tbe „''� .... . -`. • . `� '`; • �-. .', „' C ntrarl,�isl.icnntrl.auJ. . - ' , �'--' . �o�4iny �.� - , . . � ' -___. .._... ._._ _ _.__... . .,. .. . . ' L� 1 om evempt under Sec. „�.&7 G for Inis ... . . _ ._.' _ .. . . . . . .j � ..___reason . . , . . . _ . . . . � "- '�---�-- � - - - - � - � _.__Do�e Owner '- - ., .. ,. , � . � �� � . . �..,. . � ,• - �� ! _ ' , _ ... __ . . .- . .. ,. ., . ., . Appro'vola��. Dof� Inip6ctors Sign6lure , _ . ..' . ' ' • . _ , � . ' . . . ' 'INSPEROR'S NOTES�.�.- locahon_. _- . . -... --.' � �" , .. , , . �. ISe`c�nkBVards) --- - - - ------ ---�-- .. ......._. '• '�.� - ,� ,^� � . . . � Fourdat�ons ' _.. . -'- -- ._. _ .. ..� . . ., . ... , ... .; .,,. .. Siob ___--. .� ...---'-- � � ' . .,r,��., .. .. - _;. . � , Fro�ie ' . - � _ , . .-� . , . . . . . �. .. �� „ .. - Ene.gy Insulollon . ..'-- ,..._.__'. _. ___.... _ . . ._ ._ - . . i r. to�h:�rywall_ . ._.. .___ .._._. � . . . ��� � • . . . ,�, Imeiior " _.' . i I . lorh-Extenor i - . .- ., . ._ _ _ _.. ... _..__.. _, .__. _- .�- . ., � _., ... . .. HouseNumber- .� � � ----- - � � � CorreuBPosted - �' .��� � - _ ���.� ._�_ .. ..- . F�nal_ . . , � '. . . ... . . Enler on front ' ' � '. . .. . ' , . '. . . .. . � .• . �,�. . . ,e.._ ,'\ � . .. . " �. ' . S" . - —.___ _ _ "..___ � '. • ' __, . . ' .