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HomeMy WebLinkAbout1798A 1799A • • -�; , � �.. , I -� WORKERS'COMPBJSATION DECLARATION � - - , , . . .. . • � , I here6y affirmihot� �a�e a�e,�;F,�a,e of��o�5e�,,0 5e�f - ��APPLICATION �FOR BUILDI NG PERMIT � � insure,or o certliimte of Workers'Gompenstion Insurance,or � a cer�'ied copy Ihereof S ,lob.C.) . � Policy N�'�'B�� ��pany�({�?.U. � '� � COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ ar v FOR APPLICANT TO FILL IN aooaess � �?O/?� Certified co is hereb furnished. � Certifled copy is filed with tha county 6uilding inspec• BUIIDING !/ �ion deparfinenl. � . ' AODRE55 '13OZ GdTZOIl � LOCALITV /�' NEAREST /! / Date ApplicaN . Ciiv N]dlilllt ZIP- CROSS 5T. L'+'LF� 0 � CERTIFICATE OF E%EMPTIpN FROM WORKERS' NO.OF BiDGS. n55E5SOR . . � COMPENSATION INSURANCE � SIZE OF LOT� 9S�X H� NOW ON lOT MAP BpOK � PAGE FARCEL (This seclion need not be complefed if Ihe permit is for one uS O�JE MAP / 2 ,f. hundred dollars($100)or�es5.� TRACT 2 BIOCK lOT NO. // NO. � / � ,J y r � - TEL. n� SPECIAL � ' . n, I cerfify tho�in ihe performance of�he work�for which this OwNER o.598-1641 � GONDITIONS � O permit,i5 issued,I shall no�employ any persan in ony monner Oi51RICT G UP TYPE FIRE . PROCESSED BY ADDRESS CONS. Z E �so as�to become subject Io the Workers'Compensation Laws. � � - c�Tv Walnut CA z�P 91789 `� � `� � O ��oie � Applicanl ' STATiSTiGAL Cu55iFiCAiiON APT. ' ONDO. V �NOTICEiO APPLICANT:-If, aher moking this Certificate of ARCHITECTOR - -� � -�� � TEI. � � . _r/ W �Exemption, you�should become subject to the Worker5' ENGINEER NO. ClASS NO. � DWEIL.UNITS_� y Compensation provisions of the Labar Code,you must forlh-� � qDORE55 SEWER MAP � Z with compiy with wch provisions or Ihis pe�mil sholl be TE� � � deemed revoked.� - - CONTRncroa - SdI[IL' dS �IIIPY' No. - BK. PG. ' � VALIDATION- ' � UCENSED CONTRACTORS DECLARATION. � � ❑C. . . I hereby affirm that I am licensed under provisions of Choprer 9_ . nDoae55 r,o.328279 VALUATION (commencing wilh Section 7000)o(Diaision 3 of the Business and � ��� �7 ' ' Professions Code,and my licensa is in full force and effect. CITY CLASS B-1 5 ,,�(! (,��f '. � ' . � p+� � SIOZEFTZ 4OH STORI�ES 1 F MItOIES ]. CONEK License Number ��o2�q i��.aas� � �� �q�p• Q� t DESCRIPTIONOFWORK New Hane NEW � b Controcror_1L(�! /�/.N�le Daie_J!�2/� , , � � � �• • •+f� . � I am exempt from the licensing reqoiremeMs as I am o � ' ADD ' � � . licensed archi�ect or a re9is�ered professional engineer , . , , .. , .. _ ,_... aliER � FINAL - 'r s 1 8 3.G 4 , acting in my pro(essional topocity (Settion 7051, REPnia DATE R Z,Z� _ Business and Professions Code). . USE OF ❑ FINAL 1•!" � C J Q LI� � � E%IST�NG BI�G. � - DEMOt ❑ B - �. � LiC.or Reg.Nv. Dala APPLICAM 'TEL. - � . . O 4'2 7��� -- ��' � OWNER•BUIIDER DECLARATION � ' �°R�NT, � � � � -� N°. �- � SrQ p<��'�F7v I hereby offirm that I om ezempt.from the Controctor a License �� 7 9.9�� . .law for the following reason(Seciion 7031.5,Business and " ADDeE55 - �,� . ..•b � Professions Code): . . , . ke eN . - - •.❑ . . � . OUILDING . . . . �I, a5 owner of fhe property, or my employees wifh nDDttE55 ;I e G 9 L'.Jr O wages as Iheir sale compensa�ion,will do the work and � - � -� the strocture is not intended or oifered for sale(Section lOCnuiv ' ' ' �'e 2 9 t c�(;� . 7044,Business and Professions CodeJ. MOVING TEL. � ' � I,as owner of the propeny,om exclusively contracting� cOr.rtanaoa No. . � �� Q 4,G.��,�� wi�h litensed contractors lo conslrvct the projeU(Sec- qD�RE55 \ ' - � - tfon 70a4,�Business and Professions Code). - � � � , � , - � REQUIRED .TOTAL SETBACK FROM EXIST. �\ ' CONSTRUCTION IENDING AGENCY SEI BACK �ARD HWY pROP.LINE WIDTH. --"-- - .. � �\:. ` -.�� � I hereby afiirm�hat there is a construction lending ogency for � FaONi � - � . � � � the performance of the work for which this permit is issued P i � � . ... � _ � . ($ec.3097�Civ.C.J. . SiDE . . . . _ - . . . ._ . . . . . � v.i. ' Lender's Name / A �J / � . --�I „ • � ' S , P.C.Fee 5 lJ�r�< . Permit Fea O{�L� OO ' ' ' , ' ' � _ Lender's Address _ . C _ t , W I certify�hot I have reod this applica��on and state�har�he iss� ce Fee � � � � above informotion is corred.1 ogree to comply wilh all Counly ._. Invesiigaron Fee . �� q � . ordinances ond S�a�e lows reloting ro building construclion, To�ol Fee Gt"��d'r and hereby uthorize representotives af 7his County to enter � � u on the o e menlioned ro� t for ins ction r ases. � � � � - � m P Y' P Pe�Y Pe f'P�P � ' ' . a`� � ;���J���,�,� /^2�—�/ SEF REVERSE FOR E%PLANA70RY LANGUAGE , � � � S�gno��re of ApPl;coni or Agen� . . ...�O�e. _. _ ..�_ . . .... . . ..- . . . I, . . . . . 1/ l 'PLANS 70 APPLICANT � - � � INSPECTOR'S NOTES O�i'NER-BUILDEA DECLARATION 1 heraby affirm Ihol I am exempt irom tfie Contraclor's To: � � Beturned� � ' . � ' license Law for fhe foliowing roason. (Sec. 7031.5J ' � � �, Approvad _ . , - BruixcssandProJcssiqns�odr171nyry'tyurcopntywGicb No. - Da}o -� � No. � � DaTe - � � � - -,� - regttires a�2nnit�to ro�slrutl,altrr,i�nprovc,demolisb, . , orreyairanystructare,priortoifsissuance,e&orequims -- -- � - - -- - �� � �-' -��� � - - -- - - - - � ibe appficarsi for sucb permit to f'le a signed statement , � , , tLat Ge is Jicenscdpvnuant to tGe provuions oJtGe Con- • � � � -�- �� --� �' � ' �� " ���� - " � � �- ��� 1" " tractor's Llcense Law(CGapter 9J(comnrexcing witb Sec- � � . , . _ ._ . tion 7000J of Divisron 3 oj tbe I3usinexr and Projessians � � - � � �- � � � � � � - � � � , . CodeJortlatGeisexe»rpttLerejron:andtLebasisJortbc � -- __ . . ulleged e.rem�tron.Any violution oJSection 7031.5 by . �Raquirod . DetaRecelved � � � � anyaQpllcameJoraperniitsubjeclstbeapplicanitoacivif . _. ADArovcis ._ er Approvod pcnatty of not rxorc tban Jivr buxdred do!lars(SSOOJ.J: Yos No ' .. ❑ I,as awner af the property,or my employeas with ' Wo;er Cerlificate , - wages as their sole compensation,will do the work,ond - � - the structure is nof intended or offered for sale(SecJ044) � Healifi Departmenf' �, � . �� - � _ IIusincas and Professrons Code:TBe Contraclor's License, - ' � . . --- Lom docs not apply to an owner of propnty wbo buifds , Fire Department '��- • � �or improvea themon,and wbo doesaucb work bimielJor � - � �� � � - - � -- - tbrougb bis,own rrnployccs,•provided tGat sucb im- � Groding - , � provemewt� are not irttended or ojfered far safe. If, � - - . � -- - � � - -�-� bowever,tbebuildingarimpravementuaoldtvitbinone � � Geologiml- � � - . . � �. � . . � . .._ yeur of completiox, lbc ownenbuilder wil!Gnve ibe �. � �� �. � � � �- � � -� ' 6urden ojproving lbat be did not build or improce for Pedeslrion Protaction � - , � . . ` tbepurpose of sale). ' � ' . (Pence)(Canopy) � ❑ �I,as owner of the property,am exclusively coNrac- ' � tirg wi�h licensed confractors to construct the project(Set. Special Inspection . ' � � ' � 7Q44j.�jfusinets and Prb�(eastons CoJe:Tbe Conlrattor's (Cont.)(Masonry)(Welding) � � _ - ,I.ifen\c Lau�does nnt a[�pJy to an otunrr of property wbo . - • �� � � - � � ���buifds�ds"�irnproves tbe�eon,,ani�w�io�'ontracts for suoG ' Lot�rainogo . . ' " � , p}ojectS iai1G a eontracto�J ficeased prsrsuanl to ibc � - . _ .. . . . . _ Contractor's Liccnse laacJ. ' � � Porking - � . - _ . . . ❑ I am exempf under Sec. ,B.BP.C.for this . ' . . ' - - � - -- - . ._ . . reason � . . ' . . �.,., ., � ,.�„ , �Dare � Owner � � � f+PProvals .' �alo 1 pettor's �not�ro ' . . . . - INSPECTOR'S NOTES - . . . Lomtion— � � . .._ . . . . . .. . - . � (Setback&Yardsl � �' �� � "� � . . � . . � � .. . Foundations ' r .. .. ..- ... _ . _. . . . . , Slob � . . . . .. _ ... . . . . _. Fmme ��/ ' - ; . � � . . . Energy Msulation � � . � � � � lath/Drywall— . .. . . . , ' , � Mterior � . , . . lath—Exterlor ' � . � � � . �. Houme Number— " � . � . , � � .. . . Corretl&Posted � - � Final— _ - . . Enfer on FroN � � � � . ' . . . . � � _ . . , /