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HomeMy WebLinkAbout1362A WORKERS'COMPENSATION DECLARATIdN� � � / � � �/ . I hereby affirm Iho1J have a�tert�icote of consent to Ifl,�c./ A ����� w�'����� �/���'���` �1��"� �t��'� - �� � insure,�or a certificate of Workers'Compensahon Insurqn e � M _ M , V LN G or a�certified copy thereof(Sec.3800,Lab.��C.)� ��� ._ . � . ...... ... _ _. _ ,.�.. _ COUNTY OF LpS ANGECES BU�C151Nfs A�ID'SAFETY Po�icyNo. Company � . . -... . .. � , .�.. , � rtified copy is hereby tuinished. FOR APPUCANT TO FILL If� '- � noozess ` 5,.� ✓ Certified copy is filed with ihe county building inspec- BUIL�ING � J� ( �` J. ' fion department. � '' �. - A�DRES$ V�N� . {�"� �.., LOCALIN Date �� �I� ���AppliCdnt , CITY ZIP � CROSS ST. � � � dZ�C/h.�.--� . �CERiIFICATE OF EXEMPTION FROM�NJORKERS' �� � - _ . No.oF BLDcS _ ,. ... � : ASSE550R � � . GOlvtPENSATION INSURANCE� ��- �"� S�ZE OP LOi - � rIOW ON:LOT MAP BOOK � PnGE PARCEL (This section need not be completed if ihe permit is for one V ' . �USEZONE�'-� MAP �I���- - �� hundred d�lldrs($100)or less.). � � TRACT �eZ� BLOCK LOT NO. fJ� .NO. , , � � �� tEL . SPECIAL I certify that in the performance of the work for which ihis owNER a� . N�l CONDIilONS O, permif is issued,I shall no�employ any person in ony manner �t J . DISTRICT '.GROUP TYPE FIRE SSED BY � so as to become subjecf to ihe Workers'Compensation laws. ADDRE55 U � �� CON� ZQNE 4.! `J � Dqfe� - Applitant � CITY a1 Z�P � STATIStICAL CLASSIFIGATION APT. CONDO. � NOTICE TO APPCICANT: If,�hfter making this CeHificate of ARCHIiECT OR TEL. , a �Exempiion, you should become subject to ihe Worke(s'' ENG�NEER "' NO. CLASSNO.�DWELL.UNITS � Compensafion provisions of the Labor Code,yov must forth- ADDRESS _ SEWER MAP-� - � � � wiih-comply with such provisions or this permit shall be iet. deemed revOked. � � � � CONTIZACTOR d ' NOa/� y BK. PG,���- � ��� YALIDATION � LICENSED�CONTRACTORS DECI¢RATION��-- '' -�- � � . uc. 6 - I hereby affirm ihat I am li<ensed under provisions of Chaprer9 ADDRE55 o NO. ' ypLUATION (commencing with Section 70W)of Div�sion 3 of ihe Business and ��,. � � � LIC. ,p ,� ➢ � R-ofessions Code,and�my license s n fvll force and eHec �-ITY � CLASS�Z!" $ � , 1 J�F�:%`{�"� SQ.FT. - NO.OF ����-�� NO.OF'- �� �� CHECK' � � License Number � c.Clrrss� SIZE� STORIES FAMILIES ONE �y ! �- ��.���y. � 1�.��/J.�p S DESCRIPTION OF WORK L� 1/✓JiY� J NEW � $ w r�..��a,,..�, � Contracfor 'ildte � � ADO. l G�.��.,� / � � G, F �I am exempt under Sec. � � / � � . . . . qL7ER � �FlNAL � - � DATE� "��i +4 � B.&P.C.for thi3�ason � REPAIR � USE OF Q FINAL - y:- ' ^ � ' EXISTING BLDG. . DEMOL gY �s� Signature ' . � APPCICANT� . 7EL.� . . � � N -BUILDER. CLARA710N �� PeIN7) �NO ,� L , . I�hereby af ir thal I am exempt from the Contr cto License qD RE55 -?� /� ,� low for t e. Ilowing reason(Section 7031.��iness pnd - . � Professi ns ode�: . - � pRe 7 - � . ❑ � ��BUILDING . . . . I a ownar of fheproperty, or my employees with qDDRESS es as their sole compensation,will do ihe work and - e structure is not intended or offered for sale(Section �OC.4�itt . 7044,Business and Professions Code). � � - MOVING �TEL. � I,ps owner of the property,�am ex<lusively.coniractinq �CONTRAC70R � NO. witb licensed confractors to consiruct the project(Seo- qooaESS � -tion�044,Business and Professions CodeJ. . �� � �-�� � �� � �� � ' �REQUIREfS � �TOTALSETBACKfROM EXIST. � CONSTRUCTIONLENDINGAGENCY � ��- � - ��- SETBACK YARD HWV papp,-�ME WIDTH � I bereby offirm ihat fhere is a conshuction lending agency for fRONT ihe performance of ihe work for which ihis permit is issued P.0 � . (Se<.3097,Civ.C.). � � � � � SiDE � _ - . . . ..P.l. � - . �Lender's Nnme � . . . . . . $ � � �P.C.Fee$ , Permit Fee o Lender's Address . ... - . �j � I certify ihai I have read this applimfion qnd state fhaf-lhe Isuonre Fee - .J ts� � obove informa�ion i5 correct.I pgree fo comply with,all County Investigation Fee � g ordinances and$tate laws relating to building�construction,� � � � T ro�Fee �'�� �� '� 6nd here a orize�epresentarives of t 's Counry to enter ° .. _ � upon 1 6 e-meniio d proper ��nspection purposes. � ._'." . ..,.... .. .". . . . - .. � . . . . r,.- a 6^" ��.� �. ��'S SEE REYERSE FOR EXPLANATORY LANGUAGE ,, . _. � i , . .... .. , .,... .. . .,. S�gnature of ppliwni.orAgenf � Date � ���s � � ' ,. . ... , -.._.;- � , ..��.,.� .. . ;.'. . i�� � _ _ _ .. _.'z.>�,,.�:; ., �i d ` ' TrsS�Rei��3 e�'�'. .,. _� ,� �w���•�u3�,����uz..�R.�Tior� . .: _�� .. . . _ . _, . �.i�@reoy q'�er^t thaC 1.am cx5rn,p@sros'i fhe Co.nt�act4r;�s �Yo: �ReQyrnmd , Lcense LavJ rt»r the,�iollovying�.reason (Set. 703-1.5} - ' ApgroY�d � — Busdnes.r 3s.dx refessiu.ss�oc�`e F3n,y ce.y or ceus2 y wbech _.._.. . . .-� . _—___ F�o. E9e�4E PBo. �D�E�., .�. - ,�. .;��. � . _ - ,-. - �requ:res a ji�rr ct Z >�o-t� Z �r,¢nn��nvg;d�enzolis'ni � � - . .� ..--- or r�y�air un,y s.ructr�.�e.p�r�o +c..�s-€ssua�ce,a�'o reguires __:: .. .�.�..:__� ,._:,._ .:. ..: _. .:. _ -. . � ..__.. _. . .. __ , - �� �� - �;e ie{�jilien'rt�or suc��pe�rYzt-so�j%Ze�-a��sigs�eul'sdaPervagma � � �J � ' _ ' � . " -' ,. � �_'. ' ' ......_ . �_�_^ LZ>cxt l�e'r;:icersed j urs�uusst g¢t&eQlrobds%o�'s'o,i t5e Coiz- ._.... ._....__.. _...._.._. .. . �. _ .. . ..:,.� .. . ._ ..�_- - r � �.�. . �� . �� eree'or's Eicaxsc+.L¢w/C7�aj�ter 9f(eoa�ssi�ruisag wau�SEo- '. , ._..� ... .;, . ,' ` � �' .�..��� . :. -�--��Pion-7fdG'J/of-t'�ixrissovr3 o'Cbe`�33usi+sess�nacT�Professs"ons � 'k�� �'.; .:; � � �� be C�'ror'tFiat b fs x ��8 b�refrom aa�d t�ie bane for t :-:. �- .�. -: - u1Pe �.t exe�rxptwr Rziy¢sclu+tron'af Secta.rn 70�1 5*by . .:.� A e�vm.s -_'�.. Y�s:s"uieed��� 6a}APPr�vod� .. .. .... .� ..,. ���c� roas o�r�,e of t et ro ehty,o 4my�m�n6 QeOd�.i il .... �� ' . f� Y f� Jsv3 ( }.• . . .. .. � . . .. . , p P P Y th � Waier Cartifi2�te: . �:ry� �.� ... .�..�.; ,. . .. -. . . , �—"'_' Y— „','�w.ae�es 3s9h�r s�e r.ompenstivion;�wrll d.�fhe.work�and ,�- �; .,... � _... '':.� . �:::� ' ���_ . .,.; ,�, . > ._�the'sirucrUi�'s not�-infen'dedoraEiered'�fbrv521i'e(5ec.7C44�i ecl4h Doparament .:���' ���. . .. .. . . . —'i . .•. L.t.rsiness ews�a°'r�je.,srona�,o c�`IYc+Cooa rac�.nr'st�xcense ���. ' ... -.. -. ... ' ..� � ����.. ' � �: ...Z,au�daes�oso �rsp�Xv, to-ant bu:ree*r�ofprojrar�-�vr�io b�2ilda - � '` u � :. ��- o irn�raves her c �a �+vFF�o asSde<b u�- + � f,re Dapa mant �•, �.. � . .. _ . .. r t n, �t' , .f,o.. . rk'E,tmss�o� � _. ., , . -� � � .._ .__ ' _... ._ . rt�.��:.- �.:� . •, `.:..: . . .� � �� hozves.mse%C5e Fiuzl�n�.�foyeas f�rouZd d'8b€��trted' arra�- Gra3ir g . . . . ,.. .. � ._ j' . n,rin'deG2e_r..ffer d fiia!sal I� - � t7. ^�ze x u soEd w�,hrT�S?,�!'f` :a,.,.. . � . .._.�..._ . .. '.' ,. "�-------'— — yeur ej:_cn�p^l dz�m c,h r�� ,i�:5�r wall fi� ^ dbc G�olag�val <<...... : .. . .;_ . .. . . . _, - . . � _.�u..ia�o}�.�.voc,snq d.r�e.�Za das ny€'.a:iei q,s,s.c,ro�e�);or Pedes4nun PrMection � . � ..the f,urpos�e�of uleJ...:� . " �._ ..,t._ . �..:.' ,„ (fence)(Car.opy)' ,� ` ( F✓` " � '� � � I as'bamer�F{-c'�Y6efer4y,-ar,^ex E�s ��yconirac- � . . . .. � �tim�w ih i ce �.eu comiraetors ta cpnS.luu the�roject{Ssc. Special Insp¢cticn.� � �.. � _ 7CA�}Lu.�=zn rsd F:+�a{,s on .�nd• 'f"l�s�.'Crintrncmr's (Canc)(INasonry}(�JVoldir,�) �� - . " � �. .�� �__ � �� . .. Lcen Lert,-�do �aotuf;jidM1E�m;omr¢rnfp?�oprwho �. ,..... � � . � . ;� ;_x._ � _�� •. .. ��- .. .bu-tltbs a�^$Yr��mu�,a_t��s_En�x,a.k..`,who,t�i:qsqyzsfa�'sucb LoS Drainagc � �� ' G . .., .. _ ...... . . . ....... ..._...__. _. .... .......,..._. . � ,,., . ....��nRe�caBnr�'s�.� rcza L.;uaresJ eu;.ey,{� �d w?,s,si.,`�xt sq�Yfie , ,r.. ��� "- , — ,. - Parking •.. ,-•'_ �.__... z � . ... . . .._...._......._ . .. . ... : :,..� � .�,am exem�t unde•Sec;__._,6.8P.C.§or ihis ., :...�.. ., ... . . ..:._,._. _ _._ _ .:': `..rao n ��...� _ _ .. . .. .. ... . �` .: _ ' � .��_� T , , ; ,. " , ._ _ ,._l-_.. _ .- . -� . . . ., .. :� - - . ' � ' _ � . ' ... ._•._' ...:._..—r .'—�' � �_ Da(e, ' .�, .������wner .��,..a.�__"^ . . . . . .... ,� . .. _.. � ., _ . .. ... ,.. _. ., ...� �i�7�ramr3a �ei9a Inagsaxtor�5?�»�4ur� .... . .::. . .... . ', � �" '�-`�._'..".. _:�., . � ;�:iP��,.§'C��'�k`£tJ f wS ..._. _.............._�...,..� ` � ,.�...�.��..�m„ :.,...-.-,�r,_�,.,�.N.d..,,.,._„am.a,....�..,��.. . . Location— .. _... ..... _.... ._.. _. .. . .. . .. ,, (Setback&Yards) � ._ . .� � — - h, foundaYinns g( ..�. -�. � .,. — --_—�.L � . . . ,^ — ' '=r� Slab - ,. �. ,.,. . ... . �� � . , � ,:,.�: .. , .. ..._ , _ � ..: . �. , + .. . . . . �---- — --- -- . ^ �n: .... � . Frame 1 .. -..� ...; '�" Enerr� gy_Insulation � -�:. _u.. � . _.. . _ ..._. .�. ..._� .. _ �,� — .,....�� ,.� ,:,..: , . ..'.." .. "�_�.�_ .>.,,'.... � . —_.:._ ..� __ _-- __�_._—..__"_...._ Lath/6ry�ualf— � __ __ . _._.... ' � �". Intericr .. . , . ... .... _ ......, . �-- _. ._.. . . . . _ ... . �. �.. '_ T-_.� .. , _. . ,.. Lafn—Exiericr . . �... . . ':` �.._. . ... . ..._. �� . . .... .. . . . .. . - � � � ... . , .. — „r,.'_ _ __ — ., ,. _ Nouse Nurnbar.— �_ ,.• -.. ., ,..,s ._. Carred&PoSPed . % ��'' . .,,....._. ... .. _ " . � Final— � . . _ ,� � �..�__. �...,,.'� . . �n, -_.— . E�iter on Frcnt � . .-� �,: " . ,. :i ,-. , < �, .. ,�.. ;....: ._�,. . ��� ,.-,r, . . �. � .� . . . � ..�__ . '....--T.� _.._�...,V .:... :_ . � . .. ...___..... . '_. .. . . . . . . _ . . . . . .._., ..._._...... .__ ...._.. ____ .._. . _. .. . . . . .. .� __. _ ._.. _._,_ ._._____ ... ... ... ...