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HomeMy WebLinkAbout1441A (8) ' WO�2KER$ COMPENSATION dECLAR}\TION ���� i� �� � � -- . .���� n � � � t herehy affvmP�at I hov(a�cerllficate of jonsent � �� � � �-�. � ��,°se1 � �►P�'LIC��'TC�N��C�R-��UI��L ING PERMIT � msure;or a cert ficahe of Wo kers Co pen 1 on Insurance, � or a certrfied m thereo4 Sec 3e b. LOS ANGELES BUfLDING ANb SAFETY ` '- „ _ .,_. .,.:..e.�.,,. ,,......� ...�.,N., �.��..,..,.F.. � .� ,.�,�. PolicyNo. - �� Company . - - -. . '-,� . .. -Eertified copy is he�eby�fu��ished.�-: ' �""`��� � � -FOF2 APPUCANT TO�FILL 1N -� '�-" �eu����rvG� `� - .a , ._.. AaDRE55 . .. , ' � Certifi d'�opy�s filed with ihe o t ilding inSp - - � BUILDING /- ���f ���"�� '��� v'� de -rimenY.�--� � ADDRESS G,,,,,�'7 �� �Q:1Q'� <.. - . .. . . �. .. .. . ,:..:. .:�,.. ._.._. .._........_...,. Date' �� Applicant ' C11Y �P7.J ZIP LOCALITY . . � �CERTiFiCAT Of EXEMPTION"FROjy1 WORKERS'_�� � �'� ��- - � NO.OF"BLDGS' ��� � �- �������� � niE4RE5T. _.. - � �°� --COMPENSAiION INSURANG� - � �- �"-�� SIZE OF L07 NOW ON LOT CRO55 SL � - (This section�need�not�be completed if the permit is far one � � � � � ' /+SSE556k , ��-�- . - : �-� . hundred dol lars(§100)or less.) _ ,. _ TRACT BLOCK LOT NO. � MqP BOOK-' �pAGE PARCEL . : .. .. , .... .;�� .� TEL � � U$E ZONE. .�. MAP .. _..._ ��� . I certify that n fhe performdnce of ihe work for�-wFi-"ihis � OWNER �, NO . � N0. �°� } permit is iswed,I-shall not e�mpioy an p son" any ner SPECIAL �- � � � a so'as't beco �e-subjecttothe�W 's'�C mp n-tion a s. ADDRE55 -- - . � '- CONDITIONS ��, o Date�' � �, PPlicant � . . � CITY . ZIP .... . .... �.. � . ...pp ARCHITECTOR TEl ��-� � .OISTRICT,._ GROUP TVPE FIRE PROC ED.BY � IVOTICE t6 APPLICANT: If,�afier making'th s Ceitificafe of ENGINEER � NO � � � �' Ezempt'ron, you should be'cdme sub�ecf-to the Workers' � � -. .... .... ,..�_.. ,.,._ � � CONST. Z E � � Compensation provisions of.ihe Loboc 6ode,you must forth- qDDRE55 "' � �� . d with comply with.Such provisions or fhjs permit_shall be . """'�'TEL ����` �`�� � STATISTICAL CLAS ICATION��� � APT. CONDO. d�emed�eyaked.,,�, ,,, -„ , CON7RACTOR � NO ���1��+ � � LICENSED CONTRACTORS DECLARATION_ � - � '`, �- �'����r'�"^`,` -ry'�� -CtASS NO:� DWELL:UNI75 I hece6y aff rm thai I am��4ensed under proy s ons of C6apter 9 �'� ADDRE55 ��T„ S Fk�L,=C-.� NO`i� 4 �• L . .. . . . . . _ . (commenc ng wifh Sedion 7000j�of Drv sion'3 of ihe Bus'ness and . ., . _�_ � �- ���" -" SEWER MAP � � Pro�es'sions Code,and m license is n full��foi'ce a �effect � Q7V � ���� a.:,. p y . � CLASS BK.��� .� - VALIDATION ,:•1.., W�77 SQ.�. 'y NO OF NO.OF � CHECK Li<ense Num6er '``� '�"� Lic.Class� SIZE {O� STORIES - FAMILIES � � ONE . ..,. �'r..� .. , -�;.,_, . .. .. .. .. . ... VAWATION ��� . .. Conlractor Date_,` ` � DE RIPTION OP WORK � "i['L�_� � -�� NEW �❑ $ �� ,."/- ... .. ,,.»_,. ,._ . AOD , �I om exempt under Sec � .. .-. i l� � . . ❑ . . . . ..._ - .. � �.._ . . , ,._ . . . .. ALTER . � 6.&P.C.for this reason�. .. . � �,..... . . . RFPAIR � � s . . . . . . . . .._ . USE OF . . . .._...... .�..�.. . ..... .. .. ......._. ._.._-Date: ... EXISTING B DEMOL , .. Sfgnaiure ��- .�..�.. ...:.. . ,�� ...... APPUCANT .. .. . ' .._ TE� .. . ..-. .. PRINT � �' . 5-�-� NO �'*�13 FINAL .� �. '.... OWNER BUILDER DECLARAiION . },�� . ,..... ,,, �, '1� . DATE ' - .�� .I heFeby a4t rm that i am exempt from ihe Coniractor's License � �� �`��.q .�'�"'t'N-E��'�., �LJ•^•• '��+.t'.�-;�'� . . Law for the folbv✓ing reasoh'�($ecfian 7031.5,Business and ADDRE55 C.� -FINAL��� - - � ..._.Q.n_� _ _...,. � � �h �`� �..m.'I " �-PrefessionsCodej'"._.. .. _._._.. .:.... PRE N7 . _ ...__ . .,_., ...„ ...,. .,,._m,�, gY.. . . . . � I, as owner oF the property, or my employees with AD RESS �� . � - � ". '_,_.._ �._._. ....r..:.� wagesastFieirsole.mmp saton,willdotheworkand -� '-��- ��'��� � � i u�,�„ ' ` . ihe structure is not inlended or offered for wle(Section LOCALi7Y '� - � 7044;Bosiness ond�ProfessronsLode. � � � MOVING � � � `tEL �� �� -����" - �� '� ❑ � .. . ,.. - .... . . I,as owner af ihe property,am exdusively conirocling CONTRACTOR NO �CL i �"t'�ii�-o. � _'-with licensed confrqctors fo consirucY ihe pro(ecY-(Sec� '��� ADDRE55 � � � � � � tion 70d4,Business and Professions.Code). � REOUIRED .TOTAL SETBACK F I ���-� �� � CONSTRUCfION LENDING AGENCV �"--� ' � SET BACK ' YARD ��HWY' � pROP:IINE � -�- WIDTIi� � I hereby affirm that there is a construction lending agency for FRONT � � � the�performance of the work for�which,iMis permit is issued p.L � � � �� -.��---- � � . � (Sec.3097,Civ.C.]. SIDE .. . .. ... . m . ..... .. .. .. .. P.L . .. .. . . . . a Lender's Name . m . . . .. . �.... � LOMA Ref.# . . � . .. . ... .. . .. P.0 Fee$ � Permit fee . � . ... .. ._____...._'_ ' . . - �Lendar'sAddress � I certify that I have read Ihis application and state fhat ihe � iuuance Fee- � LDMA P/C N - - - a abave i orm 'on is wrrect- � ree to comply with alf Counfy �� invesngation Fee� �� � ' � � � "� m .ordino ces,pn Stat?la relat g to building tonsiruction, TomtFee �-0 � � �ioMA�Pe.m.�# u an e�y au +++'���g repr sentat ves of th s Couniy to enfer ��� � � �� p � pr pe y insp. fion� �...._ «*,�a�,.n��e.�x��y.,a«. �-.�s s. . . m u n th al n o t for. . . ,.... . .__. , M.. .�..a.r.,,K. ��.�n.�� . � _.._ , ... ... � .. . .. . . ..,, . r..,�.. . .: . a � ..-. ..� . . .� + ^ SEE REVERSE FOR E7(PLANATORV LANGUAGE � � ��0�'�y�`3` /�`�5 �N� �4=6�� � ignat�re of Applicanf or AgeM �aie ��� I �. . . . ,:_. . . �a„�=�:...�... .. . .a-«,.,,..Q.�*.,.._.�».�.�.:.a...n..,�;...-..,..,-.-.e...�-,.M,•,-.�...�...,,,,-b.....�.:Mw�.,,.e::�R ......�.,.,,,- . ...... . .. .. .. _... PLANS TO APPUCANT - � INSPECTOR'S NOTES O�VNER-BUILDER DECLARATION _ . . . �f here6y afflrm ihat I om exempi�from ihe�oniracior's To: Refurrled - � � . � - � � � ' r� �License Low�ior the following reaSon (Sec. 7031�.5) - �- � �� � � � Approved � � Businessaxd�ProfessionsCode:Any.cityorco.untyu�hich, No. Date �No. �"Do}e � - � - �� � � � � � � reywlres u permit to constrazct,ulter,improve,demolis$ . . . . . �. ��`or repasr¢ny structure;preor to�iu rssunnce,ako requ3res� . �.:._ ' . � •r,-6-, ,,,�, .;�:} .�:_�..a.�.���.... :�� . tAe applicani for sucb perneid co�file�¢sigued statement. __. . �� ��-"��� �-��'� �������'-"" tAat he ie�licensed parsuant to the provlsions of t6e Cqn- - � �� � � . trmctor's Luense Law(Cbrapaer 9J(commerecsng aeith,�ec- ""'��"� - -""� ��� �" ����-"� . " � tton 7000J of 13ivision 3 of the Business amd Professians - � . . � , : �� . � �+.. CodeJ ar that he ds��exemnt tberefrom mnd t5e basis for tbe � � � �'�� a[leged esemptiott.Atty.udolatton of SectCon�703L5 by Re uired . . :� . �.� . . . . . � ... -� any uppficant f r a permitsubjects tGe applicmnt to a civi! � Approvals � 9 '—Dote Reeeaed � � _ - enalt�o not rnore tban fve handred dollmrs $500.: .. Ves No or Approved . . � .... E' 1 f f .. . -� �� �-' � ' -�� ��� - ��� �-� ��� � -� '���� ❑ I,as owner of the properry,or my employeeswith Water Certificate . ...-�. . . . .. . , . . wages as their sole compensation,will do the work,-pnd -� � -- � - � � �� the structuce is not ntended or offered-fo sale(Sec.7044) � Health Departmeni. .. . . .. . - � � � � - �- � �-' BusinessandProfessio�r�Corle:Tbe,Coniructoss��icense Law(loe noa appLy to nn owoaer of property wbo builds s Fire Department.. .. . . -� --- � -- -�� �- ��� ��-- --� � ��� --�- -��� ��dr iinproves tfiereon,and who daessucb wo`r�6imself ur � � . tbrougb bis�owm empLoyeea. proofded t5¢t�such�im- Grading . �� - � � - �� '� provements¢re not ixtended or.offered for.aale. If, � �� Fiomever,tbe buiJding or im[�rovement is sold witbitt one Geological � . � . � � � , . , .: _�-"}'eK��of compleLion, ahe oa,�rier-6uilder will have tbe ' �� • � �� � � . - . . bu�rlen of provimg dhut�he did mot build or�imQrove fo�r Pedest�rian Protection � �� ; ..:� ... . �� tl e purpuse.of salel. � .:�. .�, - (Fence)(Canopy) � . . . � � � � � � � - ' �� �-"❑ �,as owner of theproperty,am e clus vely contrao- � :- . ling with Gcensed contracfors to consiruc�Ihe project(Sec. ' 7044)IIusfness and Profe.csioru�Cnde: Tbe Corif'r`acdor's Speclal Inspe<tlon ". . ... .. .. ..� . - , .. � (Con<.)(Masonry}(Welding) � �' -� � , �" ��,. � � . - Licemse Lau does rooGupJi�y to un u�u�ner ofproperty who. . � "bui��or improaer tbereo�,und who coxtructs for suc5 - �- � '��� �"-:p'r jects�witb a contructor(sJ ficensed pursuant to tbe Lot Drainage . . �. �. . .. . � . .. . . � . . _. � . .. _ .._.. .... . , � - Coritractor's License Laui/. Parking . � . .. . . . . . . . . .. . . _. � . . . . . .. ... . . . .. _ ❑ IamexemptunderSe. ,8.8P.C�for��his " ___._._... . _.__._..._. _..._..-. ...:..._..... . ...... .-,.. reaso � . . ..__.. ...... ... . . .. ... - ,�., . . . . . .... ......... _._..__.. Dme Owner Approvals� Dote � Inspec}or's Signafore � - � � � � � � . � � . .. . . _ _. � INSPEC70R'S NOTES Locorion—.. .. . . .. . ' .. . .. (Setback&Yards) !� � /�- � - - � - � Foundations '�*� � � f " . . .. Slab � .. . . _.. -. � Frame . � . . .. �� . � .. .. � .. . , . . �. . . . . � . ,,.. , . , ..,, Energy Insulafion � . . . .. . .. . . ...�. .. � � La�h/Drywall— .... . . . . . _ . . . . .., ., .. .. . . ._ ..,.,. ... . .._... . . . � Inierior � � � � � ��� Lath-:-Exterior . ,... . � . � . �... . � �. .. . � _ .. . . . . . � House Number— � _„G;,*���. . .. � - - . . . � . . . . . :�. Correct 8 Posted , :��.: �� . . . ;. ..,..., .....r,,. .._... � . :_,.: „ „�_.�.,,,.,�... Final-� � - . . _, . , . . . . . .. . . . � �. . . .n Enteron Front - � ..:�.... ... „ ,_ ._....�.. . ..... ...... .. r.�:�:_ ..: ".