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HomeMy WebLinkAbout0899A (4) , r�-. .._ -,. ..� - _ _ _ � � ,..�.�_,: ::��,�.�.�..-,.._.� , WORKERS'COMPENSA710N DECLARATION . , . /�, �. �y y� ��/(�"/f� � / ✓ I ATI � F IR����D��P IT I he eqy aff m iho� I have a cert ficate of consent to self e��� � O� � K� � N r= C Kr/� insure,or p cerhfiwie of Warkers'Compensfion Insuronce,or A . . . , - Y V L� 1Y\ a certified copy thereof(Sec.3800,Lab.C.) � � � - „ . �� � - � " � � COUNTY OF LOS ANGBlES BUILDING ANU SAFETY. .. � . �...,.. ,_ ..�w .,. . ,�:._.w. _, �.,: ... � �� . ,��,.ti- . Polity No. � ComPany � . ...�.. . LDING ` � Certified copy is hereby fu��ished. FOR APPLICANT TO FICL 1N .,. ,,.,, ,aDDRe55 +��G� � . Certified-copy is filed with the co�nty building inspeo gUiLDiNG 1 � � � n�J tion deportment. � , ADDRE55�1�� � �-.� LOCALITV � `/7 � � -�- � � � � � Q �.�. EARES7 _ Date � Applicanf CITY � ZIP ! CRO55 ST. � CERTIFICATE OF EXEfvIPTfON�FROM1A�VJORKERS' �, �? l NO.OF 9LDGS � � ASSESSOR� � � � . � � COMPENSATION INSURANCE - � SIZE.OF LOT.Ip C, I � NOw ON LOT I MAp BOOK - PAGE� " -PARCEL (This section need not be completed if the permit is tor one -"3 � , USE ZONE 1v�+4a ( �c`�'� . . hundred dollors($100)or.less.) � TRACT � 5�B�OCK LOT NO. NO � l . �„ � � � j , � TEL SPECIAL �, I cenify thai in the performance of ihe work for which rhis OwNER . �� �MO. . CONpiTIONS � .�. .. permit is issued,I shall noi employ any person in any manner � DISTRICT GRWP TYPE FIRf � -PROCE i�j so as to become sub�ect to ihe Workers'Compensafion LawS. ADDRE55� G C.� � � �� CO� ZQNE_ �- � Gt.f�-�i�" 0?�i' �i� � Date � Applicani � C TY Z P STATISTICAL CLASSIFlCATION - APT. CONDO. � �� NOTICE TO APPLICANT: If, after�making ihis Certifimte of ARCHiTECT oR TEL � ENGINEER � NO. CLASS NO. �� DWEtL.UNITS� � Exemption, you should bemme subject 7o the Workers' - � � �-----� ������ ey Compensdtion provisions of the Labor Code,you must fonh- A�ORESS �SEWER�MAP � � with comply with such prcvisions��or this p�ermit sha�l be � L � . �' deemed revoked.� . . , cOviaaCtok� S1�[.i,�r-7�,Q. � �No. � � BK. / G, VAUDATION� _ � UCENSED CONTRACTORS DECIARATION�� � .�iC. . � . . I hereby affirm�hat I om lipansed�nder provisions.of Chop�er 9 nDDRESS NO. ..... VALUATION �� lcommencing with Section 70001 of Division 3 of the B�siness ond � ��LiC � •�— Professions Code,and my license s in full force ond effect. ciiY �� ,__,. _ ,. . C�A55 $ � ��� - � - �� � �� � � - � � � . - � Sq.FT. NO.OF ��, NO.OF „�„_ CHECK . . (.icense Number ' Lic.Clpss SIZE STORIES FAMILIES ONE � � � �-� . � . . - � - � � . NEW $ . Conirocior � � D te �� � � - DESCRI7TION OF V✓ORK . � � I am exampt from the I cens g eq ireme is as I am a . � M1 V� �- A'p � � liCensed orchitecT or a eg�stered professional engineer A�TER ❑ F�N'4� ���-. �� aciing �in my professional copaoty (Section 7051, REPAIR � DATE � � � Business and Professions Code). USE OF� FINAL � .. . . � EXISTING BLDG. � �� �. � DEMOL Q B �"' � Lit.Or Reg.No. Date APPUCANT �� TEL.� Y , ' ' � - � � � DWNER-BUILDER DECLARATION� � ���� -!PRiNT;� � � NO. - I here6y offirrr�rliat I am exempt from the Contractor's License Low,for ihe following'reason,(Settion 7031.5, Business and AD�RE55 ' Prcfessions-Code): , .. PRE 7 . � . O � � � BUILDING . . .. , . . . , �I, as owner of the property, or my employees with ADDRE55 wpges as their sole compensation,will do the work and , - - � -- ~��'���'� - � � -� tOCALITY �� - e sfructure is hot�intended or offered for sale(Section - � �� ,,� �, a y.,y„�, - , , 7044,8usiness and Professions Code). MOVING � - : TE� � , . - �". �. �� � �. I,as owner of fhe property,am exdusively can'rotling CONTRAC70R � NO � - � with licensed contractors to consir�ct ihe project(Sec- AC�RE55 � f � a�"��.,,���.'� � ��, . iion 7044,Business ond Professions Code). � �- �--' ""` ' �� '�^ ���"� REQUIRE� TOTAL SETBACK FROM� EXIST. - � - �CONSTRUCTION lENDING AGENCY� SET aACK YAR`� HW� PROP.LWE WI�7H . � .m.s�v,�,)�f �"El�� � . I here6y affirm that+here is a�cons�ruciion lend ng agen<y for� FRO��i � � rhe performance of the work for which this permH is issued � P L - � � ��,?'�_��. .. (Sec.3097,�Civ.C.1. -� � SicE � � � ' . . � P.L. ,. - . Lender's Name . . . . .. .. �.C.Fee$ Perm��.��fee L-�:-� � - Lende%s Address �y � � I carHfy that I have read ihis a pliwiion and stare that the Issu Tj� � ❑bove information is corred.I ogree ro comply with ail Counly_ Investigarlon Fae anca ordindnces ond State laws relafing ro building:onstruction, � . T��p�Fee ee � „S�"�' , and hereby authorize representa!ives of this County io enter� � . . . . upon iFe above-mentioned properry for inspectio/nypvrpcses,..., -- � � � . � . . � � . � ��f��J��y,.�,' �r,�y�„ — ^ -�, SEEftEVERSEFOR�EXPLANATORYLANGUAGE .� - � - - . . Signai���re cf ppl�:ca�r or A�ent �� .. . . �s . . .. . . ...._. ... . .. _. . .. . ....: . � ..,.. . . . .. . . . ... , ,... ,� . ..._., . .<.-._ .. .. . . . ., � . , . .. � .�. .' ,-., . '� � � PtA63S i0 APP8,3CAB�7 . �.. � -.INSPECYQR'S�SFOT�S d41'NER-HUZLIPEA DECLRIt.4T&OR _�v ..�� _� ` _ I hereby a#irm that I am exempi from flie Contractor's .�ae " R���,�g� - � , �� � � �.� � � .. � � � � -�License law�for-the following reason. (Sec. 7031.5) Ap�stesvgd . ... , ,,. ,. _ Bus£wess¢r,dPrafess¢owsCode:Anycityorcountqwhich [�°a. � �m4e ?90. tTeB� � � . � - ., � requi�¢;.a perrait trs constrtsct,aiter,6mprove,devnolisb, .. , . . .. ,.. . ., � or repair asay structure,yrior to ets:ssuattce,also requires - ��� . . �� �..�.. .. . . � . . -. .. . . . . � the appdicaxd far sucb permit do fide u signed statement . , . ,..�, �. ..-, ,.`,.. ....� 2hat Jle is Zicevxsed pursuant to Pbe prooisioxs of tbe Cor�- � . ... � � .. .- - � . . . �. . � � , - 6raceur's I.icanse Law(Cbapt¢r 9)(ro»z»�¢ncfleg wFth S¢c- . .�...., �:.�� . .. teon 7�1QOf of Ddvisson 3 of tbe 73waness and Professions . .:. �: ... . ... ..- _. ,� � � ., CorZeJ ar.t1 at 6e is exaoropt therefrom and tfia basis for tb¢ �.,�,,.,m,A„w,.� .. . . ¢[Cegxd e.uemption.Any violation of Sectsoa 703�.5 ay ..� . . . ' �- ::.R��caired. ..-p�@�,��`��v� . . . ::. �� . . are;�applecant for nQernsii subjecEs zbe appl'uant to a civil . ..C4,�prdvdts. _ ��,�P �o � ar 6.pps�e�aed � :...... .. . ... �.. ��.....,.. .-. _. P�ssatey of seo6 snore ahxn five busadred dodlurs(8500).J: � � . ' .. � ❑ 1,as ownmr of the property,or my employeas with Wo4er Ceriificata� �� � � � � �� � . . . , wages as their sole compeosatian,will do ihe work,and - '� ���� � '���� � �::. , , ' � . ihe structure is not intended or o`fered for sale(Sec.7094) i koalih Departmant '�. . '� �- . �'. . �.� �-.... ...-Bacsine.cc and.P�r�essfans Codes"t'be ConEracla�sLicemse ,��_...:� . :�� . . � - �-�� . � i.eeu dees rtos ap[rly to an oauRer ofpr�percy,�bo butkk Fre Department - � . - ' �,, . .. . or imflroves thereo+e:send wbo sloes sush work himseljar � - -� - � � . � througfi bis own emQloyees,provided tJ�af sucfi im- �Grad'ng � � ���. I � ��- . � � provements are not inten8nd or offered for sadm IJ, .—. _S � bou,ever,S6e budldirag or erispc�oaemenE es sold witFiin oae Geabgicat � � - . _ . , - . ,year of rnmpletaova, tbe ouner•$ualrler urill bave tbe J � .�� �urdera af provswg that he did naE buidd or im¢rove for Podesir an Protection� .. . �. . . . . -_-.-- . , Pbe ji:�f�ose of saTe). . . . . ... . �Fen:e)(Canopy) � ❑ -I,os owner of fhe�property,pm exclusively contra<- � - � � �� -�� �� . � � ., , ting with licensed conirac4ors to consiruct the�roject(Sec. . Special Insoection - ���� � - - - � - 7044)Busaness asad Prnfesriosu Cody:Tbe Contractor's I(Cor�.)(Masonry)(Welding) . � � � . - Licenxe.(,amdoasnotapp7ytomnoivn¢rofprape�ey�� (I— - � - � � b>s4?ds or emproves tbereon,and a�Fio cantratu for such . �l LaP Draindge - . �i � � � - . prajec#s wiah a�contractor(sJ lieeaued pursuasi8 to tfia i. . � � -� � � � � - Contractor's I,acexse LawJ. - Parking ' . . � . . . . . .'.. ' . � ❑ Iam�z�mpiunde�See.-... �,B,&F.C.forthis � - � � .. . � � . . . , reason � . . . . � . .. � .. . Date . . . . . . , . .Owner . .. .. A¢�Cc¢avals � - e'2c4a ir,&,ry+asPm^s Signmtaar� -: . . . .. .. . .�• .. . ��:: . ..:. � � . . . . . � � iPRSP'cCYOR'S NOTES�� Loca9ion— '___. � . "" ..... . - . . . . . . ... . ... . .. .. � (Set6a �� Y� � � � �. � � �Pounduri ns � F�� .. . .. �� . . . . . . � . . . .. � � � . . . - SIa6 � � ' . ,__ . . . . _ ::.-._. :_-_ _. ......: - .... , ..- ..._ ....., _ ., ... . - � . . . � , .._ ..�. . _..... . . . .,... - . __ . .. .. . . � � FrQms . � - . . .. . . �Energy Insulation�_� � . � . _ _ . . .. � . � . . ... .�.. . . ..�. .. . laih/Drywal!— ..,. . . .. - - . .. . . - � . . .. . . � . interior � � � Lath�xPerior � � , � , e �� � ' _. . . , ..,_. � House Number-- . �- � '�--; �� "' - ` ._. �ortecP&Posted . � �. •:�. . __ .. _ . . �. - . . ._ ... ,. . .,.: . final—. . . . . .._. . . , . . .. . . . . -� .. ..- , . . . . . . .. Er.ter on Front � � � - . . . . . . : . .. . ��'�'