Loading...
HomeMy WebLinkAbout1244A WORKERS'COMPENSATION DECIARATION � � ^ I hereby offirm that 1 hove a certifica�e of consent to self �pp���CqTION ��FOR���BU�ILDI�NG�-PERMIT S insure,or a certifiwte of Warkers'Compensation Imurance, � - �1 or a certified copy thereof�Sec.3800,Lab.C.� COUNTY OF LOS ANGElES_. BUILOING AND SAFETY Polity No. Company BUIt�ING A � � Cenified copy is hera6y fvrnished. FOR APPLICANT TO FIIL IN poosess O �G U � Cartified copy is filed wilh Ihe co�nty building inspet- BUiIDiNG fion deparfinent. � . ADDRE55 Q � � [� LOCALITY � (-� NEAREST Date ApplicoM� � . CiTY �!'i. � �p.("' ZiP J CRo555T. CERTIFICATE OF EXEMPTIDN FROM WORKERS' NO.OF B�DGS. ASSESSOR . COMPENSATION INSURANCE $IZE OF LOT NOW ON l0T MAP BOOK PAGE PARCEL (This saction need not be comple�ed if ihe permit fs for one - Use ZOnIE hw7 hundred dollan(SI00)or IeSS.) TR�+� BLOCK LOT NO. � �� NO. '� -TFL'r 11 p '' - - SPECIAL I certify that in Ihe performance of the work for which this OWNER O NO.J '`��j CONDITIONS 0. � permit is issued,I shall not employ any person in any monner � -�-- - - - � DiSrRici GROUP TYPE FIRE PROCE5�ED BY � so as to become sobject to the Workeri Compensation laws. .400ae55 Rv n �C'� /O ry� CONSt. ZqA�\ �� /� � (� /� [ / . � � � CITY��c�YY�er. VSa ZIP �� u ��� �Q DOte ' AppliCant - . ^ STATISTICAL CLASSIFICATION _ _ APT. CONDO. 'F- NOTICE TO APPLICANT: If, after making this Certificate�of ARCHiTECT OR _ __ TEL. . __ � � V �ExempfiOn,�you should beGOmO SubjaCi to fhe Workers' FNGMEER NO.� ('�A$5 NO. DWELL.UNITS � a Compensation provislons of the Labor Code,you must forth- �� ' _. vi ADDRESS - �� � ��-�� -- -� ��-� � --- SEWERMAP� with comply with such provisions or this permit shall be � � � - � deemed revoked. � - � . _ CoivrrtnCfoR ryp, ' BK.' � 'PG, "� - YALIDATION ' IICENSED CONTRACTORS OECIARATION - ii� � I hereby affirm ihot I om licensed under provisions of Chapfer 9 ADORE55 � NO. � VALVATION ' � - . (commenting with Settion 7000)af Divisio�3 of Ihe Business and � LIC. �� � � Professions Code,ond my license is in fvli force and eHect CrtY Ctnss S l �Q ' �� z�I.Q A � • � � 5l].Ff. NO.OF NO.OF CHECK .. �iten58 Numbef UC.C�O55- SRE STOklES FAMIIIES ONE � �• • o �2 3 ,. . . . . . . . . . , . .. , .. .._ _ ._.. . _ . Contractor Date DESCRIViION OF WORK (� N� O I •��L�O O ❑�am ezampt under Sec. " _ � � o� � � U� ADD •.,,. . . � � ALTER � FINAL . . . . . . 2 J�.O O� 8.8P.C.for this reason c �� '�+�S 1 - �� REPAiR�� DATE ' � , O�.2 6�S�l Date: USE OF . DFJvtOt - FINAL.. �. : - .. . . � E%IS11NG BLDG. � �- -❑ BY , $ignotufe ' APPLICANT ...lEl' . OWNER-BUILDER DEQARATION PRINT NO.. ' � : � � � I hereby affirm that I am exempt from the Controctor's License ► � - law for Ibe following reoson(Sedion 7031.5,Business and .. Aooeess � � • � . � �- � Professlons Code): . . . �— � . ❑ . � BWIDING . . - �+J� � I, as owner of tha praperfy, or my employees with aoDRE55� ��-- �� ' ' wQT • wages as their sole compensalion,will do ihe work and . � ; �.�=�1- � _ Ihe structure is not Imended or offered for sola(SeUion ��`��TY . ..__ �v`�� 7044,Business and Profes�ions Code). MOVING TEI. . � I,Cs owner of tha property,om exclusively coniracting CON7RAROR NO. ��� � . wilh licensed coMracfors to construtl tha,project�Sec• aDDREu , . O . � tion 7044,B�siness and Pro(essfons Code. REOUIRED TOTAI SETBACK F20M EXIST, ' � � CONSiRVCTION LENDING AGENCY SET&4CK YARD HWY DROv.UnIE WiDTH , � I heroby affirm lhat lhere is a consfruction lending cgency(or. � fRONi - - � — � . . .. . . �he performance'of the work for which this permi�is issued ' Rt.�� � - - � � � .. t5ec.3097,Civ.C.J.. ' � . . ' . . �.SIDE ' . ' � . . .• .. ... _ . . . . . _ � .�,RL. '.. . . . . . . ,. - Lender's Name � � � � ' � - � �� � .� � . ' P.Q Fee S - �ermi�Fea . � �.. . � .. . . Lendei s Address � � � I certify thar I�hava read this applicotion and slote iha��lhe � issuanm Fee� � � ' � above information is correu.I agree to mmp�y wiih all Couny in�esngaron Fee �� . � ordinancas and Stme laws relming ro building conetrvction, � ���� --�� - � -�� -� - � - � Tatal Fee ' � 9 bnd hareby authori:a representativee of�hls County to eMer . � � S9 u on the a6o e•memioned proparry for inspection purposes. �� � ��� � � - � - -� ��; - � �--� �� � � � � O � �si f I �I6 � , . SEE REVEItSF FOR E%PUNATONY LANGUAGF� __ , . , . ,_� SignaNre o}Applicant or Aqenf pate ' � . � ' ..�t . - r.it�:�i�,.-,�� . - •PtAMS TO APPLICA1dT . � � �INSPECTOR'S t10TE5 ,. . •-Obi'\F;S•�U[,TAfR�DLCI.ARATION,;_ ,i ; .,�I harebyalfirm.ti�a1 I am exemptirom the-Contro[lor,'s To: . � Feturnod, _ , . . . License Law for;tho followlnc��reesan.�(Soc:�7031.5) `� • ���Approved Betinrsmar,dProftccrnrrsC�d�:An,pdryorcovney�a•GicG No: '"�_. _Dato.-----.-- Ho.. .� Dato. �_._� .. .�_�-�-- ;.. �.� . .. . . . , . � . . ---rcqfetrrrnrcn, �t1�tn��:� {i.ct��al:cr.ir;rproe�e�JeniolisL�, . , . , , , . - „ . . . . __._ - .. . , orrr/�airar.}strieN:iro,�J�rrnrloitsrsrannCc,alsorcquirc's _ _ _ '_. ."_ . ' .__. . _' '____ ..,__��.�" '-_'- ' "". _ _ _ _'_ -' - _ _ '. ._ . __ � _ i t � �_ i � .• . ��•7Ac apflicni�t/nr sueb permit!o f'!¢a ti,qncd aldtcnienT i �. � :.,- i ., . .. , . . i . i,' �,'. . . - � ... .____..__.'. -___.. ' .' . -' . ... . ._ .._ .,. _ . . .,. _ . �_... ` . .-� lbr.t bn ic ficcnsrd j,srsum�t tn t!a J�ror�isinns of[l e Cnn- - ;�, ', ' . ' � �-' .',`'I J-' , .�.., i"i -- �- trnctor'sLicrnscl,a:v(GGaf�tcr9)(ronmacncin,qu�rtJ Src- --trnH-7000J of Uie�isinr�-3 q(tL•c DHsiness and Projessions , � _ . � ' � .. � , Cndrjnrtb:itl+0I5pSCHl{itlbrirfronrandtic�basrsfortGc i - � a!lr,qed cscnr,ntr�r..Anv rr<ilrriion nf 3rrtlon 7031.5 by � Roqulrcd Dat�P.�cdved �� `,�, � ' ' � '.I_. L .1,� '��r. � any a,n1�fi<<vrtfn�nprrvi tsu7jects�U+��c�plicanttnaciri! -----Approvch . ...-.- .. ar Appraved -.�: , ---. . . -_r . - penal[}nf not mrore thnn fu e l.,un�red dnllars�.SSOOJ.J: • Yas No .. . �� ��..,. �� �� , �- .� :--- . . ' %.��- �, . ., .{,�,,; I,os owner�of tha prooer7y;or my employees wilh . Waler Certifimte �,- . ' � �� � �� , . - ;,, �- - �� .�+aces orlhr��csolo mm onsotion;will do tho work;and '- ' . i • . c._:.: ,�. . .. , P � -- -- .-� - �� - �---�'� � ----- - • ..; the sito<rurc is nol Inrenaed oroffered forsale(Sec.�7044) � ' ' `' � ' �r -'� � -���� _ �" ,., ��. - Uusiacss anc Frq�cnionr Codc:T!c Contractar's I,itcnsc . Heahh DeAartmenl'_.__..-" .-_" ___. -.-,-: .-. -'- - ._'._ ".__'.,_ ._ ._ __ __.�_.": .�'. _ ._._lau.•docr nn1 applylo¢n�ott�r.cr oJpropertv u•��buildt „ , . , .• �� .c..� � , ��� FlroDepartmont : .�. :. � . ...'_ _ __ '___'__. ..�'� ;l, i�it/rroe �loid� isef�r 'nY �ff/�IEfClIN�61:�L' ff 1•JCII[L'Af.�IJJII . . ._ .. --- '`lbrnu,¢b Gis oarr �en:fla}'oer, �rnrrded tbaf asidi'im- :.�' Grodiny . . r �. ., . ._. _.___ ___.. ._'___ _ _. . . .-__..._._ _ .. .�.,j'ro�enrri tr � i nt�intci or nfJemd;for ..-If, o arc �J�d 'ial � ' fi u rrer,'tfm� !d'r�orn rJ inrcna nt i��sold u rtl+�n�un � Geolo9ieal�--� -- --- , - ' . .. . .. �,ear f cnnrple:inn..tb�.n+rerr-f+�ild�%r udll'har��rG� - . , �. hvr f Fr�i 't%'° ,. .'ot FuIU or in�J�rnre Jnr Pedeslrian Protection � .. .. . . , t,..,tLe�+u"r/�osr a7e, 1 . �� - .; .. - .,, •,;,`. � (FenceJ(ConCPY) . �.� :` \ - ' _ _ _ t� '1' I,nsornieroftMr Pil•;,-amexduoivdy�ctMroc' . , . � .. '... ' '� �- " , � � , rx3 wilh licensed mnlrecrors ro conslruct the rojeU(Sec. ti P Spe[icl'InepEctfon� � ���----'.---- . . ' . . � '-' -- --.-'�" -_70441 Giuirirs:cv!Prr,�rssrn;:s Code:_T6e Conlractar's ' (Conc.)�MPsonry (Weldin9) • . � . ... ..-. -, , L.icensel.au�Ja.-cnnicJ�rly7oannu�ner�Jprnperly�ohn :l��i �,o .. � � � , . . l.____�' ��! .'. .�: � _ •.. ' �-:' t.-_ .. , h«i/d<o •n;rnrrs ti�.�rr�_c,_n.rrl�rhn rnvtrarts f raucb Lot Dminogc� � . . . ., . ' � _``. . . "'projrcls ru•i11 n c �:trcc�nr(J licnr. d p:�rsuant eo'ltL>�� . u�.i�. . . . . . _ . . . " _'C,bn.Nc:mr's..i.rrsrl.avf. � i Porki --_.... � _� . . .._...--�-�---._ .�; "i '.'�_.�_.:_,._: ., _... .__ .. .. ........ ..., ,� .�QS��lj 1.�� • ' . ...- � - --- , - -';. � � Tam e.empt undcr Scc .E.dP.C.forthis . . . . __'.---------_ . � ,----�---_.. ..___._--_'. -._- • ' � -- --.. __._._ .__. ._. ..--'_'-�-'---'-- -�-- rcasoo ._..__ ...' _ __. . . . , � _ , � : __"_ '_`._'_"_' .____... .__."_.._ _. �'. . . ._ _ Date "Owner , I.� � , . . . .. ._ .. J....J , Approvcls D6fe'� Infpacter'�Slgn�fut� � - . . . . , _' I:I';'i"YC.'�d97L5 - � . _'-__ ' ' . , _ lotation- � ,� � ...' ___'_._._... _.-_ __ ____._ _ ___._ . ..,',- ,_.. (Setback 8 Yards) � •'J t'.' .. � - .. . �� . . , �. , .�,.. ,. .. ...; �'� .,. . ., ... Foundations ���� • ,..-, . ;-. ' . ' ��� .. � '. . S�a6 . , � . , :,' . . ., , . �� . . C J � , � Frame . '� � i :: . � .. : , . � . � . .. �.. .. .,. " . . � ,., . �. .� } . ,�.. �^ � . -.�.i . ... Energy Insulation ' :. � . � � . � �"'�� � . '�' � .. '' � � ., � � , ... ,. . ,. .._..'.__. '._"__' '..____ , _.. _ _. .._._. _. . .. . .� ,I 1 Lalh/Drywall- ... , .. . ' - i , � Inlxrior � . .: ... ._ '.. ':. ,. ....�.,. • Loth-Extorior ',' � _ i�-.'l .�'� � <� _.�_� . �:' � ,� , _.: - House Numbcr- .,� �..' . � , � �, , .'. . •. . .'�."._._:_ • --..._.___ . .. ".._____i . .; . ,�,. ..,. � :� r � . �I.•:., . Correa E Posted . ..--- --�--� --- .� J' Final- . , " . - ' - ., . . Enteron Fron1 - .. ` . . � , .�, , . . ., ' ` ' , . . '. . .. . . . ,- .. ' ' ..1. - , , e .. '.. . . _ ' _ _. .. ` L