Loading...
HomeMy WebLinkAbout0951A 1023A (5) WORKERS'COMPENSATION DECIARATION - � � � ��� �� - � � ' � � � I hereby offirm ihoi I have a�e���f,�o,e of�o�se�„o 5e,f - � � � APPLICATION F4R BUILDING �PERIVIIT � � insure,o�a certifica�e of Workers'Compensation Ins�rance, ar o cerirfied copy�hereof�Sec.3800,1a6.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � Cert�t�ed copy is hereby�umished. FOR APPLICANT TO FILL IN gUILDING�3b � ❑ aooaess Certified copy is filed wilh Ihe counry building inspeo- B�RDING tion deportmenl. . � ADDRE55 Date ' Applicam CrtY ZIP �p�q��Ty � CERTIFICATE OF EXEMFTION fROM WORKERS' - . . NO.OF BtOGS. . . NEqaeSr \ � COMGENSATION INSURANCE SIZE OF tOT � NOw ON l07 CROSS ST. \' � (7his section need nof be wmpleted if ihe permit is for one , TRACT - 6LOCK � LOT NO. � � AUES50R , hundred dollars(5100)or less.J Nd1D BOOK � 7AGE PARCEL . TEL USE ZONE MAP OWNER NO. L7� 3 }, I certify ihat in the perlo�monce of the work for which this � N0� a permit is issued,I shail nof employ ony person in any manner qDDRE55 SPECIAL � so as to become sobjett to the Workeri Compensalion Laws. � • CONDITIONS � (� Daie �--„-��S-SrSI APPlicanr � � � ' . arv � 2iP / ` � , , � NOTICE TO APPLICANT: If, ofter m ung Ihis Certificofe of ENGMEERT OR , TrJEQL.�/ pSiRiCT GROUP TYPE FiRE PROCESSED BY Eaemption, yov shoold become('yGbject �o the Workers' . . � ' NST,�'-�� Z� W Compensotion provisions of fhe lobor Code,yo�must(orth- qpoue55 I � �� w `� �� � a wirh tomply with such provis�ons or tbis permit shall be tEi � V7 daemed revoked. CONTanCtOa NO. $TATISTICJ��QA$$IFI�TION APT. COf�DO. Z IICENSED CONTRACTORS OECIARATION ���, IXASS NO. ��—DWELL.UNI7S I hereby affirm�hot I am litensed under provisions oi Chapter 9 � � nooReSS NO. (commencing wiih Section 7000)of�ivision 3 of the Business and �i� ��R�P Proiessions Code,ond my license is in full forca and affeU. � - CRY -� ��� - - - CLp55 � BK � VAIIDATION ' " . SQ.FT. NO.OF NO.OF CHECK �iCense Number Lit.Class SIZE - STORIES FAMI�IES � ONE . . VAIUATION' Conl�octo� - Date - . DESCRIPiIONOF WORK NEW �`QOO^, - ADD s , ❑I am exempt onder Sec. � _ ALTER 8.6P.C.for this rea5on REPAIR = � � � � � <0 9 5 1 A Date: -� USE OF. . -.. . . . EXISTING BIDG. �Ma ❑ tt � � � �2 j Si9nONrp -� A7CUCANT..�.. TEL'j/y fIN ,{� OWNER-BUILDER DECLARATION f7RIN7 NO. - pAT��(J� , I • •L.�i,O D I hereby affirm thai I om exempt from Ihe Contracfor's license � -- ��- - - � � � � -� - � ldw for the foliowing reason(Seuion 7071.5,Business"and aooaE55 FINAL � �� � - e � v 2���� Professions Code): . . ... ._... . N . BY �" � euu�iNc I, GS owner of Ihe properly, ar my employees wilh ADDRESS ��� 7—8 s wages as Iheir sole compensafion,will do the work und �OCALI7Y , Ihe structure is not intended or offered for sale(Section � - , } 70d4,Business and Professians Code). . nnOviNG _ . . TEL . _ . .". . - -- 4 I,os owner of the properly,om exclusively controtting COMRACiOR NO � with licensed mntroctors fo wnshuct ihe projett(Sac- .. qDDVE55 � ' ' '� ' ' �� tion 7044,8usiness ond 7rolessions Coda). , . CONSTRUCTION LENDING AGENCY . -- sEQBACK YARD HWY. iOTApROP.LINE W�DTM � � " I hereby affirm thar there is a construcrion lendin9 ogency for FRONT � . ' � � ihe performonce o}ihe work for which this permit is issued v.L ,. , � - (Sec.3097,Civ.C.). - Sioe v.�. �1023A Lender's Name - � ��� (� a LDMA Ret.N '��� • • • � n lender's Address P.C.Fee S CS��-� Permir Fee � I certify that 1 have reod this applimfion and sm�e rhat�he iswanc�F�s `� IDMA P/C M � , � � '3��5 0 46ove informotion is corrctl.I agree ro tomply w{Ih all County " � In.estigaeon Fee i 3 G.7 v x ordinontes end Stoie laws relating lo building construction, To�al Fee � IDMA Perm.N ' � " � o�d hereby aufhorite represemmives of this Caunty la enler --� .� � u on Ihe above- entioned p ope�y fOr inspettion pvrposes. �- j� ,�_f-� g�l���I�g i �T ' � . . _ .. . . . "i � � � � SEE REVERSE FpR EXPLANAiORY MHGUAGE n� 5,9�a��,e pplim a, e�� —�9 � ; ` �� l � _ � PLANS TO APPtICANT INSPECiOR'S NOTES ' U���M�:K'�1����,D�'•H U�'-��-nHA'I'IUV I herchy offvm iho�Lom r. mn�from Ih�Connoctc�'s .. To: � .. .� , �Retumad .. .� � . . . . , . . . . licrnse,lnw }nr;�he followmg runcon (Sec. 7031.5� I APProvad , , Bufinr�.runJP.u�rs „nsCndr:',9nvii�e��s:nvnfv�<•hi:A � No. Dafs No. � Oa/a � ' ` ".. „. . .�, . " rryu� �s✓prmrit!��c•�nvtrucl.u!lrr.imp.0 •.Jemnlrah. '_ — — - . � , rrepoirnnyxlrorn.r��,priur.t„itcisvwrsze,lalri,reyuir�r ! , � . � � � �hr appfi;m�t Jor tuch/,rrnrrt tn/iIr�i ki,qnrJ st�lvinen! � , i :. � . .- .- . �..: �-. . `-- �-'-� - �-.___ - -. .. ---- - - - -- .� �_ . - � - - - - tu�l rurismm n/�hr i.n. � rr�r�r;sb.����dp,,..�uant �i•p (. + �.� �.... ���.�r��� ....�� .Z._. '.� _ � � . eroJnr'cl.rrea�rl.a�r(Cl�e�lrr')I(inmmrnir�¢u�irl�.5er- ,..._.-. ....----�------� --. -.• �.: _ - . . . .. ..� ri�n?Or qJ o/U r•re,in r rl,r nra and Pn�� nan. _ � . �. ! .._. �. . .: ...__ ��. � _. t.�.•l���'. . _ �`::'�-,�I . .f �,. , . _ � � --CnJrJorfl�ff,riei:r.-3nrt�tGerrfr nrundlLrF��sis/urlhr .___ _'_.__..___ '_ _ _'._. _ . �' ' n . . alle,¢rd rxrn2p�ihn.:ilnv�rinluiion-f Soc7i.in 7(131.5 hti. j.�'. ..,_: .. '" __'..�-.Reqoirsd' ..-, . � . __ .. . _.... . -�:-� . .._..i_ _. .. .- ant'✓pplrrantJ rahcrnri[sub�octtd,�,.�rr,«��r,���r���, I Appro�ais Dofe Ra�iv�d� f�rrul(Y ri(not nrrire eh�n 7 ne!>�<nJreJ Jnitd��s I55(�0).1. or Approwd- ' . ._ _-_-_,_ _..Yac No .__ ... ___ __ .._�._ ...__ . _....___.. .._.- . .. .. ._ 01 rhe praPrny.or my employr.es wnh _ ,, I._ I,as owne� i':we.Ce•ai�"cotr:_�_�_',. _ -_ . . . . .. - . -� _. . _ . wages os�he�raoln<omPensonon,wJl do�he wo�:.,ond , I {-- � �� , S `, � '. �� the stroUure is not imended or offered for sole(Sec.704CJ }+eoNh DrPm�ment-__'______.._ _- .�..� . . - � i . rn .c in�s . 1..�:'f r.C ut�a<turS 1 rrvnce . _. . . Dur nrtr and P Je s Cn ! :n � �,�. \�' �I i�� �� . .l.au�Jnes nn(appl���nran n�rnrr r�prnrrrh.0 h��hui(Js . fre E�rPartmen;- ---..._ ...- -- '- ... -- .. . 1 . � or m�prn na bere n,artd�ebnQ�in bu�h nrk �ani.�Jnr i t u �' •! �i . : �• ' .'�r`LL'. �,�., .�:r a � ����tbrr�u,e! L»z bn nr�rrnpfqrrri, proriJrJ tbu� surh�irn- ' C;rod nq, , �- ' frnremenfr �re�nnt inf nJrd o, J/errd/or sul.^. f/, , . ��_„ � I • _. _. ...... �._.. �� . . .. _.. bnu�rirr,�bebr�ildrngorl�nprn(em�nt+srolJuillinone Geolcg�mi''� � � , year nf imm�lc/inn, t5u au�ner.builJer�irill Iorr t/.+r � � _. "_. .." � ._ __ . ._, `:l�_._. . ._.�_ .. Furdon n/prnvrn,�tl ut br did nut b�ailJ nr rmprore/nr � . PedestrionProtec� n".�'. . - . .� ; ..� � ,�' . . ..__. . . � ' . . . ., thr purpi,se nJsc7rJ. � �Fence 1 IConoPY) ' � . . .. ___. . �,,____ ___. ... . __. __ .. .�..: :. P �P Y� Y - C.I �,as ownerof Ihe ro e�l nm e�clus�vel mnvoc� .......�. ,. � � iing w�th licensed connocron ro conirruct tho proiect(Sec. ' ----._ . ..�� . - �----. ---- . . . . - ---��- � � 7044�dusrness unJ Pri/estinna Cnde: '!'he Cnntroctnr's �p�c� I 1 pe<tian ^ .�. ...- . . . . , . � '. . ICa�c.11h1osonryllWeldin9) : . -..-.. __ � _, _ ..- ... ..__ . .- ... ._ _ .Lrtentel.�mdorrnnf��p(ytnanuu�arrn/pruper7paJ,o � � ��� - � �i ' �1 . � - - bui/Js nr imprnrer fhcrrnn,and udrm m�lruc�s fr+r ru.! tr.i Dra�noge . _. . � . -. . __..Pr Jc�tt_u•iJ!�u cunlrurfnr(rl_lirenmd.pureusnt fn [be _ � v Coner¢4nr'sl.irensn l.nu�/. Fc�4mq��' � � . � [] I pm crempt under Sec. ,8.87.C;{o��Ffs , �, :,:i_ . __. .,"..'_.. ._"_..'.' . .. . .. -. ____". '_ ' ' � � ' . rcason y _. ,. .. _ ' ' _ __-.. _....- __ ' ._. . v , . .... __'Da�e Owner - � � " "��: ��.' � ,;,�' .� . . ,� .. - �Approrol� " Data Inspoctor'�Signafure � . . . . " . � � � � •- � . ... . INSPECTOR'S NOTES � loco��on:_ . . . ._� .. . .. _.� .. ., .. . . . . .. ISerbac4�B�Yords) � -- �-- - '�--' - - -.-_ . -.- -- � ��:, r . � . . .�- /i �. ' ._ .. .. ... ,., � Foundat�ons . - - ._..__.. . ___.___� .. � ��. . �. . . � . . . Slah �., -..--�- ����-�----- . ._ .. � � , ..,,...�, . ,_ . ,-: �. .. ;,� � ' Frame . ' ' ' ' _ . . . . ' . . . ... , . . . L•e�gy Insular�on _."_, _ . . __. _-__ _,_ _.___. ... ._.. .. ` , . . ,... .. � '� ..,�. . . � - . . lmh:Drywall_ , . . . ., .... , ,. , ,.., ..., . . .�. Interior ..-. -' -"-'�---- - � � .. . . Laih-Eiienor , . ., .. .; ; . . ....._ _...._._".....__'__ . ..__._ _. - . _ _ _ . _ . r ���t _ j . , .� , , . . , , . House Number- ,•.. � . . . . __ ._ . _ __ .... __. . ___._... � - . Correcr 8 Posted '' l . ' ;)f ' . . _ . . ,. . fmol- _ i , . . � . , . . . . .. -. Enter on front ' '�' . = . . �. '- ' - .' . . ' �1�_, ; � ��_ . . � . . C�� . ;:. ,. . .., .. . . • - • . . . . � , �