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HomeMy WebLinkAbout1736A WORKERS'COMPENSATION DECLARATION � �- � - � � I he�e6y off�rm�ho� 1 hove a certi(itote of�o�=e��,o,e�f � � - � - �APPLICATION�����FOR� BUiLDING �PERMIT . inwre,or a certiiimre of Workers'Compensarion Insurance, _ or a cert�tced copy tbe�eof tScc.seoo,lob.G.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PalityNo. Campany BULLDING � Cerritied copy�s hereby furnished. FOR APPLICANT TO FILL IN nooee55 S � Cerlified copy is filed with the tounty b�ilding inspec- BURDING ��� ���� C '�^ IIOn t�epo/1mint. ADDRE55 Dale Applicant � Cliv ' I � L/Y/L' I LP � tOGAUTV CERTIFICATE OF EXEMPTION FROM WORKERS' � . . . NO.OF BIDG. NEAREST COMPENSATION IN5URANCE . 5�2E OP lOT P70W ON 107 � CRO55 5t. �This setlion need not be completed if the permit is for one �7 � n55E550R � . Fundred doliars(5700)or less.) . iaqC�.3 6lOCK �� lOT NO. µAp Bpp1C PAGE PARCEI .1 rcf�A�L /v �co NO — �(1� U�JONE �P I certify thot in the performance of rha work for which this OwrleR Np, permit ie issuad,I ihall not employ any parson in any manner qDORE55 30C:J� "�1Vi� \.'! ' K O�� CONDITIONS � eo os to bemme sab�ect to ihe Workeri Compensotion taws. -7 q � � . . . . . CITY �L�1� � ZIP t /� / . - .. � . . � a Dafe APP���a�1 � ARCHITER OR TEI. DISTRICT GROUP tY�E flRf �ROCESSE�BY O NOTICE TO APFLICANT: If, of�er moking��his Certifimre of ENGiNEFa Np. ' _ �� �3 �pNST. �� 20NE � �� V Exemption, you ahould become subjeU.fo the Workeri � � Compensotion proviaion:of the lobor Cade,yov mvst forlh- ADDRE53 � W� wNh comply with such p�ovisio�s or�Ihis permit shall be . . . . TEL 57At15TICAt Ct0.S51FICATION APi. CON00. � dcemed ravoked. cONiRnCtdR NO. �I . Z UCENSED CONTRAC70R5 DECLARATION . . . . . . . LIC. CLASS NO. DWEIL UNiTS I hereby effirm that I am licensed under provisions of Chapler 9 ADORESS NO. � SEVIER AAA.P (mmmencing wi�h Seclion 7000)oi Division 3 of the Business ond UC. � . Professions Code,and my license is in full force and effect. CiTV CtAss gK � VALIDATION � � Sq.FT. NO.OF NO.OF CHECK �� '��(�A licenseNumber � � IIa�Class SiZE � STORiES FAMilIES- ONE - ❑ VALUATION �� s • • •� � � OESCRIPTION OF WORK � NEW S SDD" Contractor Data A /"�} aoo ❑ � , 1 • •3 b 7 5 ❑I om exempt under Sec. � ��� "µ G ��-" AITER ❑ • • •3�7 5 c=i i B.BP.C.for ihis reoson � �-�+�� _ � ZU REPAIR � f . . use oF 0&1 8,-8 7 Dale: EXISTING BLDG. . DEMOL �Signature � � - AvvuCANT��,11 . ,��'L ' �CG No. . - .��!� FINAL OWNER-BUIIDER DECtARATION � PRtNi � DATE _1 hereby affi�m rhm I om exempt from fhe Conrractor's License qpottE55 ��`�rJ� � � FINAL � . - taw fo�the fol�owing rea�on(Secfion 7031.5,6usiness and 6 ' -Profeselons Code): � � � - � ���� � - �� � � � Y ❑ BUIIDING � � I, as owner oi the properly, or my employees wilh a�oaE55 wages as�heir sole compensation,wltl do the work and ip�q�iiv � the atrocture is not Intended or offered for sala{Saction � ,,( 7044,Business ond Professions Code). � MOV�NG - NFO ; �O /N 5���°c/ / ✓�S � I,as owner of the piaperty,am excl�sively centracting cONiRAROR � with(icen:ed conlroclors Se consfrud 1he project(Sec- ADDRESS KJ • fion�044,8osiness and Professions Cade). �' � � CONSTRUCTlON IENDING AGENCY � �- - - sEQeqa YnrtD Nw'� T�TApaoc uNe � wiorH -� � �� - 1 hereby affirm�har there is o mnstruction lending ogency for feONT �� . the performante of ehe work for which Ihis permit is issued R�. � - (Sea.3097.Civ.C.). SIDE � O.l. lender's IJoma � -;^� IDMp Ref.M � ° P,C.Fee 5 � Pe�mit Fee � � � � p lender's Address ]� � 5 I eertify thot I have read Ihls applitolion and state ihal}he Ivuanee Fee � '�`� iDlv1A 7/C M - � ' obove Informatioo is torrect.I agree to comply wlfh a11 Covnty in�eeaqanon Fee I ordinonces and Smte laws relating to building construction, Tmal Fee� F� ' '�� � IDnW 7e.m.M � - ' ond he�e6y aufhorize repromntafives oE Ihie County to enlar � � � upon tha o,bove-men�ioned property for Inspec�fon urposes. � �I�/(��//� //,/�r.(�_l, � . � ..�. . SEE REVERSE FOR f%►LANATOUY LANGUAGE��, .. . ... . "Signalure of Appl�<on�ei Agent Do�e �� - ' . �. � PIANi TO APPLICANT � INSPECTOR'S NOTES -,�, 0�1'11!K-f,S�ryI.UP:H_UGCLARA'1'IOV - I hrtreby nffirm thoi I nm exempt from the Contractor"s � To: , . . . .. keturnod�.. . i , . � _ . .. .. �.l cence.tam•"for,the:riollow�iny.renyyn..�(Sec. 7091.5'� „APPmvod� I3 . r.asnndJ �rscinns( dr:.hrtq<LVnr:,�utth•�rGi.! No. Date No. . • .Da1e, • _ .. .. ` � .. " .`, .' .• .. '' rvyuires�frrn�i!fu eonslruct..+ltrr,i�nprnrr.Jninr,liclr, -- -nrrrpnirunr trure {'fn� i i se�u u al,nrryurrr� � �.' . ' �- ' . . ��' - . . !br apphwn�l�rsurl�-Ti�rnrrt tn/�7r'a r'{qneJ stutv�n�•v�i �__ _ _:'-' . ' •,- . ._. . ,._, :..:_. - - - - - - � r� � J 1, ... � � :. . ..._ . _ _._._ ....._ ..-. -_' :_ �_. _. r • .'"". ,.��:�� pur,uanr r,����pr,,,,.�����s�� r [,>n• ' :� ��', j .r. � : 4.� .- �� .:.� -.�.tru.11nr'c I.tmncr L�ur(Cl+ap�rr'))(�mm�irucin4���d 1co ' �. .. __._ . ... .. ... � ' _ . ... _ ... ._. ...._ '._. _ .. _. � . :. . , � .. ri�n 0 of U r sinn r/the Itusin�u anJ Pr��J nns ; . 70O J i i 3 � rui J••- !`� -- + ' ' � _.-.• �r_`"�•'__. "_ .. ....��^`:�. i?� .�.'� __CuJclnrtlatL�c�rsrlcmptlLcrcJrnnrunJlhrFnsulnr�b� j5 r. ' " '._._.._' . _ . __ _ . . . u77r,crJ cxempn.irs::Anv-rn�lalmn.u�Ji•clinn'U37.i b�. r , . S; i`:...p��: :...._ . r-. ,. �... . .. � .._ _ ._. . .._.___._.__."_ __ . .._ . . .. -Reqtiired��- ' - , �rt�app7i:en�(nraprrnntl�hjrdclL�applicnn�tiuuril , � ' ��-� .`D'ot R 2eived ' .... �. �� FpProvols �:. or Approved�, ��� .� C r... . r nr�(rnn . n . .. . � -'._ . �'Yes.. _No -- - � . . . ..,. . . •' frnuf[i'�!� � >r.[la.i/�rLunJnJJllnn/tSU01.J.. . _.. . ,.._� ._ _.._ .. . ,�_._ , ., . _ . . . .. _ .. ._. _. _.�._.. � ,. - - .`,-. � �:.... _,, ' ,._ .� . �,.: ' . �_� I,as o.vner of fhe property.o�my employ�ces wrth L":o'er.Cec:.h:o�e _r` �.,.C. "� ..._ : ��_ . � _�":.• _- .,_,,.. _.. ..�._ _ . .. . . ._ . .. _, ._. ._.. ., woges asJhe�r so�e campnnsar�on.w�li.de rhe a�o.L.nnd � ' � ^ � �� � •�� . •� � � _ he si c� e.s noi tended o of(e�ed fo sa e(Scc 70�J; ' � � � i -. r � . .. , , .., . ��,� . . �' : ,.,t HrahhDe;,�onmeni ''-.., /�• - ",�' . .. .. . - . . . . � .. ...�f3�vnresunJPr�/�.cs�nneG�d�. fbe�.(. +tre�tnr.l.�u,n�r _.. _ . . -.:,.. _ .� __ .__.. _. . . . . _._. . .. . - `�C, '.. r- . -' � + /.-+u Jnrs nut ufplv tn an merter oJ froper(e�rh��builds , ' _ � � � FtreDcacrimcnt -."-___ . .._'.._ _. ____ . _ .... _ .� � . �-- � ____ �< � , o i j •rad•rr n anJy( J ssv�!u��,rLbinese!/��r - ' ,. " � . . �dr�,�1-!bis mon',amplo}r�s:���J.roridcJ fGr+t su:L�inr- ��.• . . . �� . ' ':j�rnrements'arr n�rt rrsrenJed ior oJ/errd/or sal�. fl. G od 9'�� [' �'_ � �� i ..._ ...._ _._.. . ._._.._ _.__ ._.______.__ . -..� �' tro�errr>.�Ge b�iilJrnK or i�irprm e»ren!i��ulJ u�ithrn nnr : �, �.. �. Geolog�cal.� .� i � . � ,. �.•'� . lrar n/'mmffclinn,'t! u�nrnbriifJer eeiJl�Jara tGc ' I � l'� ' " � .)_ ..�_-.'�::.:-�. �bvrdrn n/p>nrin,�tLat 1 e d:J n��t AuilJ nr ir.i o/nr __ .r'�.,-, p m .._ _ _ _ _.--. _ - . . ._ . tl pu nos�n/ tl J�; ,�. Gedestrlan P.oteuion��:. .. . .,.�.. ... . . . �. -. , , �,. �',a ;., . .; � [Fence)IConooYl ' � �� . � � �. . ""�-'�.. -... ...._ ..:..---���-� �-. ..�: .. � somcrn�thepoPerty..amee:lusrvelytemrac .. ..... .,., . �Yng wiih Lcensed contraao�s to<on�irucr ihe p�ojea,ISec. " .... ....' ..-.�-� .�... .- -. ..- _.... ... 70da Ur�srnrst anJ!'rn ssinns Grdc: 7'bc Cort»aclnr't Specinl I iPection... f . _:. ._..� _. _ : . . ; . . _'.. 1 �• � (Conclf�'.Sasonry)11Veld�ng) : .�. .. .. . ... ... :__.._' _._�___._ ____.� .. ...��_. ... ._ ___l,irrns�•l..urdnesno�op(�7Vlnunnu�neroJprnferti•,u•Ln . , < �. , ... . . , � . � hurlds nr irr,nrnrrs tl rrnun,anJ ud�n.ontracl.c Jnr surl Loi D a nnge, . j � '.`J :C''. '. �.. ., .-- .- ... ___. . ___.. . ._ _. - _ ___Pr jrats u�itl a r traatr sJ 17orssrd pr�r�uant.tn tbc - - I _ . -"C�,nliailnr'x I.t,.Cn�e IAu. ' " � . V6�kinq i. � , _ . � � V� . f __ _...__ _ — _ - .. . �i. ..[] I om rzempt�nde Sec. ,B.RP.0 fo�rh�s __ , . . _ � .- . ; � ' • . � .. reason -,.... ; ' . . _ ` . .'_ . __.__._ .__... _._._ _ ..._ ._ . _. ___.. Daie U � __. ., - _... . ''".._ .__... � � -�- -- -- ' .- - . . _._ ._-----. . __.__ . . . . . _ APProvals Dcto � InspeNor'sSignolure i .��,` ` 5••.^.'."� � .. �.,..,� ,.. .... ��... .�„�....... , � � ' , ._ � � � `� �'� ��``INSPEROR'S NOTES�' � loculion- : .-._.—._._.__...._.__..... � . . . ,. ISerback B Yardsl '���._.-__ __..- -�-----------�' ------�-'� � :� �� �., ._ __. ,.. ,_. . ��. q ,:. :.. . .... Foundanons •�� � . _._._-__ .,,.. .:� .. .., �.'. ..�-,.:�. ,� ..,��.�:.,��. . � � SIa6 ._�._ .. � , �.�.. .��, , � ._ . . . . �- d.� .. 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