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HomeMy WebLinkAbout0838A 2141A _ _. _ WORKERS'COMPENSATION DECLARATION � � - � � � - � � ��� - �- �' � " � �"'v� /7 I hereby affirm that I hove a certificote of�o�5e��,o,e�f � - � �APPLICATION�-FOR BUILDING PERMIT � i insure,o�a certificate of Workers'Compensalion Insuronce, � or a certified copy r1h7e�e�f(�e(�r�y38,��lab.4 ��� � � - COUNTY OF LOS ANGELES eU1LDING AND SAFETY PolicyNo����bJ Tortt}o'hy ��-�L�- y � Certified copy is hereby lumished. FOR APPLICANT TO FIIL IN BUIIDING / r r � OADDRESS . . . Cer7ified copy is filed with the caunly 6uilding inspea BUItDING L, Do1e��tion d partment. �. � - � AODRE55 S C`�Y� 6�/L�, Appliconl CITY �� � ZIP tOf'AtITY ��' CERTIFICATE OF EXEMPTION FROM WORKERS � � � � - NO.Of BiDGS. . _. � NFARESi � � � �COMPENSATION INSURANCE SIZE OF lOT NOW ON tOT CRO55 ST. ' ' � � � � (This section need not be completed if Ihe parmit is for one . 7RAC7 BIOCK LOT NO. � �ESSOR hundred dollars(E100)or less.) , MAP BOOK � PnGE PAR�� J� 1l�,,/ TEI. USE ZONE NJ�F '` OWNER IcJ�1 �'�/1� - � I certify that in Ihe performance of the work for whith Ihis � C / � 1,, ' N�� /1 NO. �-3 Y' permit is issoed,I shall not employ any person in any manner qD�RE55��%2� l�f.W+^� C�� 57ECiAt , , � so as�0 6ecome aubjec�to�he Workers'Compenso�ion Laws. � �,,�� ,..,�,! 1p���� CON��7iON5 � Date - APPlitanf CITY ��llN�"'��'�`- �c.u�t �,�zl ; � � NOTICE TO APPLICANT: If, affer makin �1his Cerlificofe of ARCHITFCT OR TE�� G DISfRICT GROUv TYVE FIRE PRO SED BY O Exemption,-yoo should become sub�ect to the Workers' ENGINEER SS6�'l . NO.�"J2� � � ry�y�,,"." . rn Compensotion provisions of iha labor Code,you musf(ortb- qDDRE55 �O �-0.-Q Q,�f l.l.l�-'�- � J �'Z Co�^r z�, `� t+.l with comply with such.pravisions or this permif sholl be ' LL deemed revoked. CONTRACiOR ohrt�sn ��•No-�5�-141a STATISTIG4L CLO.SSIfICATION APT. CONDO. Z UCENSED CONTRACTORS DECIARAT�ON 1 �V1� n .�� Ai�,� n Ctn55 NO.�DwELL.UNiTS 1 here6y offirm Ihat 1 am licensed under provisions of Chapter 9 nooRE55�J°l�( il«t-LQi✓ MYNO. l/ (commencing wl�h Sec�ion 7000)of Division 3 of the Buziness and ��� SEWER MAP Professions Code,and my license is in full force and affect. - � G7Y � ����� G�-aass � . gK -� VAtIDATION I�a� . SQ. NO.OF NO.OF CHECK Licensa Number�,+ E 7 - Li[.CI033� � SIZ � ' STORIES FAMILIES ONE �.�` � VALUATION�� Confrad���� �w Dote DESCRIPTION OF WORK NEW q � - ADD � s � ` � , r� 8 ❑I am exempt undar Set. ��►^- �'f/1�.[' ❑ �0 'a S A ALTER 8.8P.C.for Ihis reason � S � � � � � �2� REPAIR � - � -� - USE OF DEMOL Date: EXISTING BLDG. ❑ I •2 9 F S O Signafu�e � . . APPUCAM - n TEL. FINAL � OWNEB-BUILDER DECIARATION , PRWi O IlSSO`A .WNO. -1 pAT �2 9 S.E�D i� . I herebypffirm thot I am exampt from the Contractor9 License qDDRE55 O �Ll � �8,��� -8 8 low for the following reason(Section 7031.5, Businass and FINA - Profeaslons Code): �-� - �� � - . . _ . . . !y OBUILDING I, as owner of fhe property, or my employaes with AD�RESS -woges as their sole compensation,wlll do the work and i��TY -� � � - � � ' - � � , the shud�re is not intended or affared far sala(Sectlon �, � 7044,�Business ond Professions Code). - - MOwNG � . 7E1. �, - . � I,as owner of tha property,am eadosively conlracting CONTRACTOR � NO. , � with licensed coNractors to construct the projeU(Sec- � qDDRE55� � -- � - ' �'2� (',� � � tion 704a,Bosiness and Prafessions Code). _ • - GONSTRUQION IENDING AGENCY � Sc�enc� VARD� NwY iOinpROv UNE ' wlorH � � � . ` � �• • • • •� I hereby affirm that lhera is a construclion lending agency(or fRONT � the performance of the work for which this permit is iswed P.�. � , . � •3 5 8 5 0 ($ec.3097,Civ.C.). SIDE °.� •35£.50� Lender's Name ' � IDMA Ref.N m �LendePs Address � � - �� �- P.C.Fee f � � Permit Fee ��� �� , ' �d.�3-s Pi � I cartefy that I hore read this applica�ion and efare that the Issvonce Fee l� mr.w aie A � abave information Is mrrect.I ogree to eomply with oll County � - invesuqae�on Fee $ ordinances and State laws relating to building constroction, tmal Fee � tDMq Perm:,M � � Q and hereby aulhorize represanlatives of this Counly to en�er � upo the above•menti ne pro arty far inspaclian purp ses. �, �y 1 � � C,c� SEE REVEIISE FOR EX�LANATORY IANGW6F � � �� � Siqn wre o/ApPllcant or A ent . . poro - . . . . . .I . . � . � . . . . . . . _ . � PLANS TO APPIICANi � � INSPECTOR'S NOTES .' ON'tiI;H.DUILDI:K UHCI.ARA'1'10?i I hereby affirm Ihot 1 om cremp+Irom thc CoNroaor's To: . � ., . . Raturnad �� � �. . . .. �, . ., . � . .. . . , . .. . liccnse„law.for Ihe.(ollowing reason .l5ec.,�70J1.5) �APProvad .. . .. .UiivuessandPrnJrs.;nnsCoJc:An��ci��rir�uuntlul.�icb - Na. - Data Na. .�Dato. . ' '�� .. . . ' � ':��.�` �. � (� rcyuirc�a frnrnt t_'[ni�sf uiY a4< �nr � �demalisb, . �ur rcfnrrunY itratlinc,hr ur hi rti tia�auzr,clan�ryuirrs . ; �, -,-.,• • G :�:: . --: . ':� t.�� ' �� . . � '�•'���,:��;. ....._. fbr uffliiait fnr suiG/�rrmit!n file a si,j;ueJ st�leulrut , ._.�.. __. . . .__ _ . . . . '�. _ . __ . .__. . , ' '' ,, ,...;., .�. ._, .. r , _ ._. �.il�tLe�itliirnseJ�iursum�tlrr7le(�rnrisinns�/!!< Cnm . , ,, _ � �i � . lr�clnr's l.i��ence l.au•(C.�bup�er Jl(rommrnnn,q u rtl Jer- . __ ..._.. .. . _ ..._ . . . . - . ... .:. . ..'.• . -_ . tion 7000 �f racrun r 1/�r Uusi�rsr II�J P i� c�uns J Di ' 3 ./ . r/ec' . . '_ f. .. , . �� '� �' r ����... ._.-CndeJ nrll at br is rx�nrrt t!srrJr�m�anJN��Fr+ie�/rir fhe � , . . ._.. . ... ... .. ... _ _.. _. - . .. _.� . __ ...... . . � � u(legeJ�exrn�htinn:AnY���iulatinn�n/Ser(inn 7(131.5 by �..__�_ _ ..__. ._..._ . . _.Requirod-.- .... Dcte�Reeeivod - ��-� -. �•.�-.. ... _ . . . . .�...:: � � � Nn�'up/�fitant/nra�ern�ilsubjerNtlrrapfJi<nnf�np�•iiil ; Approvals ,, � � '�� �frnaltV�+I nnf rnnrc'tban�oc bundreJ d�,u��.s(s5nol.)� � 'Yos _No. ar Approrod . . . ._... � _�� , � . . � . . � . . . . ._ . _....___.. ..'. . .. - ��� -�-� �- +� _ I,as owner of Ihe p operty,ar my e�np�oyr.es with Woier CertiFicaie � �� � --`� ` " '� ` � � � � -... ..-. ...woges as+heir sole compensa��on,will do rhe work,.and .... . '._ . .___ . _. _.. . _.._.. . ._ ... ._. .__ __' - ..� ;'. ,-j � ..�-, � „ .ihe struc�ure is noi intended or o{(ered 1or sale(5ec.7044; . ..-: . .. , _. .i Hcal�hDe a•tment..-.._-..-- ---.. .- -. .---. - . . ` � ' �' '--� .� _ � � � .. Uu.rrnessunJPrn/essinns'Code:77reCantr,�cloril:iaenve � (.' . �i-i�. . ..� . _, .�� , I.att•Jnca nnf arj�lv!n ari aunrr h/prnperte«•!n huilJ� � _._. _.. _... .-- �--- . . . .. _ ._. .• � � • . d d d i i� . Frc�D,eParrment ,;1,_I. . .,,� ��� . . ornrrJ�rnrrsl{cre��n,un a�n r�es.sv��xnnr.Linrcr!/ur _ , . � .� -:�'.� � ...;�-J:,r . � iGrnu,�lr 1,is nn•n rrn/�fu}ert,'rroriled lbat sui7� irm . .Grcidmg-�.i�i�J . ��..{. ....'� . . .. � '� �� •. rnxemenfs uro�nn[ intendrd or uJ/crrd ar rolr. !f. P / � �_` .•..� � .- .• - ,�_I"! . . _ "(m�er�rr,�lbrb:iilJin,��irimpmvementissol,lu�illinnrte , � .. � -. ., . ... .., ; ' �. Geoiogiml � .. ' ,�.� � -'' .'. . . ' . . . . . . . ._.�...':.,.�� ... 1:rur qf cnnrple7irin. !!�c ntt ner-builJrr uilf 1>arn'thc . . � ..C. .S�.I��r ...�'.. -,.• ' � '..�� .,,�.:. :.�-�_ _ .� hurJrn n/j�rori�i�d�u!Le diJ nuf builJ or irm(nnre/rir . . . ._._ .. ..,. _. '.::.:_.. . . .. '_ . . . . � ' . ,_ . Pedesvian Pwtechon .. . '� ..� .. .. :.� �1 '--•,� �1 '�., .:'i� I ': � . . � - �be pur/�ose n/salrl. ' . .. . jFe�ceJ(Canopy) � -� - � � � � � �� - . n I,as owner of Ihe properiy,am exclus�ve�y controc� .. _ . . , �. ., . . .ling w�ih licensed convacfo�s to construcl ihe proiect(Sec. . .. . . . , � . .t :�_ ' . Special Inspecfion � . . . ...�....__.:'. ... •.� �.... .. -. � - . _. . _ . l_�t, � � 704d)Unsiness and Prn/cssiona Cndr: 7'bc Cnntractnr's (ConellhtasonrYl(Weld�ng) �. � ._ ... .. .... . - .-_ 7,irersirl..eu•dnesnnl¢rrll:foSnuumcrofpmfrrfYu•Ln . _ . _._____'__ _ �.__. .... . ._ . .. , � � ,� � ,.� i huilJs or imprnres(bercnrs,ursJ u�Lri tunfru�ts Jnr turb lof Drainoge � �.l'..i 1 ." ':.. . ' ,.._. ... . . . . . ....__._ �. �_ _ . _ ...,�mjecls u�ith a�ort ractnr/s1I+�'ensed pr�rau. .. ' _ � �,. t ant to t e . . . ,'. • .. '. ' '�. .. . � I.•.t`.i : !� � ontrn�lor'sl,icenxr7.au.), . Parking .... _ • .. , � ..... ; ��•, �. . �.� � � l; .•,' .,''� . . . -._... . lamc emptunder5ea .8.&P.C.Forihis . . ._.. ❑ . ., , .1. .� - ;-. - ,, i .._1 ___.._ .. ._... __ ..__ __. . : .�. . . � ;.� . � �.� � -'-_reoson �. . . ... _' `.. .. . ,. .. ' - - � Date... _. _. . Owner . .... .... . . . . _ , , . ; ; •' :. 11 � ..� ` �;,' r',. _ � . ,i , -- -- .. _ — - - < Ayprovols�� �� Dafo ....Imp¢ctor's Signature ., . , � �t' . . � >:..(. . ., . r. ., .., . �,.. .. . � - . . .. � . . � "INSPECTOR'S NOTES-" Locn�ion-. � ._..____:.... . ... . .. . . l5etbock 8 Yords) � _.___._._ ._- � --.._ . _._._.._..— ---�. ' •�.�. .�:_.:.,.: � . � .�. .. _ - �•. _ ., �, �: Foundmions � .. . . .. .�, . , .- .... � ,. .i . . . ... .. _ �.. �.. . ___ _ . .'_ .. __.._.____.. .. _-_ .___ ._ .,.. . . �. .. .,. .. . Slob � . .. . . ' �'-`�. � , , .. , � Frome`. . . .. . ,_�-=' . .. � . � . ...... . �_ . .... . , � „ � .:._. .__.__._' . _.._..__ ......._ .....__. �.___.. __..�. . . .. ... Energy InsulaFon I i I ' . .. . . . , � ':;� � . , Laih;Drywall-. . ___..__._..._.__- _. __�._ � �. � . ., .. .. . . . .\, �.. .. ,. Inlcrior' - � i , .. . . . . . . ,.. , ' . Lait�-E�fe.�o. . � . ..� ,. - '.. -.. . . . _ _.... ._.._.._._._..__._ —__.._____. . . ' '� _ . _.__ ." :.'�1 ���l l ��', ..1.� . . House Numbe.__ . �. ...� _.. _.__ �__..__.. _. � � .�...�..__. __.�_. ... .._.._ ...__.. . ._ . , : Correci R Posted - ' �!� J Rno�-- � . � ... . , .. .. . � , ., ,. � ., . . Enter on Front � - - � � ' . � . . . . . .. .. .. . . . . . � . . - ..... .. �,'_ . . .. . . . . . . . , �. . . . . ' . � . i.."; � .� I. . /� � ;,-' _ ' � ._ _. . . i _ . . . ..