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HomeMy WebLinkAbout0839 3574A � !�= _ _ ' �.,,�, �-r • �WORKERS'COMPENSATION DECtARATION ��- -�� - - � � � � � � � - I hereby aifirm thot I hove o certificate of�o�,e�„o 5e�� -----� �� --- A�PP�LICATION � FOR -BUILDING� PERMIT ���jjj insure,or a ceriificale of Workers'Compensa�ion Insurance, II or a cerffied copy'�hereof(Se 3800,La . ) � � � ' � II ��7 3��„� COUNTY OF LOS ANGELES BUILDING AND SAFETY , LI PolicyNo. C any � Cemfied copy is hereby furnished. FOR APPUCANT TO FILL IN Ao REu�//J C, � /�v � Certiffed copy is filed wi�h�he covnty boilding inspec- - - BWIDiNG � •// ' � tion de�t.� �J�p , ADDRESS .. . J�jf - . yDole Applimnt,-����l�l CITY /�1C�Y� ZID J /7 �p�P,IITY 2 � . r` CERTIFICATE OF EXEMPTION FROM WORKERS' . . .. . . NO.OF BiDGS � N[naesi � �/ . COMPENSATIDN INSURANCE 52E OF LOT Now oN toi CROSS SL �.C^� i/ � �This sec�ion need nof be completed if the permit is for one , , _ .. . ASSESSOR hundred dollars(5100)ar less.) � � TaAQ ' BLOCN LOT NO. MqF BpOK ' iAGE PARCEI � . . � � - TEL. � USE ZONE � M4P � I cerG4y Ihof in the performance of the work for which this - OWNER / � NO. pp ��j_ � permit is issued,I sha�l nol employ ony person in dny manner SPECIAL O so as to become wbject to the Workeri Compensafion Laws. - - ADDRE55 ��� .Q U CON�11i0N5 U Date Applimnt � . . . CIiY / 2' 21P /��(O� . � . p NOTICE TO APPLICANT: Ii, o(ter making Ihis Cerfifi[ate of ARCHITECT OR TEL. DISTRIC7 GROUV NPE FIRE GROCESSED BY {{P--1 Eaemption,�you should become su6jecf fo fhe Workels' ENG�NEER 7 .NO.7 �� l� CONST. �� ZOpNE W Compensation provisions of ihe Labor Coda,yov must forlh- qDDRE55 �6 /� � L � � J N ith comply with such provisions or this permir Shall be � 7EL. SIATISiICAL C1A551FIGATION Avi. C NDO. Z deemed revoked. � � CONiunc�Da � T No. f J" / -7 � - — LICENSED CONTRACTORS OECLARATION �yy ���, �5 CtASS NO. �` DWELL.UNITS I hereby affirm thot I am licensed under provisions of Chap�er 9 " nDDRE55 6�A�./� /1�ti�F L NO. ��Q�P (tommencing with Section 7000)af Division 3 o41ha Business and r � UC. Professions Cale,and my license is in full force ond effect. � dTv N(J G/k/� �e.CLqSS "� BK .� VALIDATION �7 1 $O.FT. NO.OF NO.OF CHECK License Number,y.{�j1Y�� lic.GIa55 ��,L -� 5¢E 3.3[� STORIES FAMIl1E5 ONE , 11 O(7�C� VALU T N ��� d �/��� DESCRIPTION OF WORK N� . Canirattar��u�►"L`�7. �ate . . ADD � _ ��� ..� � �I om exempr vnder Sec. � , �'A/ 1 � .�� � , , � � �� ALTER 8.8P.C.for fhis reason � REPAtR � s. . //�. /� USE OF � � �. b � . Date: E%iSTinlG BIDG. � �E� � AV7LICANT TEL. Signarore ' � 6 FINAI ry OWNER-BUILDER DEGLARATION oR��i No. Y 3 DATE ��II O� I hereby affirrtt thot I am eaempt from the Contracror's License � � pDDRES��� y� �: .SiJ.•�J�✓C s FINA � �� �law for-�he foliowing�eason(Section 7091.5,�Buziness and . � � Profe:sions Code): . � � . . . . . . . . . sY � � - ❑ - BUILDING 1, as owner of fhe properly, or my employees wilh ADDRESS �j F j,Q�'�, .wages as their sole campensation,will do ihe work and �-� � - � � , � � - � ��. , � � the structure is not imended or offered for sole(Section ����T� � �!�e c s o o � 704d,Business ond Professions Code). . , MOviNG .. . TEL .. . .. . . . . ❑ CONTRACTOR NO. �, ' � I,os owner of the properfy,am exclusively conlracfing � T � �l J n�) _ wi�h licensed mniracbn�o constrott the project(Sec- . qooR[55 � ' � � tion 7044,Business and Professiona Code). , �-_ � � e � � (�,G��,r REOUIRED TOTAlSETBA K � � ' WNSTRUCTION LENDING AGENCY .- -� ... gT gA�K YARD Hwv PROP.LINE ' �WIDTM � .I hereby alfirm that�here is a mnstruction lending a9@^�Y fo� FRONT ' - � � 2.�1� —�fi �he perlormonce o�the work for which�his permi�is issued v.i. .. �. . ' � � � (Sea 3097,Civ.C.). Si�E � . P.l. , . Lender's Name - � ' . ' � /��� IDMA Ref.M ` a lender's Address -� � - . P.C.F«S Pe��,�i Fee , ' - � 1 certify that I have read ihis applicaiion ond srate Ihat the is:uonce fee �J•� iohu viC N ' .. obove informmion is torrect.t agree lo[omply with all Coonry -� invesrgmion Fee � ' q ordinances and Stale laws relating fo 6uilding mnstruction, Toral Fee � ��U� IDRM Perm.N � . . � R and hereby outhorize represeMotives of lhis County to enter -�� � � e upon ihe above-mentioned property for inspettion purposes. � _ � � ,�, �'�� /� SEE REVERSE FOR E%PLANATORY IANGUAGE � . . Signature of Applicant or Agenl pale � . � . �PLANS TO APPIICANT INSPECTOR'S NOTES I'..U1VNIiR-lSUI I.UIfH UGCI AHA'1�IOV. . . I herehy.al(irm thoi.�am caemp�Irom ihe Canlrocier"s Tof� i .. .�1;7�.� . Relurned �.� . ' � � �. � - . . . . . ' � ,, , .l�ceme;-.Law-for,�he�follow�ny.renson...ISe.c. 70�1.5; ",�. . � . �. . . . �. ... Approvod ... . . . . l3n.cinc<sa¢nJP>nfrsiidnsC:nJt�:AnYziayar���ua�ru�hich No. Dafa No: ..,.Dats '- � °�.'.�� • . . . . . �� ' � reyuires'rrrrniif.fn ranctrutf.a7(i•r„inrf�n.ri•,Jeqrulo:sh.. _. � -urrrpmrunpslruclun,J rtnittisn�an�r.uhu�rc��uirrc � > `� �:�.., . . . ,' �"-�� -= '., ,. � . � . . .� ..- -� . - �. /c app4.ane/r suth pernrit en Jifr o si�neJ aratrmrnt _ ' � . ..__ -- �_..... ... `- ----�._. _-.._---_ . _ ._�_ .. ". . . � .. . � � � tl ot/��•�is lic�nrr✓purovunt tn�/r prue•runns��//l.e(:on. � .� _ ' � �' _�.` ':�..-_ ._. ��`.� _ _ _�'��,'. : � : ._ . . , _ lructorkl.i�rnx�.l.au�(f.l�/�h,r�(cnn�mrnrrq�� �L.Sv�- . � . � '','.�. " 'F�-���.. .. ... � '�... . �� ��� � �� . . .. . . . , . Ur�ici�in 3 rJ7h� 3usinrstanJPr f t�mx , , . hoa 7flqllJ rrJ �. � � t ' t ... . � ' ..,.. : .• . �. �.-�' .• • ,�.�,.� ._(�dcf nr lb�e!hr is axeinpl fberr)rom und fhe-hos�r Jnr�l:c ' '_. _"'..__ .___.._ _ .� . _ . . . .. .. _. _ _ . . . _ �-- . . . �71rgeJ rxrzne(�tion.'Any vin(6linn n/,Secfirin�703/.i hti. ��'�'_: .�.��'._-_ __ '�._.. ...Reqvl�od� DateR�e�iwd ._ __ . � . .�.�. ..- .. .- ..._ .... .-.: .. uneaf,plic:ent/ �ahernilauh�ectt/tieapplirunlh���i�v/ APProvals _ :.:- or Approved.�^ ._ --'-� ' �- '- .. . . �- � �� lwogrs`as�hc t sole compensaijon J oJ Jo!larr IBSOOJ.y _ . _. _ Yas .No . -- -� �� b y o yrmploye=s�w�th - r:u.��Ccr.�tica�e.. _ _. . , � �� � � the struuure�s noi intended or offered for saic Se<�lOC< ,(, . . � ` '.', . { 1 Hrvhh Depariment------�---- �-... ---�. _-:.. .�-.-..-.-... .,Qatiness�nJPrnfetsioni CuJe:�7�be Cnufrmctnri/_irenve ' �i.'_ . � .. . . l.au•Jnrs nuf ofpl�'fn un nu•ner n/properh�u�/u hurlJi Fre Oe . ..� . -- � 7�rtTCn1 __ _. __ _ . _ _ .__ _ .. _.._. __ .. . . . .or imprhues t!erena,unJ u 4n dues rur5 uvrE himce/J oi . •. ... ; ;��� �� . •��� � ..-_.._\ ' `,, . '�"„ `.�...' � ..., '� �1/rnu,eL�-�/ric ou�n-ewp7nyees.'prrir�Jed'Ihnt�-suah� irn. .� �rod•ng�-.�. ; �• .-. , ��, , -,�. . . , , - � - -- � ��rnr�rrtenh are nirt inlenJcd ii�r�of/ereJr�iir safe:�l/, . � - .. � _ . . . ._.��� ``� . , �nurrer,tbrbuiGlin,�nrimrrnuem�nlissn ititlinnne � �. ... . . . .•,.. . . �- veologim(-i � : i � �. . • ,�,. .- �...; ... _ .,,... � .,. ,: -1,ear n/eninj�letion, tJc nu�nerbuilder �ril!ha�n�t/+r . ; ' � , .`. `�,... . .. - . �.�: . . ' �' -'...-� ..-:. .. burdcn nf frrnvin,Q tl at he diJ nn�.builJ o�i�nprnre fnr Pedesrrlan�P.me<iion ��_.. �.. .. . .. . . . . ,.. , _,. ;.. ..�.� . . ,,.. !hr/iurpnre,i/sulrl. �.., . .' � �. ._;: .. .. �Fencei(Canopy) i. ' � � ' � �� ���� � � � � � -�� . - � .•❑.� I,asownerofiheproperly,omezclusiveiyconvac „_ . : ,. � . . _ . ,. � . _....-_-.- _--.-. ._._.___.�:._.._....,_,.�....._ - - � ting wnh Lcensed convouors io�onst�uu ihe proieU(Sec. -�-� --�� - -- SPe;rol InsPe:�on. ;�. . . . '-" ��- ..--�- . . ' : ' . ' � . ::�. ; ' 7044)�(iurineri and Pmfesrron:.Cnde:Tbo Cnntrurfur's� i.o�2��IMosonrvl�(Weld�ng) . . . .. .. . � - - -.__._ .. ._. __ . _ __ _ ._ _..l.irense7.nu•dneinolu/ipls�loanuu�nrrn/frupertvu�Ln � _� .. -. . .. ' � . huilds nr improoes lbcrenn,und u�Gn rrinfracls fur surh lo�D.airogc � - � __prnjetes u�ilL a tnnlruttnr(r/li�rntrd.pn'rtuant-to thc � � ��-Cnrctrrttl�ir's I,icentr l.au/. � . Fo,kmy , . _ . �- .. . .. . . . _ _ . . , - ,.�. � .-. ; . . ..• . . `. .. ' .`, �J,..I am eKempl under Sec. .B.BP.0(or thls I � ., . • ` . �- .__reason . � . _.._ . _ . . ._ . _. _ .. � �� ,t�i :� ' � � � . . ..... . . -_.., .Dale Ownor . . �, , . , . . �... . .. . .. �. � . . . . � • ..�__�•-_ ��. .' , ., . . . _ , . , Approvals Dote Inspactor's Signafurs . � . . � � ' ; . , , ' � . � " ` � ���-INSPECTOR'S NOTFS � � . lomrian- , _.._.._ . . ... ... _ .. . . , ISetbacL 8 Yordsl __.___ . .. .....____. _.. .________. �. .� , - .. � .'... ,.. .,-,,. - . , t., . . � . • .. �_. . .� . ., �. ..,. FovnduGons - ._. ... ... . . .__.. -.. � . ,,. .r, � .. .. .. .�. � Slob � � � .. . ,....� : ., . Frame. �� . .. . . , ...i. . . . . . . �. - Energy.lnsula�{on ,i . . .'_.. ._ __. .__ \_.... .� _ _. . . .. . .. � ... laih:Drywalt- � . ,�:; ..,. .� ... , � _.. ,,.�, � ...� ._..... .. _ ..._ ' ' �, j Infenor - _ .... I lo�h-Ee�er�or � i . . . � � .� ___. _.-_" ..- . . ..___. .... . _ _ . __""'"____" . __ I � , i 1 House Num6e��- + � � ' -� � Corr'eu 8 Pos+ed� � �_.. . . �- ��-� . . .. ..-��� -��'� F,nal- ' ,. . :, ._... , .. ; . , . ..� , . .. Enler on Fron� � � � � . � � � . . �.., .. , �.� . �� . . . .. , � , ._. ,... ... .' ... ' � ( . . '. _ :.. .� .:... . . _. . „ , • . . \ ... . �.., � , ._. . ....� . ._' _"__. _'_ ..�. :�. � .� .