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HomeMy WebLinkAbout0839A (4) WORKERS'COMPENSATION DECLARATION � - � � � � � insurebor�afcertifca'feofWorkers'�Compensalionlnsurane" � � � APPLICATIO�N FOR BUILDING PER1 IT � �� or a ceriiiied copy thereof�Sec.380�,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY /� PolicyNo. Company . � - � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 1 ' �1� � Certified topy is filed with the coonty building inspec- �� BUiiDtNG 1 � �r ,v.�� �n,. _ li0n deporlmenl.� ADDRESS ^,,-_ .^-� 1W����•� Date APPlicanf . . . . , ... OTV }/�w�^"'�rY/\ 21P �O� IOfALITY �YQ/v�' . .. . � CERTIFICATE OF EXEMPTION FROM WORKERS' � - - - � NO.OF BlDGS. - .� NEAREST . �Y,._.,.J �„n � � � �� COMPENSATION INSURANCE - � . 512E OF l0T NOW ON LOT CRO55 ST. W�'YI\. VWL (This eeetion need not be'completed if the permit Is for one � iQA� � � BtOC �� l0 NO. � Mqp55BOOK � • PAGE PARCEL � hundred dollars(;100)or Iess.J .. ' �t I tertify Iha�ln�he pariormance of the work#or which this � OWNER USE ZONE �?' . I ��7 I permif fs lesued,I ahall not emp�oy any person in any manner � �� ���A� � � � nooRess CONDITIONS so as to become 6ubject to ihe Workers'Compensation laws. � - U Date-�� � -Applitant . . .. CITY 21P . . . . . ', . . � ARCHITECT OR n' TEI. �ISTRICT GROUP TYPE FIRE VROCESSED BY O NOTICE TO�APPIICANi: If, after making�this Certificate of ENGINEER ����h L7�'V No.��Z' � �p T �� -Z F- ERemption, you ehould become Subject lo the Workars' J� . Compensation provisions of the Labar Code,.you musf forth- ADDRESS �J � � �� /�"�z �l� a� wlth comply with auch provisiOns or this permN shall be �t �TEI. STATISTICAI C1A551FICATION APi. CON00. N deemed revoked.. . COMRnRORJ� Y�.7'�Yl • NO. 2' � � �7� UCENSED CONTRACTORS DECLARATION � � - �n � � Z � .UC.� �CLASS ND. ^�`�'DWELL.UNITS.. . 1 here6y affirm that�am licensad�nder provislons of Chapter 9 ADDRESS d I 1�C NO. (commencing with Section 7000)oF Didsion 3 af the Business and . _ /'�����., . . . ��R�P '. � Profeuions Code,and my license Is in full torce and effec�. CITY � l.�/�CtASS �- �BK ��� � VAlIOATION - - ' � � SO.FT NO.OF NO.OF - CHECK . - , license N�mber � lfc-Class � SIZE -S70RIE5 FAMIUES ONE . VALUATION� ' � �ESCRIPTION OF WORK N� rc2�, � Controctor Dale ADD ❑ ; I v �� � ❑�am exempr under Sac. ���" AITEH , �p 8 3 9 A 6.8P.C.(or Ihis reoson � REPAIR ; - � � - U E OF � � ' �• • • •2 3 . - Dafe: � E%ISTING BLDG. DEMOL � AGPtICAM TEL � I • � � 2.6 J Signature -� PRIM o ns n �- No.�S2-�qlo FINAL � OWNER-BU�LDER DECLARATION . DATE . . I hereby offirm that 1 am exempt from Ihe Contractor's licenea � {��1.�! -1— 0.G/� FINAL � � � � 2 6 J� Low for the following reason(Secfion 7031.5,Business and AODRE55 , Professians Code): �" �� N . °Y ' - ��� �—$$ ❑ B W LDING I, as owner of Ihe property, or my employees wilh qDDRE55 ] wages as thair sole compansotion,will do the work and i�A�Ty , � . �. � 4// the struaura is not intended or offered for sale(Sec�ian � I � 704a,Business and Professions Coda). - � -� MOwNG � TEL � - � � �/ (J,(// � I,as awner of the property,am extlusively coMrocting CONTRACTOR NO. n ' 'M.!' � /i with licansed contractors to canstrucf the prajett(Seo- qDDRE55 l/7 V . lion 7044,Businass and Professions Code). REOUtRED TOTAt SETBA K � - CONSTRUCTION LENDING AGENCY - � SET BACK YARD MWY PROP.LINE WIDTH � 1 hereby affirm that�hera is a const�oction lend�ng ogency for feONi � fhe performonce of ihe work for whith Ihis permil is issued - P.L � ,_ � � t . (Set.3097,Civ.C.). SIDE ' P.L. Lendar's Nama , � / lONJ1 Ref.M Lender a Address � � ' � P.C.Fee S �II�.•b 3 Pe.mn Fee ,� - � - � I.cenify that I have reod Ihis epplicmion and srate that the . . Iseuan<e iee Lnhw PiC N . ' above information Is mrract.I ogree to comply wi16 all County Inveetigoiion Fee� � � ordinantes and Sfola lows ralating lo building construclion, io�ol fee IDMA Ve.m.M . � and hereby ouihorize repre:anwlives of�his County ro enter ; upon tha above-mentioned property far inspettion purpases.� ' � � SEE REVERSE FOR EffPUNATORY IANGVAGE '� ', S�gnoWre of Ap0licam o.Ayent pote . . . . . ' . � � � 'PLANS TO APPLICANT�.� � � - INSPECTOR'S NOTES � - �, 014\7SH�6UII.DI�.K ULCI.ARA�CIO\ � � I hereby af�irm ihot I am r.Hemp�from ihe Coniro:te�'s To: ' . � Relu'rned .. . ... . ' ' � �icense Low Fo� thE.iollow�ng,rco on ,(Sec �7031.5) . . . . . Appravad � .. . . . . . � • . liunrsessundPr/is.vnnsGndi^.AnV��t7r�r:nunty'�r/�id� No. . � • Date� No. ....'Oale�- . . ... .. .. .. ..•'. "• rcyuiresuprrmi(lnrnns7u<'l.ulfrr.imFrure.Jrnro(iaJr, ' _ '. - .' . : . . . - ��i a1 f ts ca�nurice,alan rryuirrv . ':.;..,� , j, :,} . i 1 .� .. �' :��. . ,., ;� .. c h/�fi.�Jnt fnr surL perndt�ro filr a srqnril seulrrrrenl , ... .... ., �- .. . � . ... , ... .. _ � ,� '_ - . . � n< p rlep '�i' s /1/eCun� 1 t , _ :;."'S � �r ; r: i f t .. �/ � --'':�f .. �j��; e�U�1`ir's Iir nu�1 ir(Cl a/�trr)J(roromrnain,q�cith.Sco- . . . .._ -_-._ --._.- -- . ,�� � � � , -� � ,� n 0! /U t�i n 3 n fGe Uusinrss unJ Pru/ nns , , � . � '�'�1 : -. . . _ -._��.. ..'.,. �• • '-, �._'': � �nde)ortLotl�eiccxrnrpltlernfrnnrundflcbnsis�or�lhe . �.. ._� - _ . . . . . . _: _:_: _( . _... . _ __ . _._ _. � . �c��._ �. . i" ..:....". ...Roquuod:.' -��Date�Reealvod � ___... . ..__._ ' :.� ._.._..� .. _____ _..-__ __. _ _.__ . anl�pplicantJnrapermitsuhjed3ll appficnrtthaci i'1 : - Approvals -- .Yas No . or Approvod - � .. � , :,•�perufll'n/nn!mnre thun/':�c l�undreJ J,�tm.s/Ss�io/.),-. , . ._. _ . - ._ -"....., .1:._.,' �. - ......__ _.. . - L� I,as owner oF Ihe propeny.�or my employe>s with W�t�r Cerliiimre i :' � 'y...) � .. .. .. ..-. � .. -��� � , � � ....._ . wages as their sole compensation,will do Ihe work,and � � . ��..•� � .�he struUwe is not iniended or o(Fered lor saie(Sec.7044j .__ . . -:.- � . � ..- .. A " . . ' ... -.. 'i. r'� . �.�. , ,.. � . ��:; "'� ..Iluririett anJ Prn assions Code:7'be�Cnntrartor's I.icensi .. Heohh Dcoorimen�___... ._ '._."__ _.. . . ._"_..__. ..'. ..._ . ._. -. _ .; _. _ .._ .._.. � .. � �,..Y � t �'� 1 : l.nu�Jne.a na!arr1Y!n arc��u•ner nJ^rnpeih�mbn huilJi� . . . . ... . � r � � Fire DePanment -__._._.. .. _. . .. �.; . ..;._... ..:. ..' ,.��V . o imf�mvcx tbrreon,und u�G�i doca srar!u�ork birruc!/nr . .. ..... . ,. t. . _ . _ _ _ . . � . � .. .�._ !, ._.: �... !�..�:.i .,-._�....:i:�... �� � �..: tbrou,�b,Gis ou�n ernplriYees. prnrrJed aba� turG im- G�adm � � :,i , . � :�/�rnt�ernersfs are�not inlenJeJ or.uffrrcJ fnr iafe. !f, � . 9 ' � '...� . j`;J-,: i 1;.r,.,! r,J)�i�,.. � �' � � � - Imiree�er,tLr builJin,�or imJ,rnventen!is t<dd ivilbrn onc . Geoloy�cnl ��. �..�._.'..� ._-�.. .,' -.��`. � '��' 1 . ..�.. t�. ..�.. - .. .Year nf inmplelion. lha�na�ner.ht�ildrr�«�rl1 barr�tbe � .%,��`�i .(��' -�� :, I, ����,:: . ...'. . . burJen o�fronin,�1Gn!Ge drd nnt Aulld or�irn/nnro fnr ��Fence)ICanoPY) 1:..._- "'�.. .� � � �.. ,� .. �� ... ..... .L.... v:::'�� `�l, !� �. ' ' �-'� �_ `�nu��aso�ne.roflhepoperfy,�amedusl,ve�ycontror Pedestrion Pro�euwn . � - -. . �.�. . „� i �� , , . ��,ling with licensed coNrocfo'rs io mnstrucllhe project(SeC ._ .� ..... . �. .._ .. ...' -�":,-j-:- .._..... _ . �' '.. . ':� . ..�`- 7044)Uusiness und Prnfesti�in.c�Codr:�7i�c CnnlrJrtiir's Special Inspect�on , � � . � (Conc.1(Masonry)(WeIdIn91. . �.:-� . . ;�� _--�. ' - —.... .._.��. ...____:. � .. _��. .:� ,... � -- Licen.ce!au•does nnf uppfv fn un nu�ner�J(�rof,ertt•u•1 n • . . huilJs�o��imprnres fLerenie.�and u�La-rnn(r�t1s/ur svc! � lor Droinoge . ,i '..�. . .. � ` . - .. .. . .. _ _ . . . /�mjects u�itJ.�a oonfrartnr(s/lr�e��srd r�usuant 1n t8e ,. -'�� .,, , , .. ._ . _.. .. � � •t '���G�ntrarbiis�l.icentr 1.-au•J.--" -��� - �--' � � . ... -� ,.•..�� ..,•�; � . : Pork�nq .� ,:.;_.. . �' � .. `. .. . .. �� -� - ..❑.�I am exem f undcr Sec. � ,6,8P C-#or�ih��� -. p s r i'f';I�j ',� . . . .. . �. . �' ' __'. . . . .. . . . . . . ..... .. . _..... . . . , . . . , reason . . . .. : . . _.. ..__ . .. . _ ._ . __. __._. i � �. . '�)� j �_�-_1� '. i . !'t..: .;�..; � . . .. __ . w . . . . . , .� .� Daie O �ncr :. . ..___ __. .. . . ._ ... ' . . . Approrals� Uofo Impectoh Stgnature . - � -; :'�p ��� � i-��-� � � ' . � � , . . �� .,. _ ��� INSPECTOR'S NOTES '�� � Localion- i .___... . . - . _.. _ ... . . , � ' (Seiback 8 Yards) . . . . � � . . -,.. � Foundai�ons . � ,.; `, �� ' - � � � � . ,. Slab , .. , ,� .�. . . .� . .�, _, . . . . Frame . • �� . . ' . . , . , . . . � ... . .- . �; . .. . . Energy Insulmion �. - �� --. •. , '_�.. _ _ ... ...�. ..�. ! ' . , , . . .. . . - � . _ . . . , .. ..�.... __. _'._ ., ._..._ . . . .. LoihiDrywall__ . . . . �_... . _. .. ..._-.___ _�.._... ... . .' INerior --. _.. .......__ . . � , . . . . - ' . . Lath-Erterior : . : ` . . . � .. -- . . . , ''� . .__..__._. _ ._.._ ._.._. _.. . .. _'__..._._ _._�: ._ ... -. � ' C ,�: - House Num6er_ ,. _'.__.___ ._ .. _. .._._... . . . ... ._... ._.._.. __ ._ . Correcl 8 Posted� . ; .__. ... ._... .___..__ ..._ -��- ' � . Finol- . � . ._ __ . . . :.. . . . . •... . _ ..� Enrer on fronl � .. . . ._ _ . ., _ __ . . , . _ . . . . . , , . .