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HomeMy WebLinkAbout1034A 1372A WORKERS'COMPENSATION DECLARATION � ! � I here6y affirm lhaf I have a certifimte af�o�5e��,o,e�f -� APPLICATIO�N �FOR� BUILDING PERMIT � s insure,or a ttrtifitate of Workers'Compensation Inwronca, - � -� - , or a certiiied mpy the.eol(Sec.3800,lab.C.) �QUNTY OF LQS ANGELES BUILDING AND SAFETY �Po�licyNo.��ompany ��Nta-'SpfZ'.► - � - , Certified topy�s hereby(omished. FOR APPLICANT TO FILL IN - aooaess l`, Qih �1—Q � Cerfified copy is filed wilh Ihe cou jy 6uilding Insp BUIIDING t"r�I��N� �J` �� tion dBpor�meM. �, . ADDRES$ - - �OCALITY .1� - Oale Applimn �� ' CiTY ZIP CROSSST. � RTIF ATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. ' nS5E550R , � COMPENSATION INSURANCE . SrzE OF LOT NOW ON LO7 MAP BOOK vAGE vAaCEI (This section need not be completed if Ihe permi�is for one u5E ZONE nnAP I� � hundred doltan(S1oo)or less.) Taaa BIOCK LOT NO. NO ' �TEL (�.� SPECIAL I terlify fhat in the performance of ihe work for which this OWNER No. � � v � CON�iTIONS �� ��Q 'Q C permir is issued,I shall nol employ any person in any manner ����-��� DiSTutCT GROUP TYPE FIRE PR�CE555$$$EEED 6Y 0 so as to become subject to the Workers'Compensation Laws. A�DRE55 �� � �O �i CONSTTr ZO �� O � C Date Applitant . CITY / ZIP STATISTICAL QASSI TION APT. CONDO. F— NOTICE TO APPIICANi: If, affer moking Ihis Certificafe of ARCtitTEC7 �R TEL � V �Exemption, you shoVld beCome subje[t to 1he Workers' ENGNEER �NO. CVt55 NO. �'� DWELL UNITS � c Compensation provisions of�he lobo�Code,you musr torth• m ADDRESS - SEWFR MAP . � wNh comply with such provisions or this permit shall be � 7E�. � deemad revoked. � �pMRqR q NO. - BK. -PG, � �� VALIDATION � •- LICENSED CONTRACTORS DECLARATION ���, I hereby aNirm�hot I am licensed onder provisions of Chapter 9 nDDRE55 NO. yqWATION ' � (mmmencing with$ection 7000)of Division 3 of the Business and - ��� �� , � - � Rofessions Code,and my license is in foll force and effect.� CiTY CwSS 5 � � . , ' (� -� � SQ.FT.�r� NO.OF NO.OF CHEGK : �I[anSeNVmbet���(�]„_�{�,Class S�ZE ..7� STORIES FAMI�IES ONE . i eo�vouZ,f,��S�i�irna�e__!7Yr/� DESCRIF710N�F WORK A o ❑ S � �1 0 3,4 A ❑i am axempt under Sec. � 2 #• 2`3 B.6P.C,for fbfs rcason - � � �� � �� RE�AiR � DA EL � 7� l''� �:• •2 7.6 3 �� Da1B: .. E%ISTOIN BLDG. ' . .. . ._ DEh10L � -FBINA /. .. . . .. ��:• •P Z 6 3 c=i APPLICAM Y � -Signalura� PRIN7 — . . O��.� .3�8 Q- OWNER-BUIL�ER DECIARATION � � I hereby affirm thot I am eaemp�from Ihe Contracror's Lfcense Law for 1he following reoson(Section 7031.5, Business and ADDRESS � - � �� � - - - Profeulons Code): - , N . . �- : � ❑ BUIIDING . , . I, os owner of the property, or my employees with ADoaESS wages os their sale compensa�ian,will do ihe work and Ihe strunure is no1 intended or offered for sale(Section ��`��TY � - . . � . � - 7044,Busfness ond Profe3sion5 Code). MOVING TFI. � � � � I�as owner of ihe propary,am exdusively mntracfing COMRACTOR NO. wirh licensed contractors to mmrruct the proiect(Sec- ADORESS � � 1 1 3�7,2 A -tion 7044,Businass and Profeseions Code). , , . , , _' _ ♦� - ' . REQUIREO TOTAL SETBAIX FROM E%IST. . H-�"� � • ��� CON57RUCTION LENDWG AGENCY SEi eaCK 1'l+RD HWY VROP.UN[ WiD7H � J�• •3 Q 7 5 1 hereby affirm that there is o construction lending agency for FttONt� - � �� -- � - � . . . � . the performanca of Ihe work for which IAia permit is is:ued v,l. �. �'�'�3�7$U i5e[.3097,Civ.C.). SIDE - v.�. _. ; 0203-84 . Lender's Nome t� . � P.G Fee S 1 � Permit Fee c�y.Zs ' Lender`s Address � �. � - � . . . . . . . ..._ __ . . -- �-- —.. . _ ._ ._ ... . . _. I cartify that I hava read�his applimtion and sta�e that the hsu ce Fea 1.f7 50 ' �- � S above fnformation IS correct.I agree t omply wilh all County Invesiigatian Fee . - _ ._.��.. . . _ .... ..__ . . . . . _- $ �ordinances on te laws relmi r otlding construction, ioiot ree �� 36��S Yi �d hereby J rize represe tiv of�hls Covnty to eMer , � ¢ - �n th ve- ioned oper forinspaction purF%Y°°ses. � - � - � � � � - � � �� � � � - �- -� - � � __�i�r��// SE(REYERSF FOR E%iLANATORY LANGUAGE � . .�n ture o AP can A em 1 ,� � � Daie 7 ' . .. . _._.� _. . � . •� . .� . . .. .. _m� /1� _ _... ...._ ..._. --«--- ��-- .—.� - - - . _ _ _ Pl�PFLICANT. � ' �INSPECTOR'S NOTES � � �O�VtiFI� BUILDLP DL•CI,ARA7'ION. � , � �� � . .�I hereby off rm fhat�am exempl�,from ihe Conirpclor s � .Roturnod , .. � License Low for Iho�follo�ving reoson. (Sec. -7031.5) -� ApproWd � �,;6ysfryrcr_and/�ulcf�(rm:xCndbjll7�'dtj.nrconnt��u•Gicb � � � , . , . . .. . �� No:. �._.. .__Dd4��,-�-,-�-, No�. ��--�-Dato,-,: . ,..-�- �--..- . . . . .. . , . - . . . ... reguirct¢pcn>rit tn cniulrurl,alfcr:inrprorr,dcmoJisl�. � , . . , . . . . . . , , . � � ' orrefairanystrudarr,p >rtnitsissi�ar.ce,alsnreguires . i_.__'__-___. _ .I. _._... -�:. . . . _ ._.._. . .. __._._.._____ _ . � , ` .-�- � . .._. ..---�'��--'...� . \ ..._ .�, . .. ' ,the�pl;cnnt far suc!pernrit to�'le a si,qxrd slalemedt . , . , : , , ,. , � � ��,� � ,_. ___.�__�.-'___._... . _ __.... ___ ...—_____.__ _..__. _ . . ..,....�.... . -�..........._ . . . . �tGat eitlrccnsedp«rsnarr[totGeprot�isronsojtheCon I � � - � , , � � ::�iracepr'rLirerss97.2fi•.(CGafter9l/eunjnrenalttgf+.'ifbSec- _ -' 'tion 7Q00J nf Il �inn�3�f thc Unsiness pad Profeisloiis � , � . ." � '�+., CodeJnr t1 a[he fs lCcen+pt tl rrrfsonr and t1�e basisJor tGe _ _ efkgrd cxrmftion.An,l'i�iri7r.�tiore of Srclron 7031.5 b�� � l 1 '•� 1 ��RaQvlrod DeMR�cdved . �.t�' ...-� � . � � anp¢phJicuntfnra/�enuitsuL cts�fl,enffliCenttoacivi! :. . .;�F provL�le.�'-. .-, . Yos No. �er ApprovsJ .. . , ... . �- . . �penalf}nJnnt rnore tl ax f�bc Gi.rt�i;rcd dollacr(3500J.J: ' .: �: ". - . ..._ . ._ , �.. �.,:� . �,� ' .', . . .. . �`_ .: � �,. .- ___ ,.a...�. . � . ..- ..._ ,.,,;. ,'.�. I,asowner oF Ihe properly,or,my employecs wilh Water Cedificatc� 1 `', '� ^,��t . � ., . � ,�.,� ,- � �- � �.: � , .. �-�woges oe�heir so!e compensption;will'do ihe work,�and � . � . .., . . . . ., . -. -�� �- .. � � . � -- ---� �- � ihesr.uciurclsnotlntendedoror(eredforsale(Sac.7044) H � � � I '��'J �� ', "'`'-� .�� .,, - ,,,.. Uusii�css and Pr f ssrnns Codc:Tl+c Contractor's Litrnsc ealth Depor.tm6fit_ '^ - - � ' . � .. . .. �.. . ._.._" . _",:_ �4 -.. .. �__::... .. ... :. . �..• ..�.� ,_.:�. . ; ._._� _ -_.la¢•dncs unt aJ�plt'ta cu o:rr.cr of propertv u�Go builds � ; G�' � ��� � nr irnpronesYGereoN,r.r.d e J n 6es:i:�r1i erork J inrselfor ..-�_. I � Fira Departmonf• � .�. •..� . . . ,: �. . . _ .. . _. . . . . - . _. ....__._. .. __. ._ . __ . _ .- .. tliou,FG !ir' n�rr: rm[�,Iny•er, hroridcd tlat sueb inr- Groding � ,: • .. _ .._... . . . _._ .,� /�ro.enrrxts�are not Letei.le��o-'�nfferea�for�s�lr.;,7f. � ' _._ ..— ._ _. .... �Y ' . � ,\ \ �"' hotierrr,fbc5a�i(Jin,qnr:rnn c���•nticsn/d,�oilGrn�one Geolopicol ..� ... � . ..- '. . . year vf.cor.r,nletrov�, t!e.prev�c.�Laildcr,d�il1 1 ac�e�tGe � , ti� herder.�jprn �{.td��:! r.nrh � `uspmrefnr Pedestrian Protection _ .{ . �� ' .. .!hc fui(�oar of s��lcJ . ��.. .....,. _�, (Fonce)(Canopy) , �� �-� • �- �. "� � .�❑���I,asoa+ner of ih,prap rty;am exclusively conirac- � .. . •.. _,r ���tirn�wuh�ce�sed coniracror ro cnnatruct the projec�(Sec. � . '.... .�'. �•._. �.' OGJS13i mr �aodPro�s � ' , 'c p I insoection � '- - --' '. - ._ - . _.J s c . ok Ctar'�.Tle Cantra�mr. � (Conea'.)�hldsbnry)(WeldingJ . ' . '�- . LmnsrL:e�de n 2a�.ly.t u our.rrnJj�r�ertyu�!» " .� �.._ ..�.1,.,: . '..... ' ...:__ �.'I _ .'. \ '.�h7erlds or�.n�roe�cs er.rrir..,an...rebp enrttrncf;farsreb Lot Ordincga� �� � - � - projrots irit/n rnnfrc�tnr(sJ licinsrd�jrursvant to�tl r '� � � .�. .. : . � , _ � .. . �.._ .... . .. . � . • .. � --'�Cor.rrurtnr:c l.i:oncr l.airJ.- ' - -- Parking _ - � ' '� . �__. ._i, � ..: �.�. .'.. � : ..� ._...��` _ __.. ___ _-_..-._ ._.�__'�', .-._. _ ._ __ � amexempfundcr5ec �. .. �,�B.&P.�C.(orlhis ❑ I - , ' � . _.—_ ..__...__ . . . ..._ ________..__._ . ___ , �. . _. ._. _. .. _. _._ . .__. . rroson , � - . > , _ ._ _ _ . . ... . . ..:n '�., ✓ ._.`� . ... .. .1 . . ' '_."_ . __ _ '_ _ ___ . . _ • . . . . . . . .'. . . . � �� Do e .... . ....... . ._... �Owner ... Approvala Da1s In�p�der'a StgnrTun . . . . ... � .,._ , � ... lP:Sf'�CTOC'S�NOTES --� lomtion— . .._. _. .._ . .. . _._ _ . _ _. . ... . _.. �. . .._ (Setbatk&Yards) ��-�' . � . �. .. � . .. . Foundations " � � . ' , .. . � . . � ,. .. , . Slab`; 1 � i .. � . . .. � . � . , . ..,.,,�.i. � . .. `-- . � . ., -- .. _ _ . ._.. . . Frame . .. ..:.. . ; � . ,., � ..:� � :. i � . . . . .. . . ., . .- . .. ,.. � _ .. .. Energy Insulation,. � ' �� . . �. : � .�. ' .',... � .. . . �. � . Loth�orywa��--:,l . ., . . � . .. Interior ' :- . . .'.. . . ...:��.�: .'. . _ ' ' _...,��:.�;��.,�.,.� , ._. . .__�___.__. _.____._.. _._.. ' . Lath—Exterior . . _, "'..�1.-�� .- .. C� �..�_.��_. .. � " '. House Number— ' C%,:'.UI . .� .. �. _... ..r� r. _�..- . , ..,, , .� .. . . . .� Correct&Posted : ._._'.... ._. .. .._.__�' ._. . - ..____._.. ..__. . . ' ' . . Fino�— C-� •dp . . � .. . . .. . . _ EnteronFroM . ,'... . . �. .. ... . . . . -_.......,.,.,,;�. '�.� ;�'.-, . -, . .,. ,, ;,_:.. . . _i: - `\.. .1\ " � � ��'; \'�, '�� � ' -} / . . �� . '..- ,... . .,-"/ �