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HomeMy WebLinkAbout1331A 1467A 1468A , WORKERS'COMPENSATION DECtARATION � ���� �� -� � � ..eborafcertfca}teofWokers''Compensationinsurancef , �-'�APPLICATION� FOR BUILDING PERMIT ' � cenified capy thereof(Sec.3800,Lab.C.) .� � � COUNTY OF LOS ANGELES BUILDING AND SAPETY � 'yNo. Campany � � � 7 (� ', Certified copy is hereby furnished. FOR APPLICANT TO LL IN ADDRESS Z J VC�Ih ��- I Certified copy is filed with Ihe couMy building inspeo- BWIDING 1 O ' � ' tion deporlment. � , � ADDRE55 /1� lJ'Y LOCAUTV Q NEAREST Applicant CITY �l�1� 21P � CRO55 5T. f�^ � �� CERTI�FICATE OF EXEMPTION FROM WORKERS' NO.OF BlDGS. ASSESSOR �. j COMPENSATION WSURANCE SRE OF l07 NOW ON I07 MAP BOOK PAGE PARGEL , -...,�',section need not be compleled if the permit is for one USE 20NE M1u+P � S � �red dollors�5100)or�less.) TRAQ BIOCK LOT NO. NO.� ( � � . p � TEL - �_� SPECIAL � � Iify thai�in the performance of e wo (or w ich Ihis awNER 4 c�r c� ne NO. CONDITION$ pr. � ��il is issued,I sholl not emplay a rs n in on manner DISTRiCT .GROUP TYPE � FIRE VRO�E SSEo BY 0 i A�DRESS � CONST. ZONE / - V , ;�o become sub�ec�to Ihe We� 'C p on lawa. /J , I o s, � ,C.{.Tf� a O7Y .. . $'M ZIP. ,O �' - AppliCOn � � ' . STATISTICAL CIASSIF TION APT. CONDO. V �CE TO APPIICANT: If,.ofler- ing his Certificata'of � ARGHRFCTOR •�.:TFL . � ,.,..,. � � - iption, 'you ahould�becoma��subject'�ta�tha Workeri � ENGWFER � NO . ��QASS NO.�DWELL.A1NIT5 � a �� bensation provisions of the labor Code,yoU must forth- ADDRE55�� � �.� ' SEWER MAP � . . . z � . icomply with noch provisions or ihis permit ahall be� 7E�. � � � — � �edrevoked. � . � � CONTenCroa lc�. �NO.�Z��' 8 � � BK. .PG,�. VAI�DATION - - � LICENSED CONTRARORS DEClAR.4TION -���, � - '� iby affirm that I am licensed onder provisions of Chapler 9 ADDRE55 W, � NO.� Q VALUATION ' � ' � -� � rencing with Section 700D)of�ivision 3 of the Business and ��C. (� ' . � ulons Code,and my license is in full forte and eHett. CI7Y CLASSC��J C .��� OD`–'� , . � � . � - 50.FT. NO.OF • NO.OF IiECK . 6e Num6er �IC.Clasi SIZE STORIES FAMILIES ONE '. �L'� 3���.a �� s ,�C'-�'—n . �ottOr Date � DESCRIDTION OF WORK C Q r NEW � ��'� �,2'3 . 1 ADD � . � ..-- • � � am exempt u er Sea � �� t nLTER � FINAL ? "� � • •2 Jr.0 Q �� .�.BP.C.for this r oson �j �� �t'� � 1" � REPAiR � DATE d (y(��j •2�O O U � USE OF DEMOL ❑ � ate: EX6TING BLOG. �} r FBINAI�L�a�� . . �0 1.3 1 -8 4 � .ignalufe APFLICAM TEL. Y i PRIM QY nQf� I �N' r,o. 3- - � � �� �� 4 b 7 A � O ER-BUILDE DECLARATION � � !by affirm that I om exempt from the Contractar's License 1•(� � . � , � � for ihe followin�g-reason(Section 7031.5,Business and ADDRE55 Q� 1�,. '- � -'- � #• • • •23 t ssions Code): N � � � �2 6 3 � ' BUILDING . � , I, cs owner of�he propeny, or my employees with pooae55 ' . -�-� 'woges ns fheir sole compensation,will do tha work and �����, . �� • • • .2 6 3� , �,the strocture is not intended or offered for sale(Saction � - . � . . . ���7044,Business and Professions Gode). rnOVWG TEI. �2� 0�8 fj , . I,os owner of the propeny,om exclusively conirpcting C MRACTOR NO. � with licensed contracfon to construcf the project(Sec- qDDRE55 'Yian 7044,Business ond Professions Code). , _ . . ' � � -REQUIRED TOTAL SETBACK FROM E%�51. CONSTRUCTION IENDING AGENCY SET BACK YAR� HWY FR07.LIN� wioTH - , . �eby affirm that there is a construction lending agency for . pgoNT . . ,. . . �� �l 6$({ ��erformance of tha work for which this permit is issued c.L � ��'.� � � ��1 � 3097.Civ.C.). . . . SIDE . . . . . . P.L � er's Nama ^c � • '4��� .�=.er's Address v.G Fe�S� �'�J Pe.m��Fee .�� • •4°J.��c=.i ' : if ot I hav read t is application dnd state that the � - 'f� �'�� isso ce Fea ��•`S� � �2� �`8 4 . inf matio is mrrect I agree to comply wi�h all Couny Invesligm�an Fee �� - - � �nte and rate laws relating to building tonafruction, Toial Fee 3. L'"L� � � � � � ;,'re y aut ori s mafives of Ihis County lo enter , . . � a6ov ami ed propeny for inspactian purposes. ' � � � . � -� � - � � , -� � � . � � SEE REVERSE FOR E%PLANATORY LANGl1AGE ' ; , _ � �SignotU ol Applimni or AgeN � Da�e � � . . .�� , � . . . . . . . . . i _ . . ___ _ _ .. _ _.._ _ ± , - l. ��/ , P4Ati;';1'O AY:'UCAl1T:: .. �r 'L'�Sf•FC?Qf.'S NOTES �_ � .n«'h'r��'UILI7L.�:Di.CI.AP,ATIO�I .. : � � , ,:,1 horc6y affirn�nat I om e'sempl frcm Ihe,Cororactor's � . .,...... . .. :... .:.......�.��; Ilor^n�J To: - �Roturned.- . � Liconso Lavr for.�ho fo � .•reoson. (Set.�.7031:5) � �'��Aaprevod lJusinrasa.•JI'rnfeui�rrCn:.__AnyciEynrraunEqu�lith. . . .,., ,., , _._ _'_.. - .. _.. _ .... �, No.� ,'r-"-"—�oM� � .... No. . �,Dafs' -. , . - . , . . .. - �•- .�... -'"�Yequtr.s a f:� !1 ta trin�U ucl,e!tcr,tr.ifrorc;d rolisb� -*_----�--- '- nrrsnairen�� truct�r � r rt' rt.vis.triancc,nlsnrcquircr . . _. _. .. . . . h'- ^ __ .._ : .;S_;,�. ._.. . . . . _.. .._... . .. .__. . . _ ___ _.. . ___. . �i'� � -- � ^c I�a !c G nr s d f rmat to r1c a s: red atateme'iil . � ' _.:_ - � - r rr r�n f r 1' 4. � �Z ��'�� "----�- r! r/ ! i • t rb �r � o s nrthc C n- - - --------- ..- --- . . . - . . _- -- � -- - _.... . __. .rir iee . p rre.n t ep oirsr n� ., o ���.. .i .'• ' ' . . ...�' -.. trador'sLece s 1 ��(Clnpt r9J/corrrncrsingwiLbSro- . .�^ � ' . .. ; } ---dnn i000J.f Un . .r+3 of Yl�e'Cusinrss and Profar4ions ,' � . . � CndrJnrt/utf' r�i.i��ni,�tif� -fr ii�dndtJeb2s7sfort5c: . ;, :.... -.... .. ' ,... . i,- -� . . ' �. � ' _ .. . - .-- �� allr,prd ere��J�rr�e�.��Ir.t���fotatino�'�fSec�ion 7031.5 by' � I :"�'�J.'' 'R^rufrod ' � - . �,� i . .. 'r. c'f ':f�� - � - 1 ct,,tl� c fi�ur.t to u tiai! � � .- Dato Foealv:d e I. . F�' 'App:eva!s � -- -- -' - -- - '- — " - pe ea71y �� r t tfian f r 1 rendr J Jo(lars(<SOOf.Ji � Yos tJo � orApproved� � �.; . __. _ .. _ _. _. . . . _ . � �. . .. . ., � �l. I,.u\ownerycf;lnepropc,rly,o�myemplOycoswith� . . . i ... , . . � • ... . - .woge:es thr rsc�e c.mpenselioni.will'deaha work:�and � WaterCartificate� ; ., . . : _.�. � _ � , : � I . ��. - , . . � _......_ .__ _.__ ._.__.__ ._ .____. _. •. .:. .__._.. . .� �hestrucntrnisnn"n'endcdoref!eredforsale(Sac.704d). ' -=�� '��� � -._, i J �' � � . .�Dr s� ss e Fr f.r . Cndr:7'Ge Contractor's Lrcense� Health.D pmtm6nt ,.., -_„ - . : .. .... _ .._ . . .��.�. � ` .._- . . ._.. � � /:.7,.; . .. � � ..._..___.____ . __ ._ .__., ._ .__. . _... . _-],au..u.,.no.us,�,lp.t��a�rour.ar ff�rnperiywlobuilJs, � Fire Deportme nt � -�. '�� _ . � _ _ _ . , n r �r � 11 rr � �7J f � e ar iL u�nrk fir scff �r : .___ __ ' _.. . .. _'.__ _ _____. . t/ r!ol ' . . :_.. ._ . .. .. ._. : . . t.i �` �,=. �1 ' � r�rF�fyrsaaaun �. /�n cd tGat�sacLr r.n I ' " . ' � ' .. c o � f d r!' nf(errJ for a l �.If, Grading . - . . _- ' - ._-. .. . . i ..' ..- �naerer,�ili � � � �.. __ h ��, ;.j P � 1 G 1�� r .Jrnrrn.e t sioldtivUrnw�c Geolec�icnl�--------- .. _ - , .` ♦ uf c i�nl 7 . .l i.�e�c•xr-brrfd r wi!!Gae tfie .. . ,t� - . �' :�`r, ! «. .��1,, C.f.-.t u�nt b�dJ nr insfrone f r , . . �� ' - ' .�tl c f+uiifosro/.-al) ..' :.. , �_ . .. . . � �. Pedestrian ProteUicn - . ' �� � � � ' � (Fence)(CanoPY) .:' ���' �.,',� � . � -�"' �..�.' ��� _. _..,� .�•;___ _... '�� .' of�Fep operi�;amexcluaivelycanfrac-'. ti -. i - ��� I,�asc�+nrt •.. " . . . . . .. . � . -- .. t � I<.. ,c� ractc�s to co�svoc•thc roject(Sec. ir . ' � . _ _ . � _ '__' .__. _]0 ��1; r 1 Pr k•stto::s Co<��.:,�he Contractar's i � SPecia�lnspeet�on ; ,-._\ • '.` : ; , L e 1 u� taplitncr.an.irerofproperiyu�ln'�, (Conc)(Masonry)(Welding) ; '- .. • f i . :t�1 . .,- .�..� __ 1 c71�! - . . ,. �.� , ,. _ ._ . ._ '.__:� .— . nr f•):, [[3_tl��:r^nr�.Cr:a�1l•f 1.Cnr:frarts fnr st[c(> Lm Draincqe � . . '. . ..... �i ,, •; ,� r , ' � � . t s(1 f ,. - !,('+:r.. .?q'.�7 p � n � ��rs. .cacnt 1 r . . . .. .,. : it_ . •� .�s_.'�_ . ., � , ,_ . ...__. _. _ �----c ,,,c,...,,.r;,,,�r ' ,,�, . . .. J �.� , . 1 �=�� Parkinc� . � .. � : _ _ .__. ._ _ .... .. 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