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HomeMy WebLinkAbout1762A 1977A (10) � WORKERS'COMPENSATION DECIARATION �1 ` ` � " ' � � • ereby afflrm thot 1 hove a certificote of�o�sa�„o Ea�F � -��APPLICATION�-�FOR� BUILDING PERMIT � ��ure,or a certificare of Workers'Compensalion Insurance, � �� - � �a mrtified mpy thereof(Sec.3800,tob.C.) � � � - � COUNTY OF LOS ANGELES _ BUILDING AND SAFE7Y I . �cyNo. Company . .. - .. . . . . . .. Cenified copy is hereby furnished. FOR APPLICANT TO FILL IN npoR¢ss ���� �� ��— 7 Certifled copy is filed with the county building Inspet- BUiiDiNG 2 � tion deparime�l. ADDRE55 �� �li � � L` LOCAIRV � . � ' � � . �),` NEAREST ote Applitanl �IN ��I�N U 21P LRO55 57. , BLv1/ K� . CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtoGS. ; nS5e550R , COMPENSATION�NSURANCE SiZE OF i0i NOW oN�Oi MAP BOOK PaGE 7aRGE� .This section need not be complefed if the parmit Is for one USE ZONE kuP ./ �iundred dollars($100)or less.) � , T��T B�OCK LOT NO. NO. II�� Y'� TEt. �7..� - �r 3�' SPECIAL . � - I cenify that in the performance of tha work for which this owNER L�t� ��(7A� -!�.t tlYJ CONoiiionls � d /� DISTRICT GROUP�TYPE FIRE PkOCE55E�BY O permif is issued,I shall not employ any person in any ma ner qDDRE55�GW j�C� /� � �CONST. ZCWE— � V so as to become subject�o the Wo kers'Compensmion ws. ` .. .��. �. .. . . f� � tiir �(C •S9S� � Date - Appli[an - � � ' STATISTICALCWSSifICATION .. . APT. CONDO. Q ARCHITECT OR� TEL. �p�i )1 W kNOTICE TO APPLICANT: If, after maki g ihis Certific e o( ENGWEER �� �NO. �00-� CLA55 NO.��DWEIt.UNI75 Exemption, you shou�d become�subjec� io the Workars' y � �Compensation provisions of the La6or Code,you must forth- . A�DRE55�� � - � � -�- ��� �-� SeweR MnP � ��with comply with such provisions or-this permi� shall ba TE� . z .deamed revoked. � � � . , ._ CONTRACfOR NO. � -BK. `' PG,- �- - VALIDATION - UCENSED CONTRACTORS DECIARATION � UC. � ' I hereby affirm that I am licensed under provisions ot Chap�er9 n�DtiE55 NO. VALUATION� � . ��7 6,2 A . , (commencing with Sanion 7000)of Division 3 of the Business and ' liC. � � � � ' Protessions Coda,ond my Iicense is in full(orce ond effect. CiTv MSS f ,�/ � �$•�• • •2'J ' F � � ' - - � � S�.FT. NO.OF NO.OF CHECK . I ,:[ensa Number Lic.Closs SIZE STORIES FAMILIES ONE � �:• •'2 S Q p 5 ',..fnlfaCtOf �pfe DESGRIGTION OF WORK NEW ❑ •,• •2 5,O D� � ❑I om exempt under Sec, ` � ( , ` B.BP.C.for this reason e - ADD � � � v� I ALTER FINAL,`l �\a,(� , 0 2 2 8 8 4 , � ]" �.J IS�O/� . . .... ..-_ .REPAIR � ._�ATE "l� �� . . . Dafe: X ST�ING BIDG. . . DFMOL..❑ By AL ....(��A�� / � . ` <f/ sgnatu�e APPII�rM ^ OS�C'TE�. / � , . . . OWNER•BUILDER DECLARATION (�yFt.� �, , I hereby affirm�hat 1 am exempt from the Conlractor'a license �y' �C Ju�/� �{ f �� ,-�_ ,!'9 , Low for fhe following reason(Sedion 7031.5, Basiness and � � ADozES �v � f�4' � - � � ; Professions Code):� . . � � euit�wG 9�`r•�y. �� . -�� 9�'7 A � � I,�as owner of the property, or my employees with - � n�oae55 � '���' ��� ' � �- � " � - - � � - wagasasfheirsolecompensotion,willdoiheworkand � #_�.•-• • .,� � ihe strvdure is not intanded or offered for sale(Section ��`��TY �� � �� � , � � � � 7044,Business and Profeisions Code). MOVING TEI. . � • •.��7 Jr" �i� � I,as owner of the property,am exclusively comracting .. c MRACTOR NO. , , . with licensed contractors to cons�ruct the projecl(Sec- , °3�7 5� . �fion 7044,Busineis and Prafessions Code�. ADDRE55 � � � ' REQUIRE� TOTAL$ETBAIX iROM Ex�s,. 0 3 0 b�—8 4 CONSTRUC�ION LENDING AGENCY � SE7 BACK YAR� HWY PROP.UNE WIDTH ' � I hereby affirm)hat there is a conatrutlion lending agency for . FRONT - - � � � ��� �- � - � � � -� � �� - �� - - � fhe pe�formance of the work for which this permit Is issued � V.t.�� - ' _ � � 75ec.3097.Civ.C.).. . . . . , . , . '. .�. .�'.� �.SIPE�-._�.. . . � � . " . _ . _ .... . . . . . . . .. .. . -._. . .'. .- :.''...'. ,:.�- ..� �'.-� . . . . . ..F.l. '. � . � Lender's Name . . �.. � . . ' . . .. . . � . . , . . .. . 8 . �. . . . . � iK). . . _ � .. _ . ....'. - . . .. . . . Lender's Address � P-G cee E J�• � Pe.m�i Fee �.�li-a�.� � , � I mrfify that I hava reed fhis applicafion and stata fhat ihe � � � � � � isaua�ce Fea� ��� '�O " ' � a6ove informotion is cortect.I agree b mmply with all County Inves�igar�on Fee . _. � . . �ordinances and$tote laws relafing fo boilding construction, � - ioial Fae '�i• 7.� and heraby authorize representotives of ihis Counry to enter � upon the obove•meniiona_ properry for inspec/flon purposes..� � - � �� - � --� � � - � -� ' , -� ^ � �� �/ b.��J��� SEE REVERSE FOR E%PUNATORY IANGUAGE _ ,_ ,_ . .,_, , _. . . . Signalure of Appiimi t or AyeM'� . Dale . . � . . ' ..�t �' . r ... �/� � . . • '. � . ;PLAN570 AP?LICANT � �� ; INSPECTOR'S HOTES ' � . � -OR'PIFI•DUII.DCF DECI.ARATION �. .-�I hero6y a f rm�tl�et I am cxempt 4rom�tho,Coniroclor's � ' " � "� ' - - - � � ' � � � � -� ��� �� License LaW for�the�followin , ason � Sec 7031 5 I To: _, Rofumad. .. .. .. . . . � fe .�( ��� • ) � � Approv�d GarirsrssanrlPrnfessrnr:sCodc:Ar.}ertyartounly�u•bitb Ko.- -----Dcio �-�-`�- No.., .. ..�ato'. , . . . . . . _ . : �.-��. � .:� . . q pr � j� _ ... .. . _._..---_. _ .. . ... . �- . .. , --re uErrr a r�.;�to rnu:trucq nJtcr,in: rorc,dcmofisL, - or ref�air mey strr.rfr�re,f�rior Jo iG<isviance,a(so regurres � ��. _• .:_.__ . _ .. .__._...__ . ' _ ___ . __ __ . ._. '. ____.'_' _. '_ '_'"'. ._.. _ _.. _ .. _ . .. _ _ � ' '- .1�� 7. . �.\ � � � . ��rhe applkru:a Jor such nermit to frla a si�qnrd statement ' , ' �.. � '. �' ' . . " �. ._ _....._._._...-.__�.�__. . � !!at Gc is Jrccr.sedpvrsuant to d�r'prorisinns of t5c Con- . ...-----�-� --'-�� �, -��- • �---- - -�-�- . �,..� �--'-��-- - -- � , � . tractor'sLiccrtscl.n�n(CLa�trr9J(co»mrcncin,qu�ilfi5rr- ' � �l,i., (��.�� .'�li','.-�•,�'\ .�. __ tina-7�O�J<f Die�ision 3 u tl e Dusieess and Professiorsr �. 1 . � �-�� � _ � CodcJnrtloth.rse�•enipttlemjroivanrdtLebasisfortbe { .....,. ., �' . . ;': � .,• . �� ' aUegcd crrn�rtinri.'Axv':�infutinx of Scction 7031.5 by , ', `'�. �r: Roqvind Dct�R�celrod - � � ' .. a yafJ! an7Jo���prsrmisabjccis�tficapplrcdnito 'irif ---Approvela '-- -- --�,�or A rovod, .. .__._ . �. ... . _ ./ .-.- ._. �-. � pr allti f not r.iorr t/c�r fra e hrindred do!lars'(SS00I•J+ . . - • � Yee No. .... PP �..\,J`....��,� i'�,` 1..` �'_J \�.'.-'���. �.� . z,. ���r I,rs owner-c4iha rc I � __ _ , ,�_ p per y,.or my employees with � Waler Certi(icate � � � � r � � ,, ._... . ..�..�•• +' 1��•�l(` -�':,1 1� 3--�\ . � ' . -�t e trutlure is not inten2ed °tioni'wlll do the work.:and . , ) " „ es os ihe r so e compe�eroifered for sale(Sec.70a4) Hcalth�Depanmenf �._. �.__ �.._____ - �`�_- . t... y ' ' � \ .,._ Uusinrss,.^ndFrof s.}inrts�Cndr:TlcConlractoriLrcrnsc ' , � �.. ,.� � - ..• . .;,. � ."�' ��"'�•'� � .-- - _'I,au:res nn cp ly tA-cn our.c>nf firo crtY u•Ga builds ��- FlreDeparlment ' `.. . ��... ��� .� ` ✓� t�' �.,,,:���. . . . � �� i-proi�tsfle� y,ar:3uF�o�cn¢sx�iclhc�ork'bimse(lor ;; . . '-• '� .� . ... . ..�� � . ..�,� .� ,. � � . - . ' -. -...... . ..- � ' , t!rm gG Gi.r o:ro:-rn�/�fn_y rrs, frarrdrd Ibat�suell�inr- .... � ... � __ .r (� nent.c ¢rc ttnt iiit ir,l J o ifrred for.sal.';�If� .. . Gradin9 �. �-.: ... ._-____ . _ _._ . .. _._ __. ... . ._... ._. .. . , . . . .. . , � .. � b aei�cr,tl�eb•nldin,Cor ,�prorr�r�ui��s'soJJu•ith��one . _ _ . . -... , � � wbu!d� ri(1 bcac-tGc '. Geological �� � -�------." .. . 5�car aJ.mnejf<an� 1F o.� ._ . � ' � �- � , h�<rdei:rjpr i v��t7�ct! � �:l r.nt/ d nr�;inrproref�r .,.\:t i . .. ,. ,. - , ;�„',:�tLeJ�u�/+osr.of cl f�,.- ��. :,. ,� �_ ...� i � Pedeslrian Prote:tion � ��'+1, � ♦ . - ' '�. � ' '� � ' ' (FericeJ(CanoPY).,.: ' . �\l�� � = �L I�as o of Ihc prop.1y,am cxdosively conlrac- . f, � - - . , t�ng w ih lic�ns,d mntrcUors ro construU the projecf(Se� .,r .• i ., .. '.� � � � ... � . . _ .... . . � '__J041J1�::tixr?� l.PioJtss�ons Code;�'bcContrach�. i $peciol Ins�ettoN � �-��-` - �- " ' ,., /,rccasr I.au�d nnt crhly tn cn ou•rtcr<f/�roperty ; I �Conc)(Masonry)q(Welding) . � � . , ��. .� - ' � __haiTrlr n-i�r�;orc.thrrr��n,arsd irJ�o rur.fra�•ts fnns..... . _'r. . ' _ - ... ._ _. _ . _ _._ __. Lot Ora ncge�.:�) � �� . . . � � \�:\'��\l�:��'+.�J , ��'1-�:..\�7'.\.••.�.•1. . J�mject.i u�itl a mn!rartnr(s/_li:ensrJ�a-rs:ean( fo`ll c .. . . . -Cnrr:r¢ctnrk 1,::�r:sc'Ld.rJ.._-� . Parking � .. . .. ._.�__ ._.-.'__., i ... ,,"_ _ _____... .__ '.____- .._.��._:... . _' . _.___�__16m exempi unde Src..�-�- ... ^�-6.LP.C.ior this �. . . . , _ _ ' . _ _ __._ _ . _'_ . .____..__ , „ ;. .. .__ . .._ .. .,_ . __. _ _. . .. reason � � --.- .- �-.._. .� .._.•-� ��s\2C• �\�,::��...-.��".�\���-� ;v \�,t�iii� �� � � ' .. . _ _.:. . .. , _.._. _. __ � .,:_- _ ... � ` Date O.vner , .. , _ - , ,i��� ��.ti7:\�.�l.l-, \�:�..\,� `��^�.� _ _ .� . . rtr l -,. .��.i .. � _ � )�-.. .� I�.�1• . I ; Y:pprovclz Dat� Inspedor'�Sfgneiui� , , . . . . .. . . . . . .- . . - 415P:CT0.^.'S NOTES ,. � � � __ _ . r:. , . ,_� ' location-. . • ._._.' . ___ _. .. ___. . __. _. .. ._ _��. - r ., . i . .. . ..-.-. .. ... . . (Sefback E Yards)� ' � Foundorions" ` � � .. .. �. .. � . � - . . . ..� - .�_ , � Slab _ .. . .. , - , ..:i i , . � . _. . . . .. , __.. . - --- _ -.- . . . . . . ., � - -�..�.i ��,.� . . �, . ... . . -� .� ,. i . : ..� .. .. Framc . - . ,.'. � _. � , . ..�� ,,.. . , �_.-. ,-'-.- -.. .� ._ _.. .- -'--- -- -- - � r -.,..... . ,. � ...., ..,,.,... _...�, :,..,.:., .., i Enerpylnsulalion � - ��. ' i � L- :: ;�....... ....:..�I� .. ��� .r . I � �,: , ,. ..,-:, ,: ..___.._.__ . .._ _ ._—__.. _. .. . '._,..__.._ . _. i La�h/Drywall- . .� � ; �' ' . ' '. INerior . .,, .. . . . �'. . ..,_-.. . .__________._'.___.__ ____-, ' ;'._�,.�... �.. Lath-Exterior `-.�' .,� �; .,. . . .a,. .: ... � - ....� .. . - House Number- . . �. '..' ... . i .. . ,. ..,,,.. ,.,��::..... . .. . . .�., . ,. , . . ;, Correct&Pos�ed _ ..____._._.._ _ _ .__ .._._ _ __.___.. _._._._ ._'_'. . . . x .,,.. _ ,..n , .. ,, Final- _. .., i : .. , . .... , . . Enter on Fronl � � ' � � � �� � �� _'t,.1 . .___, . ''i•, ' .