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HomeMy WebLinkAbout1492A � WORKERS'COMPENSATION DE�CLARATION . � �� - � � �' � insurebor�ofcerifcarteofWokes'�Compens6�onlnsumn�" - APPLICATION �':.FOR BUILDING PERMIT � � , or a certified copy thereof�Sec.3800,ta6.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY Policy No. Company � � � BUILDiNG � Certified copy is here6y furnished. FOR APPLICANT TO Flll IN ADDRESS 1S�' �.�\Q �'Q.S��Y� \ �� Cer�ified copy is tiled with 1he�covMy building Inspea " BWIDiNG � Ilon-deportmeN.� ADORE55 L tGt '� Date �APPlieam C�tY � d� Ziv tOG4lrtv i i� ` CERTIFICATE OF EXEMPT�ON FROM WORKERS' - � NO.OF Bl�GS. NE4RESi _ COMPENSATION INSURANCE . - S¢E OF lOT NOW ON lOT ' �Rp$5$T. +QtV� �� - (This aeelion need not ba completed if the permif ie for ane TRACf BIOCK LOT NO. �� - �ESSOR - � hundred dollors(SI00)or lass.� MAF BOOK � PnGE PARCEL f TEL. /��1, USE ZONE P 1 tertify thot�in the performance of ihe work for which-1hi5 ��ER � � lC{ C �� NO ( < NO. � permit is isaued,I sholl no1 employ any person in an manner . qDDRE55 SPECIAI . . . . . so as ta 6emme sa6jecl to the Worker' e o Laws. � { CONDITIONS � ���j�y��7 ` U Daie��Applitan� . � , ... . CiTY Zia � � . . . . . . a ARCHITEC7 OR EL. NOTICE TO APPIICANT: If,�ufier moking this C fifiGOfe Of ENGINEER S CC��! NO � �ISTRICr GROUP TYPE FIRE VROCESSED BV O Exemption, yo� should become�subject ro 1 e Workers' �O-1������,� Z_�NE- V Compenaation proviaions of tha Labor Code,you must forth- qDDRESS 1[ �� ,. '�� � `� �� �� W wlih comply with such provisions or Ihis permit shall 6e - 0.' deemed revoked. - . E�� STATISTICAL CU1551FICATION . AVT. CONDO. (A � � GOMRACfOR O. i1cY Z LICENSED CONTRACTORS OECLARATION-. -. 1"" ii�, ` QASS NO. �� � DWELL UNIiS - '� I heraby affirm that I am licensed under provisions of Chap�er 9 ADDRESS � Gu NO. � ��R�P (commencing with Secrion 7000J of Division 3 of the Business and . ,_ _ ^ ^ ��� Profeisions Code,and my license Is In full forte and effett. ��7y ` y CWSS BK � � �YALIOATION � n, 50.FT. ^� NO.OF NO.OF CHECK License Number =•�u•'��� Lic.Class� � . 512E �/�� S10RIE5 � FAMIUES � � ONE � � ❑ VALUATION � Contracfor SUbcq L1,i�pp�e�� � � DESCRIPTION OF RK - NEW ' �OO ADD � S ' �I am exemp�under Sec. � — � B - r � ALTER ❑ . B.BP.C.for Ihis reason � REPAIR s � � - Date- USE OF � EXISTING eLOC. DEI`rta � � Signature . . . . . "- APPIIfANT TEL FINAI ''') � OWNER•BUILDER DECIARATION �vRiNi NO. .DATE �C.� .. .__ . . I hereby afiirm that I am exampt irom Ihe Cantmcbr's Licensa � � ' � � . � - Law for ihe following�eason-(Setlion 7031.5,Business cnd ADORESS FINAL � � � � � Professions Code): � �- ��� �- � � !y �---�� ❑ BWlOING I, os owner of Ihe property, or my employee�wifh AOORESS wages as their sole compansofion,wiil do fhe work ond ����ry - � � �� � �1 4 9.2�A the slroctura is nat in�ended ar offerad for sale�Sect�on 7044,Businau ond Professions CodeJ. - - MOVING � � � � TEI. �� � �� � � � I,OS owner of ihe properly,om ex[lusively conlracting CONTRACTOR NO. ' �� � � � � � with licensed contracton to mnstruct the project(Sec- qoDeESS � �++3 b 7 5 � tion 7044,Business and Professions Code). � .. . . . � . REQUIRED TOTAL SETBA K .3 6 7 5 c.i ' ' � CONSTRUCTION LENDING AGENCY ' �T gq�K YARD HWY PpOP.IINE WIDTN " � • • _ I hereby a(firm tha�Ihere is o conslruction lending agency for iRONi � . the performvnce of Ihe work for which�his permit is issued D.l. � ' . �(�.O(,_a s . (Sec.3097,Civ.C.). SIDE P.L Lender's Name � � � :\ LDMA Rei.M tender'a Address P.G Fee E - PermH Fee d� - � 1 mnify that I have reod this opplicmion and smie Ihar ihe . .. . isa�onca fee d , �OMA P/C N t . obove information is correct.I agrea b mmply whh all Covnty Invest�gmlon Fee $ ordinances and S�a�e laws elming to 6uilding construttion, ioioi iee � tDhW ve.m.k - � R and hereby auth iza rap se otives of ihii Cou�ty to eMar -' � upon ihe - e io pro erty for' spection purpos�e7s. ; ,�c � �^�"(J� � SEE REYERSE fOR E%PLANATORY LANGUAGE � Si nai�re of App can� Agem Do�e � � PlANS TO APFLICANT INSPECTOR'S NOTES ..011'NIiK-I1U11.DIiK DHCI.AHA'170N • . ' _ , I herr.by oltvm Ihal I am ezempi f�om Ihe Controclo�'s . � To: � "� �.� ..,.. � � Re�urned .. �'� ��' �APP�o '- � � - ,. �.. ` �, '.� , � ' '. . . „"�l cense,La�N�io _;the follo �ng�roason� fSec 7071�.5� . ved � !3«vnrs.v and 1 r>frscionl Lru4:AnV eii.�nriouatv ecLicl No. Dote � � No.� -�-'Oate'." . ,. • .. ' � . � - .. rcyurrrs o prrmit 1n rnrtstrvrt.�ltrr,imprnre.d��o�olish, • . ._ � I�f/c�+rJiYunYslrLCtrllt'.rril�Il�+[tsJc�'IIJIIC['.1l�Fl��f)li%r(•S '' ... - . ; � . �. - � ... . . d��•a/i/di:m�f frir sucG frorniit 1n/i!r a si,��nrJ atutemeri� • ,. ..' :. ' :^ �. " ��,, : : . �� ._.. 1� ��J:. ��_Y_-•.,�...1 1� (;�'.• � Ira:Mr'a I.rirns�f.a�r/Clapi�rYl/p������<n��,,,,�u.��rl�Sco-. 1 _ - - _ _ __ . _ _ . : . . . . -.. � . . � lrnn709UJn/Urrisinn3o/tbrUu�inrssanJPrn/eavioni I . ��- � ' , .•,,, :� , . . . : <i..`��, `..\.( )'': 'l _�;, � � ' �..'i�•� : .. __CnJeJ nr that br ic c.xemr!tl enJrnni anJ7Gr Fn�rs�or�Le � .� �-' �� �__ ... . _ �� .� � n!lr,qrd errmf�tinn.Ani riulation rf Se�lion�7(1 .$ht� � ...___'_._. -..____.'_�Ro9uirod :-..=DateReealvad ...�...-�.;-"'�--. .�.�.. .. ....'-" .... .-.-. . . . � un�'QAhli.an!/nrarrrnrilFuhjotts7lr�affliranftnuiie•il . . �... . A avols � . PP� .�Yas No or Approvad� .. . . , � �-�Tenalt4 n/nnl omre�thau�ie�c!�rndrrd Jn!!urs(5500/J: . . .. '... .. _ _. ._ ...._ ' ...'�..__.. _._�__. :... . ' �� � -, . ... . . . ... . ; '.`, . .. ,,.� , .,,';, .i.. ;�5 -..- . L� I,as owner of the prope.'�ty,or'my employees�with . Woier Cert�Hcaie __..._- . . .__. .�.'�� � � 1..�.� ..� .. � ���--�-;: ',.` � ' .. \ ..1•; . . . ; wagr.5 as theh sole compensorion,will do ihe work,and . . �� � s � � �'.the str'vUure is nor imended o�ofFercd for iole(Sec.,704a) . . . � _. ... • . . - . . ... ._. -. � , . . . ' Nealth Depanment --'---- � --'-- ----- �--.�.'_�-... ._ . .-. - . .•., ...... .. , ... -_�..� .. . (3usirirss and Prifessinux Cndc:7G�e Cnutr�c'tr�r's l.icense . `-\':•, �... l.uu�Jncs ndt of�rll`�lo an ne�nrr u/prnperty erl�n huilSc �� �..; ;_; - Fire Oepanmem.. .. - . -- -'- _- --._-. . .. � ••.'` . ni rmf ��i�s h�rc.n,unJ u br does ri cL d�nrk:sr'nrself or � : ( f � �� . � . . .. . . �,� ��-�; -`.t'�...�i ��- �;,. . ..�'tJriu,qh�hi.c nirn�rin%r1�}ces��prr�udeJ:tJ�ut�rucb�irn- . ' Grodmg - ..1i ..'.._. ' . ; : • ':, � �. .�. k, .-.�rot'rrnenls am.�nf intended or uffrred fnr-saka�lJ, , :. 1:'! ��-i �, �1 � �� ' ...., : . .... �;- .. . . " .� • •. '. .l'��"��'_�'•' ���_ � '.�` . �' nu•n�rr.tbebnifJin,qn�imf�mvernrtntissuldtril/rnnnc Geolog tal -. '.� -: ���-�'� ��- - � , . . - ."..�.: � �., . .. . . �1'rur nf cnmpfetinn. !hJ'riu�ner.br�ilder.�ril!bare:the �.. .� .�,.�:. ..�.. :��i �'.'.:.; � ;..�,`: �. �''.. _:'. ._' burdrn n�prnrin�;Ihal l�e d�J nnl builJ nr irnprorr fnr ' -- � !,._- . !bc pur/�'ose r/tufej.::: �� .-. . .. . Pedesrrion Prote<tion � ' � ❑ I.'asowner of Ihe o ert �am eKclusivel mnirac-' (Fencel(ConoPY) .. . . - . "1'.�-. .. . _ .... .._ .i �_'�:.'\ .'. . ' pr P Y. Y '. r ; . .. _:.._--� ..,'....:�, \; ...,...`1 . _.- � ting w��etrnrsseand PrnCeasions�C�e�'I'h�Crmtru�l r's _: .._ __._ ., ..._ . Spec�al Inspection I ---. _ .. .. .�:. . - ... �: . . 70 ) f �Conc.1(MasonrY)(Weld�ngl �. ' �� ...._-. _..- '_ ._ .___. __ .. :`_.__.--: l.irense f,u�ndnes net'aJ�f�!}�tn�n n¢ ar�frrnferty u•Ln �,. .. - .,\ � � �- huilJt nr irnprurrs Iberron,unJ ivl�n-rontrarfs fur sur! . ,. �'. { . . , .___ `projectr�a�itl a rantrurt�ir{aJ licensrd.p�irsaane to�lGe Lo�Droinage . � , � 7,�',. ._'_'_.. . .. ,� _.�_,. ... . . ._ . . , .. . .. . �� � , . -1 ,.'• � Cnnlrnttrir's I.icensr LauJ. �•• . - _. . - .. - � � �, - Po.kinj .� .. . � � ._ .. . . __ . .. __ - __ . _ . _. _ . ,;, , ., i ,, � ,�� -� , ❑ I am exempi undcr Sec. 8.8P.C.for Ihii ,,. , , „ . .. � �f�:' � ,: ... � �. � ..� . - . . . . '� . ____ . ._... _ .. ... ..._'_ . ., . � � � - . , - � ' �reason � .. : ...�.�.. .� .. .. ---._.. .._.__. .. .__. ___. __._._.. � . ' Dafe Owner � APProvals Dote ..-. .InepeNar's Signafure ... � . ' . . .�.. � � - - - . �� � � ' � INSPFCTOR'SNOTES:.�.�. - � .. tocafion- -- . .. . .. . _.. . . . . (Serback 6 Yards) � � � � . . . . (oundailoris i .. . , � . . . . . . . . : ...,,. � . � Slab : �. . „ • � . � - . � , . _ .._.__._.. ....__ . _.... _ . _ -�. �.� ; . .. .. �_. Frame � � V � �/�"`_ � . . .. . . � � .. . . .. � , � � , . . . - EnergY�nsula�ion�. •. .�.�.._ _ _._ . .. .. . ___ , , ... .. . . . _. , .'�. _ ' ,�., . � . � ' Laih;D�rywall-�- . . .... . ._____ _-. _.__ . . . : . . . ..'_'.__ _._-._. . � ._ . -_ . ' . . In�er�or . .. • . .. . . . � Loih-Eaterior . _ . . �: . -. �.. . . . ...• , . ..�. .... .._ . __ . . . , . House Number_ ,� ,� . ..__� ... ._ ._.__.__ _i.._—_._._ . . _.__. _ .._ .__ . , .. , . . Corren 8 Poved . � .�. . � .._ . ... _._. . ..._.__ . . . r, �, , , Fino�- . . __ . . .... . . . ..... . . .. . , Emer on Front � ._ . _ _.. __ . . , "_ " _' . .._ . _ � . . . . . _ . - . . .. . . . . . - -t,= �^ .. � . . � . . . . � , . ����