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HomeMy WebLinkAbout1632A WORKERS' COMPENSAiION DECLARATION I he�-�� affir�n that I have a certificate of consent to self ���L������� F�� ��I`���� p E R�il1i T , ins�re, x a certificate of Workers' Compensation Insurance, or u ca.'ified copy thereol (Sec. 3800, �ob. C.) COUNTY OF'LOS ANGELES BUIIDING AND SAFETY �' Policy No. Ccmpony . Certified copy is nereby furnished; BUIIDING w �t,- P'^•' � '�, ❑ . . ;. : � FOR APPUCANT TO.F_ILLIN--•--___.______ . nppRess - � 1 � � �t ,�, �;_'�.,_, ,��-.'•��`.,` -, � Certified copy is filed with�the county building,mspec� BUI�DiNG ^ �`"< tion deparfinent. , , .. . . ADDRESS l�;�S v��.���� !j K� Dote ' ` Applicant ..� :; ., ,�. `CITY 1�fAr1:�i3--�� /�/�rl � '�! 'J �oCAurY � . ; ziP �5� :,� � .L�-.;.:�"�. .;'^'4� i.a �- CERTIFICATE OF EXE(NPTION FROM'WORKERS' ' `�' ` NO. OF BIDGS , - NEAREST F COMPENSATION INSURANCE ' ` ' � SIZE OF LO7 NOw ON lOT' ���-''' "� CROSS-S7 -?" ��z�'' (This sedion need nor be completed if the'permif is for one` ` �" � � �"t� 1 ASSESSOR' �`� ���� � � '�� y hundred dollors'(5100)or less.) . . . . i „` : ,TRACT BIOCK , LOT_NO... .,4 .�. (H,qP 800K � - � ° /t C �PAGE ,- PARCEL I certify that in�t6e performance of,th'e,wock for whicH this'�i ti , ��WNER ���C � ' ! !tJ �f�`/{„ :N��bC} .�i�J(� U ZONE �P. _ � permif is issued,,l;shall.not employ any persorr' ,any:manner.� , � ,t�, . �+� �' � so as fo become;sub'ed to t rs'C m en ion,LaWs .� ADDRESS 1� �s C��4-U n S''I� �,`:_' � . r,�,��, SPECIAL, , Y a r� CJ"�"` CONDYTIONS '� � .;� �� _�'� ,I. ' • -Q'�!'_'�l�'�t--'"�,y,. CITY J �iY�u��U) ;'3�- } ziR-�, ��j4��S i a.._ - �,- ., : � - � ! U Date �Appli , nt � NOTICE TO APPUCANT: If, after makm this Certificate of ��_" 'ARCHITECTOR ; 'TEl " " � , `' ^ % W 9•� • ENGINEER O W h��� Np . DISTRICT GROUP..TYPE - . FIRE - PROCESSED BY � Exemption, you sho'uld become subject'tb the Workers` --' � � - � '' - � � CONS7. "• � �= Z6t�E ' Compensation provi3ions of tfie Labor'Gocl"e, you"must forth= 'ADDRESS � -�=' �''-� 1t'" � � � .__ :1�;; - �"7- , `^"�;1}, 1 � �-,iE � ' � � with comply with such� provisions or this permit shall be�- �. � �� _ .>'.- , � deemed revoked. . . ....-......_.. . ..' ; .,.... .... .... -,. •...,, .,.,�'S.: i TEL STATISTICAL CLASSIFICATION ^�� .. w `�� � CONTRACTOR U�,V f�l�� ND f,` APT.: CONDO � � LICENSED CONTRACTORS DECI•ARATION : ti • '���•:� �+ uC.,, _ CLASS NO. �` t DWELL. UNITS I hereby affirm that l am licensed underprovisions of Ghapler 9+,�. � .�� •ADDRESS �NO._;� _ (commencing with Sedion 7000)'of Divisron 3,of;the;Busines�and �• ;,� �K. �_ SEWER MAP, - ' Professions Code; and my license.is in ful+.f,orce and effect ;,,..,, CITY � ��q� • � - �j� � C y; ',``'' • . _ . . �. .�.r ❑.t:.a . •�n1 i...;:a �50. Fi�r� NO.Of NO� OF �CHECK ' f � BK. �p�, � ; r ,-VALIDATION License Number • Lic Llass _ , � SIZE .J l� STORIES FAMILIES `!; ;ONE 5- c� ,_ � � .�. , � , ,. , :n.; =; . VALUATION. . ; _ � � �DESCR�PTION OF WORK NEW ` Contractor Dato �.... .. �. ' � _s h-� ��-"+�'� � `�'ADD, �t� � .�•. . ����..�n�n _ n n-il� i- �'�,� , +�►�` . � .. �I am exempt'under Sec. � �J � _ . ,. , i � i � . .�ALTER -� . _ - - 8.8P.C. for.this reason - " -" ' � . . . ._ iREPAIR' _ - `i ' . o - . , : . , . USE OF � . . . . Date: .. . . . . � .,-. ., . . � � � EXISTING BLDG. DEMOL � Signafure _ . . . .. _ , ., AP.PLICANT '• 1 TEL%,-- . _ - ' _ � .. . _. . .. . , PRWT . -FIf�AI - ,WN R- I . . NO. ' O E BU LDER _ DECLARATION ,. �. . ,.., _ . . . , .. . .DATE - _: I hereby affirrri that I am exempt from the Contractor's�License ` � , " '' ' ' - � Law for the following.reason (Section 7031:5,._Business and ADDRESS � , ^ ' Professions Code : _ FINAL • �_ ' � � __. . . ,.. PR N By ._ �.�:'`, .; "� r� �41 BUILDING �� I, as owner of fhe properfy, or-my employees wifh 'ADDRESS ,� y.,,:.., y ,a ;' wages as their sole compensation,will do the work and - i^� ' 1 . the structure is not intenaed'or offered for sale(Section -� � ����I7Y ,_ ' , `�"' , " : ...._..,.. .._._,..,�" . ___' '�_.' '. . ��F ' -• . '""_'' +'_ .,i . � 7044, Business and Professions Code). MOVING rE[. SPECIAL ' � I, as owner of-the property, am exclusively confracfing - --- CON7RACTOR No. INFORMATION " �' � �- . �%�,�.�' with licensed contrac;ors to construct the project (Sec- ADDRE55 ,.�, � ON REVERSE tion 7044, �usiness and Professions Code). ' SIDE ` �', ' "�`�` ` REQUIRED T0T.4L SETBA K CONSTRUCTION IENDING AGENCY SE1 BACK YARD HWY _pROP. LINE WIDTH I hereby aYfirm that there is a construction lending agenty for FRONT the performance of the work for which this permit is issued p.�. ' (Sec. 3097, Civ. C.). SIDE P.L.� Lender's Name ' �;"� �,�^� LDMA Ref. M Lender'S AddrBss P.C. Fee E Permit Fee , ;+,'i,�_.:��-.l" I certify that I have read this application and state that the � �' -`-.�^ � Issuonce Fea �'�ti� . ,�� IDMA P/C# above information is correct. I agree to comply with all County Investigation Fee �� , ordinances and State laws relating to building construction, �-�: . '; "� �'� " '�" �l Y . Total Fee � � �.-i LDMA Parm. il and hereby authorize r,epresentatives of this County to enter � '� =. . j the above-me ti ned property for inspection purposes '' /�' - J ��� � ' -�'.- .��., -� ` r i.l.--r-,,, ,1? �;Ij.R..,,� f ' r�`rS� SEE REVERSE FOR EXPLANATORY LANGUAGE �' s (Z.. , , � Signature of Applicd"nt or Agent Dote . __ . �- y�-�i . f ' � �i°�4`' ��t�__ .: _ � �'���+ �. R.�'�i . ' " • �r ����� �'tI:�N � �; �h�� �'� . � . .�.' . _POST THIS FC,�.� I�T JOB� 51TE � Qepart�ie�n'tfof�Public 1�'orks �'�` �'`:1 �, . Y� ; {3�ilding!�a,nd�'Safety Division ` , � ' 201 Easf����fi�'a Avenue , � � . San.pima�;�Ca�917,33 � - (714) 599-].�7$f� or�18 339-�281 . INSPECTIf31� RECORD ' PERMITS WILL BE.VOIDED IF WORK IS � ;�O`P�P�E,D�FOR 180 C90 iEb Tgl V�E DA� . � � � BLDG. PERMIT NO. A7E GROUP � � , l { a,.�.S C''� �� � ADDRESS �����+� , . OWNER . � NOTE:Do Not Cover Walls Uniil Frame, lnsulation, Electrical, "�ch8rfic�l;a+v�f Plumbing Have Been Signed. - BUILDING DATE INSAECTOR'SSIGNATURE � FOUNDATION: LOCAT�ON � FORMS,SETBACK �" I SLAB � ��� � ' Pour No Conaete Until Above Has Been Signed �FRAME:�FlRE STOPS. � . � �. BRAC�NG.BOL75 � �. ' ..� INSULATION� ,�- . .. ' l�4TH. I NT. � � �RVWALL ' , L.ATH. EXT. � ELECTRICAL oATE INSPECTOR'SSIGNATURE � UNDER SLAB WOFt1S ROVGN CONDUIY �� / ROUGM WIR�NG " / .� . �-9"��� TEMP. POWER I i MECHANICAL DATE INSPECTOR551GNATURE FAU A.C. REF BO�LER OTHER � . COMHUST.&QRCULAT. , �''� � �—^ . AIR,OUCTS,VENTS,ETC � � I.00ATION,CLEARANCE, 1 -- � ACCE55 � /`"���- �� PLUMBING OATE INSPECTOR�SSIGNATURE � - ' ' � � UNDER SLAB WORK '�Z y � ROU6H PLUMBING � ROUGH GAS RPING � ' � _ HOUSE SEWER _ SEPTIC TANK.SEEP PIT(5) AND/OR DRAINFlELD � FINAL APPROVALS OATE INSPECTOH'S516NATURE ELECTRICAL GAS PIRNG MECHANICAL � . ,, - . � pLUMBING FlXTURES � BUILDING , , on nnir nni.i i /o� /rr onnl �l�(� i��:;`��