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HomeMy WebLinkAbout1283A 1284A WORKERS'COMPENSATION DECLAR'ATION � � "���': a.."cea �- �� � "�` a �r -''"+'�.�' ' � . . ., .�,.., ;. ., ,�.. _._ .y� w /�I� __ Y I ieby af fhat.l have a cerLficafe of.consenf,to.sel � �. ���y���r A��o� �( 7 �g l�l�G PER�IIIT � � , sure,or a r imte of Workers Compensahon Insur6n , � i \rl�\ ,_,,_,nry,p__,�„�,�����,. _ _ ,, or u certif �op ihereof(Sec:3$Ob�`Cab.C.] � ` . � � � � � COUNTY OF LQS ANGElES , �, __ _ , ,BUILDING AND 5I4FE � � � i � TY Policy �. � Company _ -.. . . � - .. . . � . .,,..� .,.......�_.-. .__,,.... .,. .. , ...., . . _ , ,_. ..... .. ,�_. .. . � n Ce tifi co y i hereby furrrished. ` Fpl2'APPCICfXNT TO FfLC IKl� � " "�' ADDREsS (�! " �✓SJ � Cer''� d copy s filed witk ihe tounty 6 lc�ng inspec- �" BUI�DING�,�7 �- -� � � �����- ` ���� ���� � �_tion�depdrt M. ' - .. , . . . . n�DRESS�L�✓'c%.�;i �`'J ` L GL ° . . . � �. .� .�„.'-..- __:.;,... ._...... . .. . . . ._ . . _.. ._ _...._. � _ te ' � � � � APplicont �''.. :�.. � CITY�ti K.J Y'7.' 'r � ZIP LOCAIITY .... ,�..�` ERT7FICATE OFEXEMPTION PROM'1NORKERS'���''�' .... ��� .'.... �. . . ... NO.OF�et��s. .. '�'. NEaeESi ,.:_;. . ,,, ._._...... . _.. ._. � "'' � � COMPENSATION INSURANCE' �' "-�� � ' �� SIZE OF LO7 NOW ON LOT Cg055 5T .,, , � (7his seciian need nof be cOmpleted if fhe�permit is for'one - ����� � -- � - ?`��� �.. - -'� ��� �� . .. .. _ ..... ..,...._ ._.... h�ndred dollqrs($100)or less.) . � TRACi- - � eLOCK . LO7 NO MAP BOOK -"`" ���PAGE PARCEL . . . ... . .-}�. 'TEL.. . � E MAF _ .�. .- , . .,^� OWIVERyY,: .[EL..- I^. ��tJO.TI� .✓�-� .. I cerbfy}hat in the.performance-oT the woik for hich�,�his ' �� ` �-�SPOECIAL' � i � �0- permit is issued,I shall not employ any per6on m any mdnner �_ � _,. _ ' , !." �_ ' � 6�'" � " � '��� �` ✓' � so as.to become subject to the Workers'�ompensahon Lpws. .qooRE55� �� . � . F �� ' �'"" . ONDI710N5 ��� -- o Date ... . APPI cant;�. . ..� . . ... , . Cliv�'vg.`G.. .. Vl .._ ,Z�P. C(C-.�`..,.�. .. . � . ..... . _ .. . _._ .OC ��dTiCETO APPLICAN7: if, atter makmg this Certificate of ARCHiiEci e � ��T�-,,. , .DiSTR�Ci G UP TVPE FIRE . PROC SE6.sv .. o em tion, Ou should become sub'ect to the Workers' �� -- EfJGINEER "Yif� ' �r tNO(� �7�'r.,,�,T�e��� � CONST E {,y ompensati n piovisions of ihe.La6odCode,you must forth � qpDRES�. � r �� .�✓"C� 'b6�'� �� � �-�l �- �-- � y with comply with such pro isions or ihis permtt shqll be . �� -� - -- -�-- '��Tp� -"�" � STATISTICALC IFlC N ' � APT. CONDO:�� �Z deemed,revoked,,._ . , .,�. , '. - ' CONiR.4Croz n10. � LICENSED CONTRACTORS DECLARATION:,;:;. ,�:�; � - � � - �- •�-��- � �-�LIC. � �CtASS NO.����'�EL UNITS� . .._.. .. — I hereby aff�rm that�l,om licensed under provisi.ons of Chapter 9 ADDRE55 NO ' SEWER �P � ��-� � � � � �� (commencing with Section 7000)of D v sion 3 of the�usiness and -. � ��. �� ,� �:"�IC. ��-�� ���� ... .... .... .. . . .... . ._..,... . Profess'qns Code,ond my license�is n,fuli force antl e(fect. CITY CLASS - BK � PG. � --� � � �-" VAUDATIpN . . � � �` ��...` � SQ.Ff. .NO.OF . _ NO..OF. CHECK . . .. '^'. .. �.icenseNumber ,�, � LiaClass � � SIZE��������� - STORIES FAMIUES � �� ���-ONE��� ... . . . .. . . .� a:, � - - . .; V UATION.. 1 . Al . CRn}rador ... , ,'., Dqte • : ,.. OESCRIPTION OF VJORK.. .. . ... -_ NEW ❑ .S�� � a �V>�-. .. . z .3� , .. '' i 2 6 C�.�+L,s �I am exempt�nder Sec. .. ...�" �� �.�.� - ." . .� ."� , .# �`�3 .. ALTER ' . - '.. , �. _ ...,- ...�. . ..., . .�..� . B.&P:C.for ihis reason .. . ...._.... . . . .. ..._. .. REPAIR �. ... S . ° �.. . .. �. ...- . . ' . USEOF .... . . '^_....... - �C �E�O�2:OE��., , . _. .. .. _ Ddfe:__ ' .� . � DEMOL ❑ .... -�' � . ' . .. - - � EXISTING BIDG - - � � Signature� ,• _ ._ .. . . :' . APPLPRIMI .� .�..,, i . . .NO� � . .�.:: FINAL . ,. , ,.. • iU62Q8= . WNER-BUILDER DE ARATION ,. ,..._._ ._._.. . ___._<... .._ . - DATE �� . . wy..... _n i hereby affirm that I�am exempt from ihe Cont octo�s Licerise � �µ��� ��'w" � . .. . ADDRESS� � �- " 'r �I . FINAL �2 C� U ES � ...N. Law for the following reason(Seciion 7031.5 Busmess and . �� _ _, � .. Professibns tode):�. , _._.. ....:._ ,.,..�.,:,..,�.,.... _�.�,.:.:_ PRE . . .. ... ... . . . ... .:.. gY .'�� . . �� 2 8 1{� :_. ^ ' ' - . � BUIL�ING ... .. .. . . , .. . .. . /"'"�� I, os owner of ihe properfy or my employees with ADDRESS , „__ _ _ , ,�y.; � t ,�� __#o, m e �e e�_ __ _...,,. _,�q. .,_..e_. .._,.._, ,,,, t,,.. .wagesasiFeirsolecompensation,wil(dotheworkand ' � : .� ' �, - the sirocture is noi intended or offered for sale(Section LOCALITY ...I L 2 C7 O.O O �� - � �� 7044,Businessand Professwns Code). -"� "`" MOVING - -��" , .��TEL -� ' ' ���� ` ': ,,. �` . . _.r_w. ,.,� . '. __ I,as owner of fhe ro erf am ezclusivel coMracfin CONTRAC70R NO . . ; :.�y .,w�. , -. � P P. Y, Y .9 __.. . .....-. ._... .. . ;�... �.. . _ .. .. ., . . .. . .°.�I.,��OO.L�Q �� . . with licensed-contractors ro construct ihe projecf(Sec- qoDRe55� � . fion 7044,Business and Professions Code) � .�RE�UIRED � �.-TOTAL SETBACK F . . 1 . - . '' ' � ..I 2�2-�b � � �� - ��CONSTRUC710N��LENDINGAGEIJC�Y ��� � SETBACK �ARD'� HWY� PROP.LINE -� WfOTH � I hereby affirm ihot there is p construction lending agency for- FRONT - :•� ' � � ������ -the performance of the work for which ihis permir is�issued, � ��P:L �-- � �-��� - �� � ' �� �� �'` ��'- � � ." � -�."�� � (Sec.3097,Civ.C.). - SI�E � ":. .�`� �� �..�. .r 1�-� :�.� . m ..... . . . .:._. ...._ ..,... P.L.... .__. _...... .....,. . .... ._. .. .._. � Lender's Name . - . . . .. ..... .. . .. ." lpMq Ref.# ' - . . ", o' _:... s - Pe �tFee. . � .. ......_.,__� , .. = Lender's Address....- .... ... .. . . P.C.Fee�B . . .' .�.J ... ,.. .. . > �r� � f certify that 1 have read this applicahon�ond state ihat the -�---� ���--.-.-. � ..��� IssuancePee� �� LDMA P/C�f� LJLY- � ��- � � ¢ above information is correci I agree ro comply wifh all Coun�y Investigaian Fee , �'^�"'�� ' LLqrdno�ceg and Sipte,laws.relati q to..building[onsirutfion.� - ._. . . ._...._. ....... .Toral Fee- (,.1r �LDMA Perm.��N �. . .- ..-- -.....-..,_.. .... � and herehy authorize representatrves of ihis County to enter .. , , . , _ . . _ � upo e above- tioned �roperfy for in;pecfion purposes "_1-.��'+f�" ��� � ,y��` � . � + /.Q j ;_, , j ._,. ,..._. � . _.... .... ...' . . ... P a 'lJ` 9 �f �°-/.I "Y 1(' SEE REVERSE FOR EXPLANATORV LANGUAGE _ � _ ' � '�'� Signa�ure of Ap li nr ar Agent . � . ....Date ... .. ..._.. ..'.�'.' ":..... . . ::._ . ,-...::. ..:;..._�. ._ _ .,:_,._,�..,,.. � .. ,..., -...__�_..�--.. .»;..,_. _.._,,_... C�i p_. . . .. . ,... . .-.,..._._.. .. ._..... . . � .. .. . . ._ ... . .. . . PLANS TO APPLICANT � INSPECTOR'S NOTES ' � ..:.O�VNER-BUILVER DECLARATION ����- . ,z I hereby aff rm ihat�f am exempf from i6e�Contractor's � � . . . . .. _., .:; . . . . ... � , .. ...� . � � '•-"�`�- ��- "'�L ce se Law for ihe��follo �ri�- reason ��5ec. 703�T.5 To:. . � RetVrned . " r .. . :.: . . .ss � . '.... .,, - : �. g .,:. �. .� � � Approved "Bursness'axid 2�ojessioxs Gode:Any cety�or�eoarity wl{ic No_ DaTe No.'� �. Date -� � . � . ,„., . - � .. � reguires a�ernzit to cottstrucL,alter,imfmone,demolish, . � � ..- �� �� -- � - :���� -� - .or repair.any rtnacture,prior to itr issuanre,¢Lm requdres � � - � . � ��� '� tbe a¢plicand for such pernaf6 to fide a�sfgned statement �� �:���� .� � -"� ' � ..-.-- �� _.tGat he u dicensed pursuant to the prov�s�ons of the Con- . � � ' �� � aractor s License C,aw�%Cbapter 9J(com»Cencixg wiah$ec- � � � �����������- ---� ' � tlon 7000J of Divisinn 3 uf the Busiriess and Profess(ons � . , . � : ' " " CodeJ nr that be u exempt tberefrom amdtfie basis for tbe _. __ _ - ._ ._.. __._. . .-_ _. '» � g ¢,;.emptaqn..Any aiolmtiox of Sect�o� _ - � � � � a[le ed n 7031 S by .. - Required Date Reeeived-�:;:- .. . .. . -. �:--- -�--- � .....--',: . -�"r � arzy applicant for k�permit subjecLd the appldcant to¢cie�il �� Approvcls -��-���� or Approved- ,. ""'"..,._ , ,. , _;;. ��r pesalEy of not naare,tban jive.l�undred.dollrsrs/3500J.J: *' �.Yes No r . , � _ . . ��.� � �� ��� ��--" ' -� - ��' ] I,as owner of fhe property,or'my employees wiYFi � . Wpter Cernficate � � - � - - wages os 1he r sole compensalionr will do the work,and ; "�� �����" � "'�� -� - � - � ���� �'��ihe struct,ure,s ot ntended o of#ered'for sale($ec�7D44) Heplih Deparim.ent_ . � ' � '. �:,�.. � � . .__. . _... __....__.__....„. ...:,.. :�v..r�; .„-$usiness�eml Professioxs Code:Tbe Coxtraitor's Licesise � � I.aw does ao[apply to an oumer of properry�wGo�builds . � Eire._Depariment .___ . �� � � � - - -� �- � � -.--��- - .��--�� --�-e or imprnr.�es tbereon,and wHo does ruc!work bimse�or - - �-'-�"�� � '�� '>_� thrnugh hfs oum emp[ny¢es,prnt�ided that s cb�im- � , Grading . "��� ' - „ - � � � � � �� � �� �- -��� '�-•;provemenls are not intended or offer,ed fox sa1e.�'�'� �-� ' - " . - ' - � � -,�,.,��;� >,:�however,tbebuildingorimprovementissoldwitfiin�o> ... �� �-" ""� � "2¢f^6 rom letiom, 1be ou�rter-bueld'er will have tHe _ Gealogiml."_,.. . . . . ..-. . _ . _ ��.-� ..�.,Y .f p � '� '� ';.�. burden of prav¢ng th¢L he dird not build or i�obe for � (edesfr,(n ProPY'tion -. . .... .:..��' _ ..�: . ..._. .._. , .-.- . .--. .. !,"�.'��g th(ce sedreotn�a corPto'con�st uctcihe p ly contrac- fencel Cano � � ..� . � .. .. ... .. , �olect(S�ec. " �� �-- `'�'� '�-"���- - �--- �-�-� -�-�� 704d1��us7ness�krid�Pr fessions Code:�The Cnntra'ctnr's . Special Inspection �� '�� -� � � (Conc.)(Mosonry)(Welding) � ` �����- � � � . . . �-�- -� � �� _ I.:cexseLau•doesnatapplytoanaumerofpropertywbn `"�" �� � �huilds�or�improves Ehereon,�arzd wbo Yu�iYr¢cU�for such '�s Lof�rainage� � �� - � _,._-- --�� , ,-, ��� - Qrojects wftb a contr�acznr(sJ licensed yursuattL do Lhe •-:1 ' . �.. .... .. .. .� �Contr¢ctor's License Lm¢t/.. .... . FParking :: : `..�. . .. . ...:,....._�..:__._�. _.._......_. __._ , ti _.__. -__._. _._._._ ._.. -._' . �. :' : � n !� /}��// �� .. . .. . . ... .... . C I am e empt � � Sec ,B.$P.C.for Ihis ���,� ;-�^ � - qs^7 �,���,. �_. l. .-_._reason.......__. .__.......___._._._. .:_:r._ . . ..:. . . �. L .... ._.. �` �-�^ _ . �» . . . . . . . ......... _..__. _..... .. `�/ .q�,;..'. �` .._ . ,..,; ..... .._... _... .. /.^.' �✓�"�./�w . ""O ,�� � .!/��_ . . :. __ .. .. Dafe � Owner. . . � .. .._._ , _....... .., . .....�._._ .. ..._': ��.�it � :,,i! . _ . _., . ..• � '. .,Js*INSPECTOR'S NOTES � Approvals..: Date Inspec}or's Signafure� - � � � - Locofion— � - � \ (Sefback 8 Yards).. . .. .. . . . .. -�. ' -�. ��. __. ... ... ... .. ���_ ,...� . � ,.. ._:�f. .. .... �-.� , :...�^"„a � �� : :_.. .�.�,...>< v:.�.�.:,,. � foundations �'- � � � _ ....._ . . . .. .. ... .,,. :.t: - . . ._. . :,.. .,�__ . � Slab ��j �. . . � ..._. . , ,�. .. _ ; � Frame�.. . T"7 . �;: .,�..�,-. �. . .r.-,. ... �_.: :.,. :,�_ � . Gi� �.-.. . ',,.; `_ . .;. ... , _�.�; .:.•;,i . � , i�.. .. ", .F.. „ ; ` .' � .w� . ,�;�c Energy Insulation q� � "��- . .- .-' ..- ,:. ": '�' F .,, . _ U( ._._ .. . . . . ._ .. _.. ,..�. .�, .,. .. , . ,. ,. ,._. .., . _. .. Lath/Drywall— 'n,p,t . .._.. ._.._..... .. . ... . ..... . _. � .. � ... .. .._._ �..._.,. . , . . Interior UhC\ . . .- . ._.. �.. . . ; , ,�. •...� ...: .....,,�. Lmh—Exferior . � ' -� -� " "' ' . . � .. ...... . : - . � Ho�se Number— � � . � � �- '6��: ��� . _.. ..__ . .... _ Correct&Posfed � � . . . .....- . . . .. . . ..��.. .;�.��;'�. � Pinal-- � . ._. ... . .. . .� -,.. . .. � . .. . . ..., ...�. . ..... ...... .. ....:�..,., ..� . : ..- ..�. . ...-:._.: ... „ . .. . . Enter on Froni � . . �. ' ...,�...i.: .�,».;,:», ....:.:. . y.,. .: . _._ . ,. . . ,:�t,..: � -. ... .> . _e.�,. h�.._�,A,. .n.v„ �..a.: .-�. . . � ... � .. �..: _ .,