HomeMy WebLinkAbout1391A WORKERS'COMPENSATION DECLARATION x � . ��
I hereby affirm ihat I hove a cenificete of consent to sel� . �pp`�CATI�N FOR �IJILDING PERMI�T
insure,or o certifim!e of Workers'Comoenstion Insuronce,cr
a cerified copy ihereof j5ec.380q:06.C.� COUNTY OF LO$ANGELES BUILDING AND SAFETY
PolicyNo. Company . . .-... ... . . .. . . : ..,..�,:.,�
� Certified capy�s hereby furnished. FOR APPLICANT TO FILL IN aooeEss -�"--r�"tl ��''�"
^ Certified ccpy�s filed with ihe counry 6�ilding inspec- BU4DING
U tion deparfinent. A�DRE55 LOCA:ITY ,..Cris.,.c .�•a,��- �«-�'
NEAQESi
�ate Applicanf Cirv �� ZIP��2�_� CROSSST. �r�+�-+'�
CERTIFICATE OF EXEMPiION FROM WORKERS' NO.OF B�DGS. n55e550R
COMPENSATION INSURANCE SIZE OF L�t NOW CN LUT MAF BOOK PAGE PARCEL
(This sec+ion need no�he completed if the permit is for one USE ZONE MAP
TRACT BIOCK iOT NO. �., �O. I�-G`� .�`J'L }
hundred dollors($100;!or less.j p TE�, 5PK!AL y.
I cer'ify that�r the pe�forman<e of!he work fe�v�hich ihis OWUER p O. ��� CONDITIONS �
permif�s issued,I shall not employ any perso n any manner DISTRICT GROUP iYPE FIRE PROC ED BV `j
so as to be<ome subj=<t to the Workers'Cr en;afion La �+DDRE55 CONST__.� Z�ONE �
�Q �C? i�'.;j i� ��1, oc�r�.a�,�. �
c rv z'r w-
Date Applicant ARCH'�TEC`�R rE�, STATiSTICAI CLASSIFICATION APt. CONDO. ,j
NOTICE TO'APPLICANT: if, ❑fter king Ihis Certificme af ENGiNEER NO CLASS NQ�DWELL.UNITS �
Exemption, yau should 6ecome subject to fhe Workers'
Ce�npensol�cn provlsio�s oi the Laber Code,yo�m��f forth- qpCRE55 SEWER h1AP �
with mmply wiih such provisions or 'his permii sholl be =E�, VALIDATION
deemed revoked. � CON'RACTUR NO. BK. PG
LICENSED CONTRACTORS DECLARATION UC.
I hereby afflrm ihal I am licensed�nder provisions of Chnpte�9 ADDRESS NO. VAIUATION
(commenuny with Seclion 7000 f Dlvision 3 of ihe Buslness and LIC
Professlons Code,and my license is M full force and effect. C'Tv CLa,55 5 j� f f�
� � SQ.FT NO.OF NU.OF Ct!�CK
License Number Lic Cl�ss SIZE • O� STORIES FAMILIES ONE
�ESCRIPTION OF WORK NEW'
❑ g .
Co n troctor Date ppp
� I am zxempt from!ne licensing requlrements as I am o — iYL I G- �`�C' � P" ���� �'r}�T ' qiTER � FINAL.
licensed orchilec!or a regfstered prefessiona!engineer DATE�j CI ,,��j2
oning in my professionol tapaci7y (Section 7051, R:PA�R � - �,
Business and ProfessiOns Code?. USE OF FINAt''
Ex�.S��In�G B�AG. DEN�OI ❑ B I � i�'7 ?-= .
Li[.or Reg.No. _ Dafe_ APPLICANT iEL, Y`.���1'� __ �� z 9� � Fl
OWNER-9lil!�ER DECLARATI4N � ��R�M1T' N� m + e
I hereby affirm rhat I om exempt from�he Confroctor's Li<ense �`�' ¢ �'�
Law for the following reoson(Sec�ion 7031.5, Business and aC7RE55 �g`�G� ���f ��
Professions Codel: PRE;N � ° � C�.5 r
Bi;I.DI�G ,P .v>'�... �
I, as owner cf rhe a ert . cr m em lo ees wifh opDRE55 s��a" �'_
� wages as their sole compensa!icn,w�li do�he wqrk and � ��'�� � °�6 � C 3 5"
" the siructure is nc�intended cr offered fcr sale(Sec�ir,n LCCAiJTV
70A4,6uslness ond Prcfesslens Codej. •vipVING 7EL. �j,(9~��
� I,os owner cf the properry,am exdusively mnira<ling �ONTRACTOR N� 0 �
wi�h Ilcensed coMradcrs to conslruci:he pwject lSec q�p�E55
tion 7D44,Business ond Professicns Cade;. �
2K,:J:RED yqRp 4WY TO'Al5ET84CK f-ROM^ EXIST
CONSTRUCi ION i'tNDING AG�NCY $ET 3ACK PROP.uNE 'NIDTH
I hereby affirm thal ihere is a construc��an lendina aqency fo+ FR�nr
Me oerformance of�he work ro�mhlch this p?�mit is is=_ued P l � •
(Sec 3097,Gv.C.; 5�D"c
P:L
Lender's Name - �j
' Perr�i�Fee "�'�! �'Z'
F.�.�ee 5
Lender's Address 6
I certiPy thot I have read shis applimticn ono stote fhal the Iss�� ce Fee •+i' �+1
' obove irlormotion is cerrec' �ogree to mmply w:th oll Coumy in�esi,gotion F�e ��
ordlnances and Stare lows relating to building cansiruction, Toml F=e f p.:j. '�-��'? �
ond he-ra6y oo'orize represen'otives of is Counry to ente�
up ;h a6 -mentioned prcperry f - spec+lon purposes.
' /�,�.�+�� SEE REVERSE FOR E%PLANATOR7 LANGUAGE
' Siyronre oi A� i co^I cr Agenf / , �5 .
-rr..-...,*r.�..x,x.. . ..6,+� _ _
}--.�.....M_.,� PS?aY�S Yfl�FPi.3CfcF97�.,.•F•- . m,•�,,,�,.�. .,� ��.�..�.@...g iP�SPECTO�'S PSOTES �m+� O�h'iV'F.Fc-P,UILT7ER DECLRRA7iON
�^��--^^---�-�--�- - - - - ,. . -�-�-----�_-•-------+.� I he�eby affirm 4hat f am exempf from the Cor.Practor's
Io�c ���at�,rese� �R�� ��,,�,,� ! � �e�r � License Law for rhe following reason. (Sec 7Q31.5)
e A sa✓ed �=x r a*"r�.° d;.�".� kG.�... ;;q a
' 1_ �'P%'° � .�.rio:es.caRd.:q(essiansCr�e:eSn�ce£ynr•tocsr.:ywbscfs
�+'+s. � °3n!e��i EL'a� Ca4e r^ requires a�9err.zl:to!onstrucy ed6er,imCro�e,demod'ufi,
.. -� w". ��GrC:e z��aa/
T'-'j"'�"' Z —` -- � p or r�¢aira�y si:recL:ere,�rior to iEs dssazar,te,afso requirea
�^�^,�_ � ����,,.a,.t �„�,,�,.�,..�,,,. tl;e appficant fcr sach per;ndt to fs'la a signed seatement
I f :_� , t:�¢t F.e is Clcert.sed j�ursreana grs tfie provisiofs oj t$e Con-
;,ractor's f scerse.Law;�L'bahfer 9J(rnnzn:encatag widb,Seo-
��-- �i � ' - . . �, . tson 7L'OOf of d7zaiEsir,R 3 of E:'se H:asir,ess and P;o essiorts
�V� ! I -_��-_--I--_-�- I ' � � ` ' � � CodeJ or tl at be ac cxenapt tberefrom und tbe'oass 1os 3&�
.-�-�--,-�- �-l-��-� ' ul:eged e:ernfitsnn.Ar.y vdoladiotz oj Sactaon 7031.$by
.. - . V�����,4��e�i,aa ��� axya Tscant orapermitsu$jectsE.heapplican£foatavll
��as�uaes �i��s��p��;..�� pp r
,q,� �� � �ar f.p�pc��esE ". . - ;%e%'a.iz7�ef r..cS sr.ore t?;an five d�andred dollars($SOOJ.J:
� - ��g�� ^���r,�.' ^.. . �; �] I,as owner of PF.e proparty,or my emplcyees wifh
�V?a±er Cer;if'cat� � � V� wcges as Phe r soie mmpensnfion,will do the work,ana
—�.-.-. _�_^� \ , thz sirucWre is noi intended or offered for scfe(Sec 7044)
�Yecleh Deoar�marrt�� I I � � � - fiwsin�ss andk'r.ofossioxs Co�le:TGe CantrY caor's Licemse
� �.1..�__,___..._..�., ':'.{,e<y,dpes xot dpply trs aas owraer vf D±•�e-ty w7_9i FueTrls
�r_�eporimen5 I � { I "�..- - ��.�_-"`_ ' ,.. •. �� ar.sysanes a3erear,�nd eobo docs stich wcrk hiorrsedf cr
� tfirough fi!s awn ¢r.ipfayees, provided tbat sucG i»�
�din3 � provenzar,s.c ¢re not iatexdaJ or ofjemd for sale. Ff,
��,���_,r__y._.,______� bowever,Ehe build4mg or irr.jirooem.ent is sold wit5ix one
�Gao!oq�ml � � ,year nf sompletzon, ETi¢ nsvner-drnei?der w111 baoe tk�e
'...�..__..��_�...��I � 4 burdeaa��r�ovi�g Pl�at he did r�od buiEd o-:rn[rove for
�eedestrian Prot�ceion � J�-� .' ��- I . tbc nrer�osa of sa?�J.
'(i P`"`e);`cnopy; j � I I_ I,6s owne;of fhe proper;y,am exdwively conirac-
� � lirtg with licensed contracfors fo consPruct the project(Sec.
�Spaciol�nspet?ior, � � i i ;,, .� 7044j 91sf«ess¢::d Prqjes;sars Cc�:Tfie Cantrectnr's
i(Conc. Masonr•1 �,.ie.idin 1� . LiceKse�?,a;<�doer voL a,(n7y to or owr.er�r ror erC�,who
)�� l.�� 9. I � ! /'. . f�'
'_—�_.�I.-_.��_'----1 . �� b�itd.v cr in:,�;aves tlyereon,anc!e�he<n.nt«rctsforsacl�
�Lot Drainege � -f -'-'-' f rojecAc u�it.b¢contr¢stor(,f liter.aed�sursttar.s to Ebe
�---..• Contractcr's Licenss Law/.
dParking j 1 ��V-��� -_—_ "' 1 om exemoi under 5ec, _,B.&P.C.for ihis
I
�' —.� _ —� _ - _ . .. . .. .. reason _. .
� J__-_.
� i � `— Date Own¢r
F : :. �Q.,_.,��.a-.a,,.��.�...-a..�.�.R.....m...=.�.� �
� ,�ih�.Cb".d�5 � eC? � �'aiS�.,i-^2:^YR:!'rM=`$Vs@ I_� ne.�a..�.-,.=o.ms,�.�..�...�...
�- � — - �—'?_= --- �
6NSPECTOR'S NQ7ES
;Location--- �I _' , . .e...."^"'°"'""."""�
i ISetback&Yards)� f_ � � i�• � �.----� �
;��5t __!-�_�. 1 ..�.r_...�_-
�roundofiors :�Cl\� ` �11 ��'� �l�" � . � . .
Sla[-----_-�1r����- -�,��.-._ —_-�— . _ .
,�� ��l,,af a� �,��,� +
- --- � r-i:._��::_.—___._._—�
�En=ray I.^.=_ula;ion 1 �
�= '���4�+i-.I'j VlC�4.�^.J � —
`��ea:ie,yU.Qu-_ __T �_� � . —
Interior ! �
��atn-�Exfericr �� �
t�
f�liause Number--� ' �� ,
,C�rrect8'w':ed � `_._` _ .
''inal-
E En.er on Front ���.��YT� J'I . . �
��-'�-.. � _���� _ . -,� ..- _.
� �
�a^ - � T.,.�.�t...._._�.�-------�— c-�—�.� -. . - • — v . — — - — -�