HomeMy Public PortalAbout9843 FLAHERTY ST_Building__ WORKERS'COMPENSATION DECLARATION
Insure,oraafcertif cafirm tharte of Worke s' Compensatioa certificate of n eInsuran e, APPLICATION FOR BUILDING PERMIT
or a certified copy thereof (Sec. 3800,.Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY'
PolicyfllA CompanyRc•nnh1 i r- TnAemni BUILDING
❑ Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN ADDRESS
® Certified copy is filed with the county building inspec- BUILDING 9843 F 1 ah e r t . T,.'C 9 17 8 0
tion department - ADDRESS - y r y LOCALITY .
11-1-85 'Randol Roofing emp e' ity_, Ca . --9T790 NEAREST
Date Applicant CITY ZIP CROSS ST. I
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL
(This section need not be completed if the permit is for one ' USE ZONE ". MAP )05
hundred dollars ($100)or'less ) TRACT BLOCK LOT NO. SPE
TEL`. SPECIAL
I certify that in the performance of the••work for which this OWNER°A n d G r a n a o u 1 i o u S NO. 3 5 0-5 2 7 3 CONDITIONS CL
DI TRICT GROUP TYPE FIRE PROCE SED BY O
permit is issued, bshall not employ any person m any manner 9843 F1aherty � � CONST. ZONE V
so as to become subject to the Workers'Compensation Laws. ADDRESS �``/f �i
- 9-18-85 Randol Roofing t/ V I�.� °C
Date Applicant CITY ,ZIP STATISTICAL CLASSIFICATION APT CO O. V
ARCHITECT TEL
NOTICE TO APPLICANT: If, 'after making this Certificates ENGINEER Cr( NO CLASS NO. DWELL. UNITS W
Exemption, you should become subject to the Workers'' tL
Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP #A
with.comply with such provisions or this permit shall be Ra nct ORooting TEL. —
CONTRACTOR NO
deemed revoked. BK PG VALIDATION
LICENSED CONTRACTORS DECLARATION LIC.
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS P .0. BOX 303 NO. 451937 VALUATION
(commencing with Section 7000)of Division.3 of the Business and • San GAb r i e i C a . LIC C-39
Professions Code, and my license is in full force and effect. CITY ' CLASS $ 9 8 9 . 0 0 ,
4:51937 C-19 SQ FT. NO.OF NO.OF CHECK
License Number Lic.Class SIZE STORIES FAMILIES ONE
i DESCRIPTION OF WORK Re:-roof house NEW ❑
Contractor r r-.Q f i ftgge:0—I r;
❑ I am exempt under Sec. and Garage , With •3 Tab ADD. e
i erg a s shingles ALTER ❑ FINAL
B.BP.C. for this reason REPAIR ® DAT ,7-7i @,30 1.2 A
Date: USE OF FINA
t EXISTING BLDG. S F D DEMOL;❑ B # o t o o ° o 1
Signature APPLICNTT-Randol Roofing TL 288-4040
OWNER-BUILDER DECLARATION . O. B O X . S 0 '. G. 91778
. '1 •° ° 4 0 5 0
C
1 hereby affirm that I am exempt from the ontractor's License
Law for the following reason (Section 7031.5, Business and ADDRESS , o o'.o (�Q 5 0 v
Professions Code): . '.,,;� • PRESENT
BUILDING O
❑ I, as owner of the property, or my employees with ADDRESS Q a 2 6�-8 5
wages as their sole compensation,will do the-work and
the structure is not intended or offered for sale(Section LOCALITY
.7044, Business and Professions Code). MOVING TEL.
❑ 1, as owner of the property, am exclusively contracting CONTRACTOR- NO.
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professians"'Code).
REQUIRED TOTAL SETBACK FROM EXIST
CONSTRUCTION LENDING AGENCY - SET BACK YARD- HWY PROP. LINE WIDTH '
I hereby affirm that thePe is a construction lending agency for FRONT - ,• -
the performance of the work for which this permit is issued PA
(Sec. 3097, Civ. C.). SIDE
m P.L
o Lender's Name
PC Fee$ Permit Fee $ 30 . 00
Lender's Address
I certify that I have read this application and state that the Issuance Fee $ 0 ' S 0 - a
above information is correct. I agree to comply with all County Investigation Fee
g ordinances and State jaws relating to building construction, Total'Fee L} 5 0
d and hereby authorize rep entotives,of this.County to enter
uponAe
a ove ntio rop rty r inspe io purp es.
a 7 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of ApfAicant or Agent ore 0s
MTH�1rMV.?Vis'OF BUILDING AND SA ETY APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES UG 6
WM. J. FOX. CHIEF ENGINEER +94,0U ' L ® I N G
FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY
/ DISTRICT NO. PLAN CK.NO. PERMIT NO.
BUILDING ?�y.3-� ���E{�T S'�•
ADDRESS J •F ]• o /2 7_
LOCALITY RECEIV•D�BY .,E'' DATE OF APPL. DATE IS/SUED
CROSNEAREST
5 ST. I�t `. V
C BUILDING
OWNER L 1 G l �G..0 � ADDRESS L ��jTJ•
U
MAIL LOCALITY
ADDREBB , 4-C� ( ( r�L n relyy 1-=S�{ - .
TEL. NEAREST.CROSS ST '
CITY C—&, L � NO. tC�, 7j(p `L -
FIRE Nb.OF '
ARCHITECT OR TEL ZONE PLANS 2, •TYPE..- GROUP
ENGINEER _ NO. �
BLDG. r _ ,,y I ORD.NO.
ADDRESS ------ 5ETBACKLINE
APPROVED -
L '•
CONTRACTOR L1 �s SG(7 TE
-r' NO.. � C7, '1.3(oGI BY DATE
, r USE APPROVED
ADDRESS I O q- �I,• L 41 A) ^S ZONE ) BY' DATE
LEGAL r� ,-CORRECTIONS
DESCRIPTION LOT NO. BLOCK /i"1
TRACT
NO.OF.BLDGS.
SIZE OF LOT 1 I NOW ON LOT
USE OF NO.OF NO.OF ,
EXISTING BLDG. PAMILIEs —ROOMS"
DESCRIPTION OF WORK
NEW - ALTERATION ADDITION
D
REPAIR MOVING DEMOLISH
SQ.FT. NO.OF - Z
SIZE O ROOMS STORIES y
WALL - L4S. I ROOF t' I GEU U 2. - . .. i .z r
COVERING COVERING 'I
USE OF NEW
DUILDING
C.
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPROVALS
APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION INSPECTOR DATE
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMS,MATERIALS
AND STATE AWS REPU!,PTING §UILDING CONSTRUCTION.
FRAME: FIRE STOPS,
SIGNATURE OF BRACING,BOLTS
PERMITTEE LATH, INT.
AUTHORIZED AGT- LATH, EXT.
DBS-36A M SE '� ^. „ PLASTER, INT.
DBS-3 60M SETS dam/fC.
$ f`� EE PLASTER,EXT.
VALUATION W FINALEE