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Home My WebLink About5019AWORKERS' COMPENSATION DECLARATION I heeby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or ertified copy thereof (Sec. 3800, Lab. C.) Po is N6?�-�t%Df3C'ompany ❑ Certified copy is hereby furnished. C ❑ Certified copy is filed with the county building inspec- tion department. Date Applicant- CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ, any person in any manner so as to.become subject to the Workers' Compensation Laws. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such, provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions.of Chapter 9 (commencing with Section 7000) of Division 3 of the Business .and Professions Code, and my license is in full force and effect. License Number �� 6 Lic. Class C " Contractor/ _RLi2ILL14 Date ❑ 1 am exempt under Sec. B.&P.C. for this reason Date: Signature / OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code.) ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code.) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name, Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upop-the-dbpve-mentioned.goperty for inspection purposes. Signature of Applicant or Agent Date APPLICATION FOR BUILDING .PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN ADDDRESS iaDRESS BUILDING.•-� �g i ADDRESS (C-0 A (J CITY I on � ZIP LOCALITY NO. OF BLDGS. NEAREST SIZE OF LOT NOW ON LOT CROSS ST. ° ASSESSOR I TRACT ,.- BLOCK LOT NO. r/ MAP BOOK PAGE PARCEL OWNER NO, a ,�� USE ZONE, MAP NO. SPECIAL ADDRESS (} %S' ci r e d pe, CONDITIONS CITY 0 1 Ku i -Yr ,= ZIP ARCHITECT OR TEL. ENGINEER NO. DISTRICT GROUP TYPE FIRE PROCESSED BY CON.5.L ZONE ADDRESS /TEL*J I A / CONTRACTOR s ` e,- CA . No -6,27-73., STATISTICAL CLASSIFICATION APT, C DO. LIC. ADDRESS 7 Q Wre 8—, NO. 4-/q"-1 CLASS NO. _2UDWELL. UNITS UCSEWER MAP CITY I 1 CLASS C-31 SQ. FT. NO, OF NO. OF CHECK BK. PG. VALIDATION � SIZE STORIES FAMILIES ONE ' ,� DESCRIPTION OF WORK C --r(X.0 w j NEW VALUATION _ /% ADD ❑: ALTER. .. v-� REPAIREI $ I � ®C� r�, O O USE OF DEMOL ❑; EXISTING BLDG. 6 �? !� U j APPLICANT TEL. (PRINT) NO. FINAL � . U �'• I E -' O 4 PATE .. �, ! `V / � ADDRESS FINAL" PRESENT BUILDING ADDRESS LOCALITY MOVING' TEL. CONTRACTOR NO. ADDRESS REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. SET BACK PROP. LINE WIDTH FRONT SIDE P, L. 7 LDMA Ref. # P.C. Fee $ Permit Fee f Issuance Fee " `� LDMA P/C # Investigation Fee Total Fee LDMA Perm. # SEE REVERSE FOR EXPLANATORY LANGUAGE a_ Ct U 0 U LU o_ LO Z Oti1 NPH-1t1it,DUS: DLCLARATION"t I hereby 2affltrn that I ant exempt fromthe C.o ractor'8 License Lav for the,,foli®W rlg reasgrJSeo 70315) business --and Professions Code: Any city or county which requires a permit'to construct, alter, `imp'"love," demolish , or repairanystructure; prior to fts issuance; also requi}es the applicant for such permit to fffe`a signed statement that he is licenser/ pursuant to the provisions of the Con- troc or's license Law (Chapter 9) (commencing with Sec- tion 7009) of Divisfoa,,3 of the, Business -.and Professions Code) or that he is -exempt therefrom and the basis for the alleged, exemption. Any violation af,Section,703,1 by any applicant fora permit subjects ther applicant to a: civil penalty of not more than five hundred dollars ($500).): I, as.owner of the property, or my employees with wages as their sole compensation; iNilI do the Work,- and the structure is not Intended or offered for sale (See. 7044) Business and Professions Code: The Contractor's License Law.does not apply to an owner of property who builds worimprovesthereon, and who does such �workh mselfor through his own employees,' provided that suclT fin- provements are not intended or 'offered for sale' If, ihoweverr; the building or Improvement'is sold iiilithrn dne year of completion, the owner -builder v✓fll have th'e bir`den of proving that he did not build•orimproye for the purpose . <_❑.� I, au owner oftrie prbP@rty,,arin' ex'cidsively con-, tracting with licensedcantractors`to'donstrubf thepro Ject (Sec. 7(.'+44) Business and Professions Code: The Con tractor's License Lew does not appiv to an oa,a✓ner of pro- pejyr,who builds or improves thereon, and Who contracts foreuch projects with a contractor(si licensed'pursuent to the, Coilntractor's License;LaW) ❑ i-.a,m.exempt under •Seer ; S.&P:G`. for this reason Date :.Owner :, ,, PLANS TO APPLICANT INSPECTOR'S NOTES To: Returned Approved' No. Date: No. Date , Required Received ApprovalsDate Yes No or Approved Water Certificate Health Department Fire Department Grading Geological Pedestrian Protection (Fence). (Ganapy) ,, , Special Inspection (Conc.) (Masonry) (Welding) Lot Drainage - Parking U. Approvals Date Inspector's Signature Location— (Setback & Yards) Foundations Slab Frame Energy Insulation " Lath/Drywall— Interior Lath—Exterior T House Number — Correct & Posted Final— Enter on Front Oti1 NPH-1t1it,DUS: DLCLARATION"t I hereby 2affltrn that I ant exempt fromthe C.o ractor'8 License Lav for the,,foli®W rlg reasgrJSeo 70315) business --and Professions Code: Any city or county which requires a permit'to construct, alter, `imp'"love," demolish , or repairanystructure; prior to fts issuance; also requi}es the applicant for such permit to fffe`a signed statement that he is licenser/ pursuant to the provisions of the Con- troc or's license Law (Chapter 9) (commencing with Sec- tion 7009) of Divisfoa,,3 of the, Business -.and Professions Code) or that he is -exempt therefrom and the basis for the alleged, exemption. Any violation af,Section,703,1 by any applicant fora permit subjects ther applicant to a: civil penalty of not more than five hundred dollars ($500).): I, as.owner of the property, or my employees with wages as their sole compensation; iNilI do the Work,- and the structure is not Intended or offered for sale (See. 7044) Business and Professions Code: The Contractor's License Law.does not apply to an owner of property who builds worimprovesthereon, and who does such �workh mselfor through his own employees,' provided that suclT fin- provements are not intended or 'offered for sale' If, ihoweverr; the building or Improvement'is sold iiilithrn dne year of completion, the owner -builder v✓fll have th'e bir`den of proving that he did not build•orimproye for the purpose . <_❑.� I, au owner oftrie prbP@rty,,arin' ex'cidsively con-, tracting with licensedcantractors`to'donstrubf thepro Ject (Sec. 7(.'+44) Business and Professions Code: The Con tractor's License Lew does not appiv to an oa,a✓ner of pro- pejyr,who builds or improves thereon, and Who contracts foreuch projects with a contractor(si licensed'pursuent to the, Coilntractor's License;LaW) ❑ i-.a,m.exempt under •Seer ; S.&P:G`. for this reason Date :.Owner :, ,,