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HomeMy WebLinkAbout6427A (20)WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy Thereof (Sec. 3800, Lab. C. ) Policy No. Comporiy ❑ Certified copy is hereby furnished. ❑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,) certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner to as to become subject to the Workers' Compensation Laws. 5� �,8 Applicant NOTICE TO APPLICANT: If, after making this C60ificate 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 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 Lic. Class Contractor Date ❑ I am exempt under Sec. B.BP.C. for this reason Date: Signature OWNER -BUILDER DECLARATION ' hereby affirm that I am exempt from the Contractor's License v for the following reason (Section 7031.5, Business and ifessions Code): El1, 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). ❑ 1, 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 upon the above -mentioned property for inspection purposes. APPLICATION I ITV PERMIT � COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS HI' e G A-e' 491, CITY r 4 md,44 Aq/ ZIP LOCALITY e SIZE OFJqLOT /%4r� NO. OF BLDG& NOW ON LOT NEAREST CROSS ST, ��/^ TRACT;2// U 3 -3 BLOCK LOT NO, 1� ASSESS AP BOR MAP MBOOK- PAGE PARCEL OWNER `/� j NO. r�.7� 6 ADDRESS 13 � / I V 0 "7vD UkOP%E 14 0C� 0 P Qs, SP PE GONDITIOIYS CITY / t=? Wi 1 4 /r ZIP f It d 4 ARCHITECT OR ENGINEER Pt',fhR I ADDRESS /F1II� TEL. / NO. eCf DISTRICT P GROUP .J TYPE FIRE CONST. PROCESSED BY CONTRACTOR e F TEL, NO. LIC, STATISTICAL CLASSIFIC TION CLASS NO. DWELL UNITS APT. CONDO. ADDRESS NO LTC. SEWER MAP CITY CLASS BK. ' PG VALIDATION SQ. ITz/f/,rtO NO.0S SIZE 1777y NO. OF I CHECK ONE d DESCRIPTION OF WORK AR FAMILIE: l../ Cc, -*11 NEW ® VALUATION $ 4d lTd ADD ❑ V V g 6 4 2, 7 R ALTER REPAIR ❑ USE OF EXISTING BLDG. bEMOL ❑ ) e 7 U 76 3 APPLICANT PRINT � NR.� SJ o i '_-f�Gay 710 � I C_ ✓ s+ VPr � �l� DATE 0 k O 8 8 6 ADDRESS 9' l7 ld F FINAI. PRESENT BY BUILDING ADDRESS LOCALITY MOVING TEL. CONTRACTOR NO, ADDRESS REQUIRED SET BACK YARD HWY FRONT TOTAL SETBAC PROP. LINE WIDTH " a P.L. SIDE P.L. % p [a 3 LDMA Ref. N P.G. Fe a � / r Permit Fee � Issuance Fee LDMA P/C N Investigation Fee Total Fee tDMA Perm. N O V Ix G IL In z SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appilcant or Agent Date - - - © I AGENCY REFERRAL NOTICE San Dumas Regional office L.A. County Building i Safety Division 201 E. Bonita Avenue, San Dimas, CA. 91773 Telephones% (714) 399-1286 and (213) 339-6281 Plans for a structure at '2r - F2fu'umt'N�-: !y dress Locality (Plan Check No. wore were submitted on(a , for Building Plan Check. 41 APPROVAL FROM VARIOUS OTHER AGENCIES WILL BE REQUIRED PRIOR TO PERMIT ISSUANCE. The Office of Building and Safety has already forwarded material for review to certain of those agencies, These transmittals are listed below. THIS NOTICE IS TO INFORM YOU, AS A PROFESSIONAL CONCERNED WITH THE PROJECT, THAT THE ADDITIONAL APPROVALS LISTED BELOW MUST BE OBTAINED BY YOU OR ANOTHER MEMBER OF THE PROJECT STAFF, PRIOR TO PERMIT ISSUANCE. You will peea to su k t e pertinent plans, plan check number (listed above), calculations, reports, etc, directly to the indicated agencies. Please note that approval will require thorough plan reviews and will probably not be a "same day/ over-the-counter" process. To assist you, we have listed below the information which you will need to contact these agencies or their authorized repre- sentatives. As a professional, you are aware that some items resulting from these agency plan reviews may affect the building plan check. Theme should be communicated to the building plan checker as soon as possi- ble, so that permit issuance will not be unnecessarily delayed. All approvals must be furnished to the Building and Safety Office by the time of permit issuance. PLANS FORWARDED BY BUILDING i SAFETY 3 ' YOU MAST OBTAIN THESE APPROVALS DIRECTLY WATER CERTIFICATES. Obtain completed Copies from water company serving site. DRAINAGE: A. Contact Peter Dunn of Flood Plain Mgmt. Section, San Dimas Co. office of Bldg. 6 Safetyt No set hours at this office. Phones (213) 730--2158 _ A, Contact Rod Kubomoto of L.A. Co. Flood Control Distr., San Dimas Co. Office of Bldg. i Safetyt on Thursdays at 800 a.m. Phone: (714) 599-1286 and (213) 339-6281. Tues., Thurs., Fri., at Flood Control Dist., 2250 Alcaxar St., Los Angeles, 9 a.m. to 1 p.m. Phone: (213) 226-4324. GEOLOGY: Contact Engineering Geology Section, 550 S. Vermont Ave. Los Angeles, 90020. Phones (213) 738-2161. REGIONAL PLANNING: Contact L.A. Co. Regional Planning Dept., 320 W. Temple Street, 13th Floor, Los Angeles. Phones (213) 974-6411. HEALTH DEPARTMENT: A. Food Services --Contact Mr. Morikowa of Environmental Sanitation, 14247 E. Morgan St., Baldwin Pk. -Phone? (213) 960-1861. A. Sewage for Septic Tanks --Contact Mr. Saito of sewerage i Sub- division Control Section, 313 N. Figueroa St., Loa Angeles. Phone: (213) 974-7865. C. Occupational Health and Environmental Managerment Sections, 313 N. Figueroa St., Los Angeles. Phones (213) 974-7981. INDUSTRIAL WASTE: Contact Jerry Wong of Industrial Haste Field Services Section, 5909 N. Kauffman Ave., Temple City, Mon., Wed., Fri., 8-9 a.m.- Phones (213) 297-97511 or San Dimas County Building 4 Safety Office, Tues. a Thurs. 8-9 a.m. Phone: (714) 599-12B6 and (213) 339-6281, ROAD DEPARTMENTS A. Street excavation and Curb Breaks, 14747 E. Ramona Blvd., Baldwin Park. Phone% (213) 338-9515. S. Dedications —Contact Rowland Jones/Russ Watson at 1540 Alcasar Street, Los Angeles. phones (213) 226-8281. FIRE DEPARTMENT: A. Inspections, Minor Approvals --Contact Inspector Clarence Wilkinson, 605 N. Angeleno, Axuss, 8-900 a.m. Phones (213) 969-7976, B. Fire Prevention Bureau. 1320 N. Eastern Avenue, Los Angeles, Phones (213) 267-2467. STATE INDUSTRIAL SAFETY: For a vertical excavation of 5 feet or deeper--3460 Wilshire Blvd., Los Angeles. ,�lh4C� lJi w m h ID to m w. m 4 rr �. QUO qi c to w. O w w s > ro i < m Fri N rt X rr rD I 0 H O N O 0 G rr � �r C rD ro G iL :j :j CA. 4C h � m c �• ro � rt a. 0 0 cn t 0 w• F, M W C n LO W rS G Qf p rr Pi r. 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