HomeMy WebLinkAbout7892AWORKERS' COMPENSATION DECLARATIO
I hereby affirm that I have a certificate of con ntr t seif k
insure, or a certificate of Workers' Compensation urnc,_L, A P bCATION FOR BUILDING PERMIT
or a certified cop thereof (Sec. 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.��v `�U� C�Ompany F
n:
❑ Certified copy is hereby furnisl�edp z ?J
❑ Certified copy is filed wiVtuntyding inspec-
tion department t
.. tDate - Applicant
CERTIFICATE OF EXEMPTERS'
COMPENSATION
(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 �J 03�Z^-Lic. Class_
Contractor_,�i� ��T ii Date
❑ I am exempt under Sec.
3 i Lt
f
B.&P.C. for this reason
Date:
Signature
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Law 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.), n
Lender's Name. � ` �( � `'v O N K
Lender's Address N
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinance and State laws relating to building construction,
and h r b authorizer r ntatives of this County to enter
upon t e ove-mentia ro erty for inspection purposes.
-I Z-691
Signature 6f A plic nt or Agent Date
' ,; FOR •APPLICANT TO FILL IN
BUILDING
ADDRESS Z:-L5-UD L-A"
'r (tl
BUILDING �� y ��y n f /
ADDRESS L 1 l � -I u,
� RAR
CITY ZIP
LOCALITY
p NO. OF BLDGS. I
SIZE OF LOT ( 8 \ C�LC NOW ON LOT
NEAREST
CROSS ST.
y
TRACT I
BLOCK
LOT NO. I
ASSESSOR
MAP BOOK
PAGE
PARCEL
TEL. '. /yT
OWNER NO. i l 11
USE ZONE
P �..
�J, s-
ADDRESS 2_6 9� VONGON "�``V
FSPE,81—AL
G}
DITIONS
q p
CITY y A ZIP
ARCHITECT OR TEL.
ENGINEER NO. q i
DISTRICT
GROUP TYPE FIRE
CONST. ZONE
PROCESSED BY
ADDRESS S MA N'M VWCA
to tT 1
P__'�
TEL.
CONTRACTOR < NO.
Sr I o
STATISTICAL CLASSIFICf1TION
)�
CLASS NO. °� DWELL. UNITS —
APT.
C DO.
��yy�L
Z +
ADDRESS NO. d awl I
SS
CITY V KAND
CLASS
— I
1 —..-.......
BK. PG.
VALIDATION
SQ. FT.
NO. OF
NO. OF
CHECK
SIZE I
STORIES
FAMILIES
ONE
VALUATION
DESCRIPTION OF WORK
NEW
ADD ElV-Ced
ALTER ❑
$ 4 riq rtt
►
7 �' O 2 A
a ®c_
A
L L
REPAIR ❑
❑
$
2 0 2 0 9, " 3
USE OF
EXISTING BLDG. y
DEMOL
FINAL
- n, f r- -_ i
�) f. ,� .) c
APPLICANT pp J TEL. j� c
`'
(PRINT) i�
C NO.
`��`� 1CQ
DATE
Q h, 1 2 ` <8 9
ADDRESS
FINAL
By
PRESENT
BUILDING
ADDRESS
LOCALITY
z 8 3 f b A
f A ® o o
2 - G 6 1, 6,
® 2 �J .' (i 4
-
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
FRONT
P.L.
0706� 9
SIDE
P. L.
LDMA Ref. #
Z�✓
P.C. Fee $ ` j
Permit Fee
�
a V�
Issuance Fee
LDMA P/C #
Investigation Fee
/
' 47 �.
Total Fee
);
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE
INSPECTOR'S NOTES OWNE -Bl EiLDER DECLARATION
I hereby affirm that I am exempt from the Coniract®i's
PLANS TO ,APPLICANT
To. Returned
,License Law.- fear thefollowing' following reason: (Sec: 7031.5)
Approved
Business and Professions Code: Any city or county which
6"d0. ®ate No. Date
requires a permit to construct, alter; Jfmprbvd, demolish,
orrepairany:structure, prior to lts issuance, also requires
' the applicant toi- buoh permit to file 4, signed statement
that he is Ilcensed pursuant to the provisionsof the Con-
s
tractor' License Cave (Chapter9) (coirmeftctrig with Sec-
tion 70) of Division 9 of the Business and. Professions
� � 1 � • Code) or that he is exempt therefrom and the basis for
the alleged exemption..Any violation of Section 7031.5 by
01) IV any applicant for a per mlt.subjects the,applicant to a civil
—
Roquired
Date Recelved
Approvals
or Approved
penalty of not more than five hundred dollars ,($500).
Yes
) No
_
El1, as owner of the property, or my employees with
..wanes as their sole compensation, will de the work, and
Water Certificate
the structure is not intended or offered for sale (Sec. 7044)
- Business and Professions Code: The Contractor'_ l.loense
Health Department
Lar doenot apply to an owner of property who builds
or improves thereon, and who does such work himselr'or
Fire Department
through his own employees, ` provided that such im-
proverrionts are` not intended or offored ,tor sale. If,
Grading
however, the building or improvement is sold within one
year of completion, the owner -builder will have the burden
Geological
of proving that he did not blend br improve for the purpose
of sale),;
O 1, as owner of the property; am exclusively con -
Pedestrian Protection
(Fence) (Canopy)..
tracting with licensed contractors to construct the pro-
Ject (sec. 70Li4} i3u ine;and,, "tofb.ssions Came: The Con -
Special inspection
(Conc.) (Masonry) (Yielding)
tractor's f icense Law %foes not apply to ad bWner of pro-
perty whobuilds orirnproves thereon, andpho contracts
_ for such projects with a contractors) iioensed pursuant
Lot Drainage
to the Contractor's License Law).
Parkins
®. 1 am oxampt under Sec, , for this
reason, �•
Date Owner
INSPECTOR'S NOTES
- - _- - -
Approvals
Date
Inspector's Signature
Location—
(Setback & Yards)
Foundations
Slab
Frame
Energy Insulation
LathlDM-jall--
Interior
Lath —Exterior
House Number —
---
Correct & Posted
- - --
Final—
Enter on Front