HomeMy WebLinkAbout6366AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compenstion Insurance, or
a certified co thereof (Sec. 3800, Lab. C. )
Picy No. Company u_
Ce ified copy is hereby furnished, j
Certified copy is filed with the county b g ins c-
*CERT1
r ment.
DateApplicant
ATE OF EXE ION FROM WORK S' ,
COMPEN ION INSURANCE
(This section need noWbe 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 Lic. Class
Contractor Date
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
acting in my professional capacity (Section 7051,
Business and Professions Code).
I
Lic. or Reg. No. Date
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
ElI, 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 i
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 I
(Sec. 3097, Civ. C.).
Lender's Name
W Lender's Address
w I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
0 ordinances and State I relating building construction,
and hereby author' presentati es of this County to enter
a upon the obo - ntioned pro rty f,.or inspection urpos
^ Signature of Applica -or gent D to j
i
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
0 In
FOR APPLICANT TO FILL IN'
BUILDING
ADDRESS '1C 0 9 L TtTo-n woo '
BUILDING �#u� �} ll�'''
ADDRESS/ Gt� �� ZA "
7
(�
LOCALITY (Cr t '�-6)
CITY `J Iix ( ZIP
CROSS'NEARESST.
�r NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
ASSESSOR
MAP BOOK
PAGE
PARCEL
y7
TRACT 1 �
BLOCK
LOT NO.
USE �ZO
t
/
NAP /
SPECIAL
TEL.
OWNER NO.
CONDITIONS
���.� ��,E✓�r y®
DISTRICT
GROUP
TYPE
FIRE
P SSED 8Y
ADDRESS /�_11VArX14r_1_
CONST
ZONE
CITY ZIP
STATISTICAL CLASSIFICATIO `
APT.
CONDO.
ARCHITECT OR err TEL.
0
ENGINEER /r<Ca z NO.
CLASS NO. DWELL. UNITS
ADDRESS
SEWER MAP
BK. PG, VALIDATION
n
CONTRACTOR /'�� NO.
LIC
��•�-t "PNO. 7.
ADDRES5157f s" �
VALUATION
$
LIC.
CITY < CLASS
SQ. FT.
NO. OF
NO. OF
CHECK
SIZE
STORIES
FAMILIES
ONE
c�
DATE
FINAL
DESCRIPTION OF WORK
NEW
ALTER ®
REPAIR
DEMOL ®
��'�'(.���✓,� /e� , �✓"��. •ADD
�!a4�sip D G�
USE OF �/ -
EXISTING BLDG,
By
APPLICANT
(PRINT) ®` NO.
ADDRESS
PRESENT -
BUILDING
ADDRESS
LOCALITY
MOVING TEL.
CONTRACTOR NO.
ADDRESS
REQUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDTH
FRONT
P.L.
SIDE
P.L.
119
P.C. Fee $
Permit Fee
Issuance Fee
Investigation Fee
Total Fee
SEE REVERSE FOR EXPLANATORY LANGUAGE
PLANS TO APPLICANT
To. Oc i'"WR€;d
Date No. DrsSv
Water Certificate
Health Department
Fire Department
Grading
Geological
Pedestrian Protection
(Fence) (Canopy)
Special Inspection
(Cone.) (Masonry) (Welding)
Lot Drainage
Parking
Approv€ ir, Dote
Location —
(Setback & Yards)
Foundations
Slab
Frame
Energy Insulation
Lath/Drywall—
Interior
Lath —Exterior
House Number —
Correct & Posted
Final —
Enter on Front
Required
Yes I No
Approved
Dote Rocoived
or Approved
hi peetov's siignofure
INSPECTOR'S NOTES OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason. (Sec. 7031.5)
Business and Professions Coder Any city or county which
requires a permit to construct, alter, improve, demolish,
or repair any structure, prior to its issuance, also requires
the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Con-
tractor's License Law (Chapter 9) (commencing with Sec-
tion 7000) of Division 3 of the Business and Professions
Code) or that he is exempt therefrom and the basis for the
alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the 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, will do the work, and
the structure is not intended or offered for sale (Sec. 7044)
Business and Professions Coder The Contractor's License
Law does not apply to an owner of property who builds
or improves thereon, and who does such work himself or
through his own employees, provided that such im-
proveraents are not intended or offered for sale, If,
however, the building or improvement is sold within one
year of completion, the owner -builder will have the
burden of proving that he did not build or improve for
the purpose of sale).
❑ I, as owner of the property, am exclusively contrac-
tirrg with licensed contractors to construct the project (Sec.
7044) Business and Professions Code. The Contractor's
License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such
projects with a contractor(s) licensed pursuant to the
Contractor's License Law).
❑ I am exempt under Sec. , 6.&P.C, for this
reason
Date Owner
INSPECTOR'S NOTES