HomeMy WebLinkAbout3646BWORKERS' 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 L b.'C.'),
Policy.No. D�0 "77,:tXP.0y C.
Certified copy is hereby furnished.
❑` 'Certified copy is filed the unty building i spec-
/tio departtment.
Date f� h APPI irtt
CERTIFICATE OF EXEMPTION FRO OR S' 6P.
COMPENSATION INSURANCE
(This section'need not be completed if the permit is for one
hundred,dollars ($100) or less.)
1 certify that in the performance 'of the work for which this
permit is issued, 1 shall,not employ any person in any manner
so as to become subject'to the Workers' Compensation Laws.
Date Applicant
'OTICE TO APPLICANT: If, after making this Certificate of
smption, you should become subject' to the Workers'
,-ompensation 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. ClassA
Contractor. 't-' Date
❑ I am exempt un er Sec.
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.).
Lender's Name
m
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
O ordinances and State laws relating to building construction,
u and hereby authorize representatives of this County to enter
upon the above -mentioned property for inspection purposes.
a
a
Signature of Applicant or Agent Date
I
APPLICATION: FOR
COUNTY OF LOS ANGELkS
T E(�
BUILDING PERMIT
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
BUILDING
ADDRESS
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BUILDING•
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ADDRESS a
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CITYl
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LOCALITY
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NO. OF BLDGS.
NEAREST
SIZE OF LOT
NOW ON LOT
CROSS ST.
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TRACT j' ('
BLOCK
LOT NO. ` ,i '�
ASSESSOR , „ ;
MAP BOOK
PAGE
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OWNER
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IAL
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STATI ICAL CLASSIFICATION
APT.
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CONTRACTOR
NZA
NO.
CLASS NO. DWELL'. UNITS
LIC.
ADDRESS
NO.
SEWER MAP
LIC.
CITY
CLASS
BK. PG.
VALIDATION
SQ. FT.
NO. OF
NO. OF
CHECK
SIZE
STORIES
FAMILIES
ONE
VALUATION
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DESCRIPTION OF WORK
NEW
ADD
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ALTER o
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1 REPAIR ❑
DEMOL ❑
$
FINAL C
DATE ✓��- ..
FINAL
BY
—
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USE OF r
EXISTING B t
APPLICANT TEL "'fl - , {
PRINT �ti P Vic? ! `ii NO. ��"t�! 7
ADDRES , ov wCJ,
'PRESENT
BUILDING
ADDRESS
�Pi€��-��,r•'�NSI��
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LOCALITY
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MOVING TEL:
CONTRACTOR
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ADDRESS
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REQUIRED
SET BACK
YARD'
-HWY
TOTAL SETBACK FROMPIiiiiiii
PROP. LINE
X ST.
WIDTH
FRONT
P.L. -
SIDE
P.L.
LDMA "Ref. # — G
P.C. Fee $
/ 1.
Permit Fee
poll
/ r
to
-
Issuance Fee " J
LDMA P/C #
Investigation Fee
-3z/
Total Fee o
LDMA Perm. #
SEE REVERSE FOR EXPLANATORY LANGUAGE
INSPECTOR'S NOTES OWNER, BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
( ,�� 6 License Law for the following reason. (Sec. 7031.5)
Business and Professions Code: Any city or county which
9— j—�7 G/LGvr' l'T 13 -k. c4✓ ( cY GL� 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),A
(-4-5 ❑ I, as owner of the property, or my employees with
wages as their sole compensation,, will do the work, and
G r;6S 7i tK D�hio� the structure is not'intended or offered for sale'(Se'c. 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 does such work himself or
through his own employees; provided that. with ire
Z .0 -�TG,t G raar.� rovements are: not intended or; offered or sale,:'.
p fferef
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).
❑ 1, 6s owner of the property, am exclusively contrac-
ling with licensed contractors to construct the protect (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 contracts for sucb
- projects with a contractor(s) licensed pursuant to the
Contractor's License Law).
❑ 1 am exempt under Sec. B.&P.C. for this
reason
Date Owner
INSPECTOR'S NOTES
PLANS TO APPLICANT
To:
Returned
Approved
No.
Date
No.
Date
Approvals
pp
Required
Date Received
or Approved
Yes
No
Water Certificate
Health Department
Fire Department
Grading
Geological
`:
Pedestrian Protection
(Fence) (Canopy)
Special Inspection
(Conc.) (Masonry) (Welding)
Lot Drainage
Parking
Approvals
Date
Inspector's Signature
Location —
(Setback & Yards)
Foundations
Slab
Frame
Energy Insulation
Loth/Drywall—
Interior
Lath —Exterior
House Number —
Correct & Posted
Final —
Enter on Front