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Home My WebLink About3592AWORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or Alf' tif' d co thereof (Sec, 3800, I.b. C. ) o m �cy No,_ ompany 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.) 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 ''NICE TO APPLICANT: If, after making this Certificate of amption, 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-1 /11 I ��' � � Lic. Class Contrac /�� aa_11 (C Date ❑ 1 am exempt under Sec. B.&P.C. for this reason Signature t BUILDER D CL ATION I hereby affirm that�om exempt fro the Contractor's license Law for the follovSTng reason (Sect! n 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 upon tlpi§ above-mentiogd property for inspection purposes. Signature of Applicant or Agent Date COUNTY OF LOS ANGLES BUILDING ,AND SAFETY BUILDING ✓ / FOR APPLICANT TO FILL IN ADDRESS BUILDING f` 1 ADDRESS c 6 6 ns CITY Ty''¢ v', 4., ._ y- ZIP d_J� NO. OF BLDGS. SIZE OF LOT � �T a '_ a NOW ON LOTTRACT G < BLOCK LOT NO,geTEL. OWNER t�aeme, - ifilon/'a:P) NO. ADDRESS ' {.i,: ZIP CITY � , � , ARCHITECT OR , ` �. _ TEL, ENGINEER f'" & NO. g: ADDRESS e $ 2 It'? �. e TEL LIC ADDRESS a a1s6H�4_1 z, w NO. CITYAn v UC. L t CLASS SQ. F NO, OF NO, OF CHECK SIZE -$ STORIES FAMILIES ONE DESCRIPTION OF WORK �p da 'Y NEW ADD ❑ ALTER ❑ USE OF REPAIR ❑ 3„ EXISTING BLDG. DEMOL ❑ APPLICANT TEL. PRINT p .!I+,, a NO.-g ADDRESS a1)ry PRESENT BUILDING ADDRESS LOCALITY MOVING TEL. CONTRACTOR NO. ADDRESS REQUIRED TOTAL SETBACK FR UT Rnry YARD HWY o0 0 nnnn P.C. Fee $ ` „ Permit Fee Issuance Fee d✓ Investigation Fee Total Fee il I d SEE REVERSE FOR EXPLANATORY LANGUAGE CROSS ST. - ASSESSOR MAP BOOK PAGE USE ZONE MAP �fJ, NO. SPECIAL CONDITIONS i DISTRICT GROUP I TYPE FIRE CONST ZONE ATISTICAL CLASSIFICATION CLASS NO w„ 1 - DWELL. UNITS SEWER MAP BK. PG. VALUATION -5) FINAL DATE FINAL By 000, LDMA Ref. # P/C # LDMA Perm. # 11 PROCESSED BY APT, CONDO. VALIDATION 047,YA ( o 9 1 0 PLANS TO APPLICANT IMSPMTOR'S NOTES To: Returned Approved No. Date No. Dote . ........ . ..... -/V/ Approvals Required Date Received Yes No or Approved /Y/, / Rx Water Cert,ficate &X452) LN {- Health Department ____' .... . ...... . Fire De tom Grading Geological Pedestrian Protection (Fence) (Canopy) 2, ` 10 0/ ' Special Inspection (Conc.) (Masonry) (Welding) Lot Drainage Parking Approvads Dtito lospodov's Signature Localion (Setback & Yards) Foundations . .... ......... . . ... ..... - - ----- 1______1 . .. . . . .. ........ Slob . . . ....... . . . . ........... Frame. Fit rgy Insulation — ------ -------- . . .... Interior ... ....... Lolh --Exterior ---- F'IQLJS(-' NUMbef — ----- — - FinciI Enter on Front . . . .... ...... . . .. . ......... — ----- 0WNli8-BLJ11,DF1Z 1)l,"C,1,AHA'H0N I hereby affirm that I not exempt from the Contra Ior's License Law for the following reason (Sec. 7031 5) Business and Prolessions Code: An ' t, city or county which requires a permit to construct; alter, iloprope, demolish, OV repair any structure, prior to its issnance, also rvqrfires The applicant foci such permit to file a signed statement that be is licensed pursuant to the Provisi(ttis of the Con- tractor's l'icense l"Itv (Chapter 9) (commencing wilb Sv(- Lion 7000) of Division 3 of The Business and Professions Code) or that be is exempt therelrom and the basis for the alle,qed exemption. Any violation of Section 7031,5 bl, any applicant for a Permit subjects the applicant to a civil penally o/ not more than five hundred dollars (. OO).): L_ 1 1, 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 Code: The Cott tractors 1,4ense Lau, does not apply to an owner of property who builds or improves thereon, and who does such work, bintselfor through his own employees, provided that such ;i- Provements fire not intended or offered for sale, however, the building or improvement is sold within one Year of completion, The ovinet-builder will have the burden of proving that be did not build or inyproi,e for the purpose of sale). 1-1 1, as owner of the property, am'exclusively controc fing with licensed contractors to construct the project (Sec. 7044) Business and Pro.fessions Code., Vic Contractors l,icense Lau, does not apply to an owner of property who Guilds or improves thereon, and urbo contracts for such projects uyitb a contractor(s) licensed pursuant to the Contractor's License 1.atv), U I am exempt tinder Sec.—, B,&P.C, for this reason— .Date--, —Owner ------- INSPECTOR'S NOTES