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Home My WebLink About0530A 4219A ., _ _ ... _S��/� _ _..,_ _ WORKERS'COMPENSAiION DECLARATION - - � � � �� --�� - �-�� - � � : . .. . . .. : � t h�by;afffrm that I hav�.a certificate of conse0t�o Se�f � � APPLICAI°ION� F�R��BU�ILDING��PERMIT -� insure,or a�certifico�e of Workers'Compensofion insurdnce, or a cert fied copy 7hereof jSec.3800,Lab.C.) � " -- -- � � ��-�-�� - �-- � �� e �4/� �p��m� COUNTY OF LOS ANGELES � BUILDING_AND SAFETY _, _. � _,. PolicyNo�•yJ/el'Ji/!/Company ' :._ ..._ .... . ... ... .'. � Cerrified mpy is hereby surnished. FORAPPLIC/aNT TO FILL IN �.+` nooaEss ZZ7� �']/Certified co "s filed-with th. c t buildin i s eo- " � �� - uQ PY' ^Y 9 ^p BUILDW(G'�.�. ��(�.� tipndepartme/ni. ADDRESS ,�y� �"-'_' Ol�� Date y � Q OAppiimnt C�TY Y/V%!i4'!� ZiP � � S LOCAIiTv . . . . . ... � C TIFIC E OP EXEMPTION M WORKERS' NO.OF BLDGS. �{�r NEAREST . . .. . . , .. . . � � COMPENSATION��IN RANCE �� . SIZE OF LOT ��Z NOW ON LOT �/•r�` CRO55 ST. (Thi4secfion need not be completed if ihe permii is for one TRAC47�� ASSESSOR� �� h4ndred dollars($100)or less.) BLOCK LOT -�` Mqp gppK PAGE PARCEL OWNER ' . �/y �� USE N � MAP . p{ 3 . .. I certify thai in the performonce of�he work for which ihis - N -` 7� ��, NO. �Y' �y permit is issued,I shall nat employ any person in dny�monne� ��" �� SPECIAL � � � �� A}. so�ds to become subject'to ihe Workers'Compensation Laws. ��-� ADDRES � CONDITIONS � . . . . . CIT�O�/��'/./'"1!I . ...ZIP .! �v� . . . . V Date� .. A�pplkoni . .. . . � � ARCHITECT OR �(� � TEL�7 / A �"�TICE�TO APPLICANT:-If,�ofter making this Certifimte of ENGWEER �"�� r</ Nql �NJd DISTRICT._. GROUP TVPE. FIRE PROCESSED BY F � mption, you shouid bemme subjec� to the Workers' / CON57. �zONe v .,om ensation rovisions of the Labor Code, ou�must forih- C � ' _� �� a withpmmply Pth such pravisions or this permit shqll be ADDRE55. ��+� C7 . I� _ . y cJeemeCl fBVOkeCI. TE�� STATISTICAL CL4SSIFICAiON � APT. C NDO Z . . CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION �i� CLA55 NO.� DWELL.UNITS� I hereby affirm thqt I am licensed under provisions of Chapter 9 ADDRE55 Np. (mmmencing with Section 7000)of Division 3 of 1he Business ond ., uC. - . SEWER MAP � � Profeuions Code,ond my license is in full force and effect. CITY CLA55 gK � VAIIDATION /q� SQ.FT. � NO.DF � NO.OF CHECK License NumbeS � �°' Cic.Class � SIZE � 3� STORIES �� FAMILIES ONE , � � �yrH,d� � � ALUATION . . '�- � /� DESCRIPTION OF WORK / � � NEW p �:::�I:.1,�U�': Contiactor ys-r/�.-�D�J ,�ate � .0 � �WC/�J✓� � n�o � S�� O p'� , - m c.e o�.j... �I om exempt under Sec. - ALTER ❑ � B.&P.C.for this reason ..._ REPAIR ❑ S � ' '"4'~',�C.. . � Date: � USE OF DEMOL F � � '� � - E%ISTING BLDG. ❑ � `f:'!_:�.�.i;" $ignPlufC .. . . APPLICANT . . . . �..TEl FINAL �h . �}. � . . OWNER-BUIL�ER DECLARATION PRINT NO. DATE��V� �� .�/. �'r � C—G v � I hereby affirm thot I om eaempt from the CoMroctor's License . Law for�he following redson (Section 7031.5,B�siness and P.00ae55 fINAL � � _ P�rofessionsCode): � � PRE Ni �� - -� - � - --- By �� .x-�-� BUILDING � .F 1 I, os owner of the properfy, or my amployaes wiih ADDRESS �, . . wages as fheir sole compensation,will do�he work ond - �� - � � � - � �"- -� � the siructure is not inrended or offered for sale(Section �aA��TY . � � 7044,Business and Professions Code). � -� MOVING TEL. � � � I,a owner of the property,om excl�sively confrocting CONTRACTOR NO. _ -� with licensed confractors to consiruct fhe project(Seo- qDDRE55 tion 7044,Business and Professions Code). REQUIRED 70TAL SETBACK FROM.. I CONSTRUCTION LENDING AGENCY � � - SEt BACK YARo HWY PROP.LINE wiDTH � � ' I hereby affirm that ihere is a consiruction lending agency for FRONT z��G��p. � ihe performance of fhe work for which ihis permit is issued 0.L � (Sec.3097,Civ.C.j. SIDE �o e a c c � � P.L. Q lender's Name / /� � !,j %.:,G O . P.C.Fee 3 (Q `1- Permit Fee �( ��JJ ��Ref.# - Lender's Address p"" I- ��`��`-f'- � � �� e, 'i j j,Q,J�� I certify that I have read ihis application and s�ate ihai the �•n�j . �J �� Issuance Fee ��•U� LDMA P/C M ' - ¢ above information is correct.I aqree to mmply with all County inaesrigmion Fee ' �� i (i'-L`fJ � or.ina es and Stote laws reloting to building construction, . Toro1 Fee / � r�� IDMA Perm.R � - � and her y authorize representptives of ihis County to enter � m �pon th ab e-mentioned ropertyfor inspection po poses. � �� a � � � � ) �°� ' / D � SEE REVERSE FOR EXPIANATORY LANGUAGE a ignat�re of Appli<ani or Aqent � Dole . . . . . ... ... -. . . . ..... .�... . .... . . - . 'J°! r PLANS TO APPLICANT INSPECTOR'S NOTES 04�'NER-BUILDF.R DL'CLARATION . . . I hereby affirm that I am enemp!from Ihe Conhactar's To: Refumed � . � �License Law for the fd!lowing �eason. �(Se�:�7631,5) � -� Approved Business uxd Professions Corle:Axy city nr county wbicG No. Date No. � Do}e � - � - � rey�eires.a(�ernaie to construc6,alter,improa�e,Jemnlish, � � � � � 'or repair ang�structure,prior m iRc issila'uie,n/.co requires � . ,. ._ , . . . . the upplicant/nr such permit tn f:'!e a si�ned statement � . � .. that fie is licensed pursuaret to tl�e pv+ovisions rf t5e Con- � �� , � - _ tr�ctor.'.s I,icense f ow(Cbapter 9J(cnmmenri�¢,5�u•atb Seo- �"� � - � tion 7000J pfn,,,��=�,n 3 of the Busiaeess and Profcssin c - . � � . ' �� , . , CoJeJ nr tbut hc iF exempt therefr�in uxd the 8asisfr r tl e - .. , . uIIa,qed exempEion.Ax��vrolatinx of Sectinn 7Q31.5 by Raquired Da}e Received .�� . . . . � . � arey ayfilicnntJar u permrasuhjects the applicunt tn a cixii! Approvals or Approved � ��penalty of not more 6hun fivc bundred dodlars/$500/.J: Yes No � � � �� ❑ I,as owner of fhe property,or my employees with Wa�er Certificate . �� . � � woges as their sole mmpenwtion,wlll do the work,and - � the structure is not in�ended or offered for sale(Sec.70a4) Business and Pro esainns Coder Tbc Contractor'sl,icense Nealth Deparimept . . . � ' f - � Law doex not upp�y ao are nwnar r f property wbn hua(ds . Fire Department .. � - � . or i»:proves tGereox,arut wbq dqes.cuch u�ork l imse f�r � � � . . thrnugh bis nwn employees, pmo&ted lbat sucb �- , Grading • � provemests ¢re rzot irztenderl or offcrcd for su1e. � � bouacer,tl e bisilding or improvement rsrold wrtbin on4 Geologiwl � , . . . . yeur q�rumplelion, tGe owner-buildcr wi!! bave the -� burden nf jrnzinR t/ru1 hc did not build or impmse for Pedestrian Protection - -- � tl�e pvrposa of saTe/. (Fence)(Canopy) � � � I,as owner of the propeny,am ezduslvely contrac� � ting with li<ensed contractors to construct the project(Sec. Special Inspection� � - � �� 70441(3ssseness and Prof.essinns Code: Tbi Cnntructor's (Conc.j(Masonry)(Welding) - � � I.1tenFe I.¢u!does not apply to an owxecof property u•,�n _. buidds nr imjirnvns iberern,and.u:b<j.c,ontrqcds fnr suih Lot Drainage . . _ _ � � ' � -� � '�:�projecis.with ¢rnxtruc6or(s/lirenserl jiarsuanf to tAe - � � - Cnntructor's I.icerrse I.awJ. � �- ' .. Parking � . .` — �� . � I am exempf under Sec ,0.8P.C.for this reason . � Dote Owner Approvals Date Inspector's Signature - �" INSPECTOR'S NOTES Lomtion (Setback&Yards) � � . .. Foundations - �� Slab 1 . � . ... . .. .. . . . , . Frame ��9�,. er " . � . . . . ., . Energy Insulotion �V3:)�p�w'f -� .�,�� . .. � . .. . . ..... .- .. Lath/Drywall-�- • . . . . . . . .... . .. interior � � Loth��Exterior � �- � - House Numberv- ��- � � ' Cor.ect&Posted � - � Final-- . - . . � Enrer on Fronf - � - .. . ... .. .. .. . . . �::. - ' � -...... ` . . . ,. . .. . � . . . -,;... �.. . t -...... � .