HomeMy WebLinkAbout3333 BREA CANYON RD (10) (2)W 210ER5' COMPENSATION DECIARATION
I hewby alfirm Ihor I hove a certificate of conseni o se f
ins re; or o certifitate of Workers' Compensation Insuronce,
or a certitied
4
p O Ssc ,Lob. C._ ) _ c
Policy No. Company ill rt .
iEer,i(ied copy Is hereby furnished.
Certified mpy is fiied with ihe county build ng inspec-
tion department
Ome Applicam . .
CERTIFIGITE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This seUion need no be completed if he permi is for one -
hundrod dollan (5100) or less.) . ,
I certify thot in the performance oi tha work for which thls
permit Is Issued, I ahall not employ any perwn in any mannar
so as to bacome sVbjecr to the Workars' Compenwrion laws.
Date ' Applicont . . . .
NOTICE TO APPUCANT: If, after making this Certificate of
Exemptlon, you should become su6ject to the Workers'
Compensation pravlsions af the Labor Code, yau must forth•
wilh comply with sueh proviilons or this parmit ehall ba -
deemad revoked. ,
UCENSED CONTRACTORS DECLARATION
1 hereby affirm that I am litensed under provisions af Chaplar 9
commancing wifh Sec ion 7000) of ivision 3 of the Business and _.
Praieseions Code, ond my licensa is in full force and effect.
Lfcensa Number 2=/U Ua Class
CoMroc or_ 1`LL-x`r .Do e__f_=i.l
I am ezempt under Sec.
B.BP.C. for thia reason . _
Dale:
Signature
OWNER-BUILOER DECIARATION
1 here6y affirm that I am ezempl from the Contractor's licanse
low for ihe following reason (Seclion 70 1.5, Business and
ProfessionzCode): - -- -
I, as owner of the property, or my employees wiih
wages as their sole compensation, will do the work and
the atructure is not Intended or affered for sale (Section
7044, Buainess and Professions Code)r
I, as owner oi the proper y, om exclusively conHacting
with licensed confractors to construd ihe project (Sec-
ion 704d, B siness ond Professions Code).
CONSTRUCTION LENDING AGENCY -
I hereby affirm that fhere is a constroction lend ng agency !or
the performonce oi Ihe work for which this permi Is isaued -
Sec. 3097, Civ. C.J.
Lender's Nama
Lander's Add ess
I cenify Ihai 1 hwe read Ihis opplitation ond s ore thot.the ..
above informarion j rrect. gree to comply wi h aIi Counry
ordinan and r lating fo buiiding tonstruclion,
ond he e au ri e re
s
ntatives of this Couny to en er
vpon t e bov nl o roperty for Inspeclio pur oses.
Si a u e Ap onr o A - Dote -
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGElES BUIIDING AND SAFETY
SEE IIfVERSF fOR EX IANATORY LANGUAGE
il. OU
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t W
aN
Z
PlAqS TO F\PPIICANT
To: ! r. . Refurned .
Approved
No. - Dote ' No: ' Dafe' ' '
iI
r._. _ .
t
i.
Roquired'_ Data"Raccivad
Approvals .
yei Na
orApproved
VJoler Cerl hrate. _ _ ... - _ ...' ... .
Health Deponmene . _. __..._. ... ' _ r . ..._' _ . . _.
Fire DePorimeni . - -. . --- - -- - .
Gradmg . ' _ ' ,
Geolo9icol ' ' • -
Pedeztnon Prolechan .
Fe ce)(Conopy) ,
Spec'iol Inspection ,, -
Canc.11Masonry)(Welding) ' ' -
lo Dr lnage . . ,
Parking
Approvols - boto
lon -1 . ,
Foundatlans
Slob ,
frame
Energy Insularion
lmh: Drywoll'-
Imeno.
Lath -Extenor
Hovse Num6e-
Gorrecl & Poz ed
Finol .
Enle on Fwnr
I
Inspactor's Signuture....
I _ ____ i . . ' .
INSPECTOR'S NOTES
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I he.rby o!h m :hoi I am exemp 6om d: Cnnvac!o's
Licen.e l v:' for -he.follo -ii;y re.a;on Srt:. .'G3t;51
I)si asamdlr f venn( d•ilni'h r nunl rhidi
reyu n prrnrrt f rnrcU !!t . r r). ri. J mn/iah.
r rc nir ntty s rurti r ./ri r! i t. is. +Jnc[, Jl i n yurrr
be appli:dnf fnr .r!'il prrrnit to Jile a si,urJ a[.trrni n
l ut.Gr is licrnsrJ/ursuan tu 7hr pr i inns f thr (:ori.
tru<'Inr's f i rrur l.are• (('hap rr'J)Ruirsmm<n u•ith Jin
ion 700OJ n/ Die isr+n 3 nf U e lluvnrxs .rnd PrnJrcv ms
CnJeJ nr thnt l rrnipt !/ e rr/rnnr nnJ fbr.Anai.a/ur fG.
uU erd cxcmphnn Anp-rinlatinn n/Srrbnrr ](37.$ l t.
un v uppli:n e Ir r a rrrmil subjttfs the applicarn t tn u: i ri!
penullYn(rnfmnrrlFun/ i.Iru ndrrd J,llu sl55np1./:
I, as owner o he p opnrP, o my emn oyees w f i
wages as he r sole compensobon, wdl do ihe worM, and
1he struUure it nor in ended or o(fercd for sule (Sec. 704a)
Uusinrss nd Pr i/crriunc Cud<•: 7hc Cniilydrtnrh l.iccnse
r.,«• J, n,r u r,• „ u, ou nrr oi .,r.,• , r n hurlJ.
or inrrrores fben un,_and erbn duea cui! u ork Firuse//nr
lbrnu,Lr L,is u n euiplqY'•s: p urrJeJ lbat surb iur
J rn ements arr unt in enJ d nr y//crrd fur sala !/,
oa nrrr. t/ e baifJin,q nr i.nprnnemene ia cnfJ rit/ in une
1'rar q/ ennrpfeti,, 1Lr ou nrr.buifJrs xr![ la r tbr
burdrn n/ frni iu, thul he did nu hvild nr irrcpmre/nr
15c paipnsc o(aufel. - ' . .
1. os owner of ihe propeny, om e.clusl e y cemroc
ting wnh licensed contrac o s to consnuci ihr. pro ect (Sec.
7044).Uiesiness arcJ Prn ssimrx (.nJr: !/e Cnnbuctnr's
l rensof irJes n7upJ,11''tn nnuoirrri/rrrprrt u•hn
hurlJi r r irnp nrs lLereon, ar d uL i nndacts/nr rucb
rnjerts.u•ith a infr rtnr/sl lirerosri! fnrsuant in tGr
Lr n(rU fr rff C['nfe-I.AIt'f. .. . . ..... ,
I am e.empt under Sec . B.&P.G. 1or h s
reason
Dme Owner
INSPECTOR'S NOTES