HomeMy WebLinkAbout3333 BREA CANYON RD (14)WORKERS' COMPENSATION DECLARATION . _ . }' .
I hereby affirm ,a, I have a cer ificofe of o ge< <o =e F. .. APPLiCATION FOR BUILDING PERMIT insu e, or o certifica e of Workers' Compenstion Insurance, or,
a ce fi ed copy thereof (Sea 3800, La6. C.) :_F-= .'— -' ='COUNTY OF LOS`ANGELES,' BUIIDING AND SAFETYPolicyN'o 1 Z S y Compony ! N . cs.t ' ` .. , - .
Ceri'rfied copy +s hereby fumished. FOR APPUCANT TO FILL IN ADDRE55
Certified copy is filed with fhe counly bvilding inspeo BUaDMG
fion deportment. ADDRE55 i-A C%' ' 1J 2U , ocnuTv . -
t NEAREST /
Date Applicant CITY V7 7 MD D ZIP CROSS ST. U---f+G iQ/ . .
I CERTIFICATE OF EXEMPTION FROM WORKERS' y + NO. OF BLDGS. ASSESSOR '
1 COMPENSATION INSURANCE
SIZE OF L01 d• ,/ C NOW ON LOT MAP BOOK GAGE PAR[El
ihis setlion need not be comple ed if Ihe permit is for one u5E ZONE Mnc
TI A [l 'S BLOCK l0T NO. NO. 3
hvndred dollors (SI00) or less.) }
TEL. i n SPECIAL a,
OWNER ,j ,I V• NO. V "" p O CONDITIONS GU 5
I certify that in ihe performanca of the work for which this '
permit is issued, I shall not employ any person in ony manner /% I' '
DISTRiCT GROUP TYPE FIRE PROCESSED BV („ ;
so as to 6ecome subject to the Workers' Compensotion Laws. ADDRE55 /' oZn Y 6 Q `
p
CONST. NE
a
CITY N'/-UR IJ N ZI7 Z('' I
Ole AppliCOnt STATISTICALCLASSIFICAIION APT. CONDO. V
NOTICE TO APPIICANT: If, aiter mokin Ihis Certificme of ARCHrtECi OR A / TEI.
9 ENGINEER „G JiA+ NO. 3,i I CLASS NO. DWELL. UNITS 6,
Exempiion, you shautd become subject to the Workers'
1 y
Compensalion provisions of the Lobor Code, yov must forfh- qDDRE55 722 % S S y J%' SEWER MAP Z.
with tomply with wch provisions or this permit shall be TE .
deemed revoked. CONTRACTOR . L} - ' nlo. BK. PG. VALIDATION
LICENSED CONTRACTORS DECLARATION i. _ -
I hereby afiirm ihat I om licensed under provisions of Chapier 9-. ADDRE55 NO. VAWATION
commencing wi h Sec ion 7000) of Division 3 of the Business ond . , a 3 3 8, 3 A
Professions Code, and my license is in (ull force ond effect. . fITV CLA55 E / L°T? { ,
j SO.FT NO. OF NO.OF CHECK H ••• 2 3 i
License Number li[. Closs S12E / 2 570RIES L FAMILIFS ONE
NEY!
S 1 4. 6 6 0, 1 3
Contractor Date
OESCRIPTION OF WORK 7- t[- _
I am exempt from Ihe licensing requiremen s os I am a C[l.t/! p 3 .
4DD " • 4. 6 6 0..1 3 c=i
licensed architeU or o registered professional engineer _ .,.. - . . _ ALTER FINAL ij n O 7. 1 6 „ 8.ZDATE ( octing in .y professional capacity (Section 7051, RE AIR v . .
Business and Profes5ion5 Code). _ USE OF
EMOL FINAL `
EXISTING BIDG. BY LO t}
Lic. or Reg. No. Da e AvvtICANi + iEl. ,-
OWNER-BUILDER DECLARATION " - IPRiNi ry SC1 NO. 73- %D .
I hereby offirm Ihat I om exempl irom the CoNracfor's Ucense AooaeS51 6) . G) % %t%p S N !] N
Law for Ihe following reason ($ection 7031.5, 8usiness and . ,
Professions Code): aeE etvi '
I, as owner of the property, or my emplayees with ADDR SS , .
woges as their sole compensmion, will do the work and ! 7 A
he struclure is nat inrended or offered for sate (Section - i Ocnuiv -
7044, Business ond Protessions Code . ' MOVING , iFt: E • • • • • .
1, as owner of the propeny, om exdusively comracting CONTRAt CidL A-f :•-`1! YT.if::i5 90 .NO:"
with licensed contracrors to constrocl the project (Sec- "•^'" "' ' °1'"' . I 4 . Q
lion 7044,.Business ond Professions Code). . ADDRE55 _ .. ., -. .., . . . .
REOUIRED - TOTAI SETBACK FROM EXIST. • 5. L 9 3 0 0CONSTRUCTIONLENDINGAGENCYSEi8.4CK . QRD.; L WY ,,,,,yRQPo LINE WiDTN
I hereby affirm that Ihere is a construuion lending agency for FROr i -' ' . C-2,
the performonce of he work for which this permit is issued a i ' , ""
SeC. 3097. Civ. C.. SIDE .. , . - . -
I ;;P.u" ... • , - ' .
Lender's Name '/ / ?
r P.C.Feeb':.T L'-IJ' Perm i fee .7 p•-i n
Lender's Address _ , , _ , . , . _
W I tenify thm I have read rhis applimt on ond staie ihai the - ,. ; r. isi ce Fee' °' '= •'V ' -
ao6ove informalion is rorrecL I agree to mmply wifh all Counly invesi gai on Fee . . '/ ' -
ordinances and State laws reloting to building construclion, . To ol Fee 5^7 . 1, , ,
a d hereby aWhorize representotives of Ihis County to emer .
an the above-m ti ed properry for inspecHon orposes. _ __ _ _.. -.. _ _, __ - - - -- - - - -- -
i
7J/( + -- SEE REVERSE FON EXPIANATORY IANGUAGE
jn
X1 ULg i zi<o JC,('x r-?o a _ . t /
Ob4'NFiR-BUILDL•R DECLARATION
PLANS TO APPLICANT . INSPECTOR'S NOTFS '
I heroby afiirm tha! I am exempt from fhe Conlraclor's
To: Ratumad . .9 K f7/ W /r/fUG LOLJ'`- C°nse law for ihe' iollowing rAason. (Sec. 7031.5)
App oved Dusirsess and Profrssionr CuJe: Any riey orcnunty mGicb
Vo. Dato No. Date , . reguirrs a penniL 10 owuerart, altcr; inrprocc, demol'uL,
or repair arsy struct are, prior tu ies issxance, also requires
w aprr anolor sucG fcrntit to filc a signcd statnnent
tbat Gc is licensed pursuant to [I e provisions oj the Cott-
c J lrcctoriLiccnarLeu(CLaf trr9Jl ommenainga itbSec-
f ' tion 700Df of Uix esion 3 f 11 c liusixets uxd Professiont
ry F'7, /, l• CodefortlalGeisexemf.lticrrfromandtGebasitfostbel{"
1 / -J. /
jp1i'"" `
nlleged excmpfiox. Any rinfafrors nfSettion 70j1.S by
Reqvlred
DoteReeoWod '^ ./ i! /,11,^S.Oa`l `I::..!../!.:•.•c°, anyapplicar.tforaf ennitsubjectstleof plicanttaaeivil
RDrovala - or Approved . , _ _ Qersalty of not r rr 1Gan fivc GursJreJ dollars (S$OOJ.f: Yes. No .. . - ` -'._ ..
j •.,._C,{:.1 _. - r , os owner of ihe properly, or my employees wilh
Yatcr Certificate ' .. .. , wages as iheir sole mmpensation, will do the work, ond
the structure is not inrended or offered for sale (Set. 7044)
Health Departmont - ' . , . ,: . _ , Business and Profetsions Codc: TGe Cantractork Licenac
Lau. docs not apply to an omner ojproperty wbo duilds
Fire Deportment ', or i»proues tGerenn, and u bo docs tach rrork henrseJJor
t/ rougG ) is oacn enr/lo ers, fronrded tl ae sucl im-
Grading . ,, . provements are nnt intcaJed or offered for sale. !f,
bou evcr,lLebuilJingorin+procrurentissnlduitlinone
Geologiml .. year oj eompletion, t/e ou.ner-builJer wr!! Gave tGe
burden oJproving lbot bc did rsot buikl or inrprovc jor
Pedestrian Prolacfian - .. tbe /+urpose nf saleJ.
Fence) (Canopy) . I, as owner of the property, om exclusively coNrao
tirg wilh licensed controctoa Io construct tho projecf (Sec.
Speciol Inspection ' - 704d) IIutrness aad Projessions Code: TGr Coneractor'r
Conc.) jMasoniy) (Welding) Licersse La:rdors riot applv toan otener ojpraperty wGa
builJs or imrroxrs tl emon, and u l o contracls for suc!
Lof Droinage - projects wilG a eantracmr(sJ litensrd pursuant to tGe
Conlractor's Liccnsc LavJ.
va k- . ;
IamexemptunderSec ,B.&P.C.forlhis
reason .
Date -. . . Owner
Approvois Doto Inspetlor i Slgnaturo . - -
INSFECiOR'S NOTES
LOCalion—
Set6ock & Yards)
Fo ndc ions
Stab
Frame
Energy Insulation
Lath/Drywoll—
IMeriar
Loth—Exterior
House Num6er—
Correct E Posted
Finol—
En1er on Fronf
b S
G --
COUNTY OF LOS ANGELES
w rie;te p:pir.g i;r t e eollectian or disposel
af liquid rrs:tes shzl: t^ ieshicled to thos
isposa a domest: cr scr.i!^r; , sr.n age frem Such Iaciiities as
reslroams. ehan¢e re''r. - rn •n'• 'nr a.
ash .6asms or drinkEr.g (p.isins irstalled in ny location^,within