HomeMy WebLinkAbout1817 PEACEFULL HILLS RD (2)r w & rv�•��y��
WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certif at of consent to eel( APPLICATION FOR BUILDING PERMIT
insure, or a certificate of Workers' C m nstion Insurance, or
a certified copy thereof (Sec. 3800, C.) (I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Common y 10, S -
❑ Certified copy is hereby furnished. -
Certified copy is filed with the county building inspec-
tion de ortment.
'Dole p Applicant -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectionneednot be completed if the permit is for one
hundred dol lots ($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- -
—NOTICE TO APPLICANT: If, after making this Certificate of --
emption, you should become subject to the Worker-
, -,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 offirm that 1 om licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
- Professions Code, and my livens is in full force d effect.
Lips
mbar _ Lic. Class
C ntra'clos Date
am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer
. acting in my professional capacity (Section 7051, -
Business and Professions Code).
Lic. or Reg. No. Date
' - OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):, -
I,• as owner 'of the property, or rry employees with
wages as their sole compensation, will do the work and
the structure is not intended or offered for cote (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 I nding agency for
the performance of the work for which thi permit is issued
(Sec. 3097, CN.
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 wilh.all County _
ordinances and Stole laws relating to building construction,
and hereby authorize representatives of this County to enter
FOR APPLICANT TO FILL IN
ADD u—
BUILDING �J
/
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ADDRESS /
LOCALITY U7-^ 4,9—•
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CITY F'f'� G(.T
CRNEAREST /T
OSS ST.
NO. OF BLDG$,
ASSESSOR - -
SIZE OF LOT OO
NOW ON LOT •�
MAP BOOK PAGE
PARCEL
USE ZONE
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LOT NO.
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SPECIAL
OWNER
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CONDITIONS
DISTRICT
GROUP
TYPE
FIRE
PROCESSED BY
ADDRESS
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CITY
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STATISTICAL
<!�O CLASSIFICATION 'F
APT. CONDO.
ENGINEER NI ER u A"
NO. b —
�SS NO. �V DwEu. UNITS —
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ADDRESS d
SEWER MAP
BK. PG,
VALIDATION
TEL.
CONTRACTOR NO. -
LIC.
ADDRESS -
NO.
VAIU�gTI N
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CITY
CLASS
s C l>�10
FINAL
DATE
(' • 2 8+' P 7 1
s A P 2' 7 1 T
-07.12-B2
SO. FT. NO. OF NO. OF
SIZE STORIES FAMILIES I
-CHECK
ONE
/^
DESCRIPTION OF WORK Ili t9 E It,
NEW
_ -
ADD -'-❑
ALTER _ ❑
REPAIR �
'
FINAL
USE OF
❑
EX15TING BLDG.
DE MOL
' BY
-
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APPLICANT C TEL ��'7�
-((PRINT) - LES
NO.`A�-/`
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J . (/'Mif% a-'r
ADDRESS -
PRESENL
BUILDING -- -
ADDRESS
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LOCALITY ., -
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MOVING - TEL. -
CONTRACTOR -
NO.
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:n 3 3 0.2 A
ADDRESS
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+ • • • • '�
•4 a 9, 0 0
••489,00
REOUIRED
SET BACK
YARD
HWY
TOTAL SETBACK FROM
PROP. LINE
EXIST.
WIDT
FRONT
PL.
SIDE--
P.I.
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IQD6-82
7�
a 5
P.C. Fee
Permit Fee p
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Al
Issuance Fee
-
Investigation Fee-
-
Total Fee ,SI
' upon 1 e ove- ed property for inspecti/u.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signorure of Applicant or Agent Dote
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