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Home My WebLink About0592A (4) WORKERS'COMPENSAlION DECLARATION � . � � hI hereby affirm that I have a certifitole oF�o�,e�;,a se�f � APPLICATION FOR BUILDING PERMIT . t,!iosuce„ar a certifica�e of Warkers'Compenstion Insvrance,or , o cenified copy�hereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PoliCyNo. Compony � BUIIDING (N � Ceri'rfied copy Is hereby furn�shed. FOR APPLICANT TO FILL IN ADDRE55 c� � �� It� rt '� �Certified wpy is fiied wifh the county 6uilding insper BUILDING !�� . �io�deparlment. A�DRE55 �3 (Y 7 L� � IOCALITY y_J C' C C NEAREST Date Applicant CrtV - Ziv / J CRo55 Sr. S - U L �� CER7IFICATE OF EXEMPTION�FROM WORKERS' �� NO.OF B�DGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT��fv�U NOW ON LOT MAP BOOK Pp.GE GARCEL � �This section need not be completed if the permi�is for one � u5E ZONE rmnP G . , � -� _ hundred dollars(5100)or less.) Tan[i etOCK t0 LNO. .�^� SO.CIA` _� _ a 1 cerlify 1Fjo1 in Ihe performance of the work for whith ihis OWNER - H. .n7'� N�9�7�'S� , \ CONDITIONS � � ermit is issued,I sha�l nor em 10 an erSon in On manne� � DISTRICT GROUP TY7E FIRE PROCESSED 6Y �,J P P Y Y P Y ADDRESS�S.�S 1 l !vY/�pW � CONSFr�� 20N so os to become subject�o the Workers'Compensalion Lows. ^ y � � . � CIT1(}/I�F^OT�-� ,:yh�� ZIP � S I O � O Date Applicont ARCHITECT OR . TE�,_ STATISTICAL CLASSIFICA710N � APT. CONDO. V NOTICE 70 APPLICANT: If, oFier making this Cenificate of ENGMEER� �/� NO. 0.AS5 NO. DWELL UNitS a Ezemption, you shou�d become subject to the Workers' �n Compensotian pravisions of ihe Labor Code,you m�sl forth- ADDRE55 � SEwfR MAP ? with comply w�ih suth provisions or �his permit shall be TEL. deemed revoked. CONiRACTOR � NO. bK. PG. VALIDATfON .UCENSED CONTRAGTORS DECLARATION u� . , , I hereby ofiirm that I am licensed under provisions of Chap�er 9 . ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 af ihe 6usiness ond� UC. r �-y-1�D � Professions Code,ond my litense is in full force ond effec�. � CiTY CLA55 5 \a`�� . � � SO.fT. NO.OF {� NO.OF CHECK Litense Number Lic.Ciass SIZ STORIES FAMILIES � ONE � 5 ConlroCtor Date DESCRIPTION OF WORK'� ' � NEW Q . ❑ ADD � . I am exemp�from the licensing requirements as 1 am o l�'Y� licensed architect ora reqistered professional engineer . _, . � Al7ER ,� FINAL octing in my professianal capocity (Seuion 7051, pEPAIR � DATE .Business and Pro(essions Code). � USE OF ' E%ISTING BIDG. � f �EMOL � FINAI � By LiC,or Reg.No. Dme APPLICANT TEL � - �� - OWNER-BLJILDER DECIARATION - PRiN7� � -- NO. I hereby offirm Ihat I am exempf from ihe Contractor's License � Law for the foilowing reason(Section 7031.5,Business and AooRESS /J�� ytd7 c�v��(�p 5 q,.2A � � Professions Code): aRi eti L . ��' > � �� Bl11LDING . �F ! 9YD�iC� Ni�•(�� •r� I, as owner af Ihe property, or my employees wilh ADDRESS �+ c wages os their sole mmpensation,will do ihe work ond ��N,� /Z_� /��O'�� +,�.•Z�.5,� the structure iz not imended or offered for sale(Section � �OCALITY ify �044,Business ond Professions Code). MOwNG TEI. r /// � I,os owner of the property,am ezclus�vely contracling CONTRACTOR � NO. ��'�/f �_.}(� ��'�2��.5 Q U .�,N,w.,__� _ � wilh licensed controctors to construcl the projeU{Seo- aoDaE55 ' 9 � tion 7044,Business and Professions Code). � , � �.� .��8� REOUIRED TOTAL SETBACK FROM E%15T. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY pROP.LINE WID7H , 1 hereby affirm�ha�there is a constroUion lendmg ogency fo� FRONi � ' � •�he performance oi the work for which ihis permit is issued P� ' (Sec.3097,Civ.C.�. Sioe - � P.L. Lender's Nome � . � . . $ � lender's Address v.C.Fee E Perm��Fee � 0� � � 1 certify thm I have read this application and state thor the Isso ce Fee `),SQ , �- above information is carreq.I ogree b comply wi�h all Counry _ invesi�garon Fce � �� - $ ardinences and State laws relating to building constroction, Tmal Fee ►�j� . and here y au�horize represen�atives of this County 10 enter � a por�the bove- e " d pro erty(or inspeclian purpases. ' `¢ ,Z�,� � SEE REVERSE FOR EXPLANATORY IANGUAGE ' � Signature of APP�conl 0 9en1 � - � �i1 ' � PlANS 70 APPIICANT- ' INSPECTOR'S NOTES ' 0�5'NER-DUILDER DLCLARATION _ I horoby affirm Ihat I am exompf from fho Contractor'! To: � Retmned � � � � Litanse Law for the following reason. (See:�iO3LS� ' � Approvad ButrnessandProfessinnsCode:AnyeityormuntywGieb No. � Date No. � -Defe - � --requires a pennit fo constract,alter,lmprove,deniolisG, . , or repair any aeruclure.prior to its usuance,ako reguires � � � � - � - � - - . � tGe aff�licarct jor sueb j�crnzit to file a signed atatement , „ . 1Gat bc u licenscd parsuant to!Gc prouisions of tbc Con- . . " iractor'sLicenseLaw(CGapter9J(rommencingu�itGSen tion 7000J of Dinerion 3 of tFic Dasrness amd Professions Codcl or tl�atGe&cxcmpt tLereJronr and tbc basrsjar tGe , u!leged exemption.Any violation of Section 7031.5 by RequGod OnteReceived � anyapplkantJorapernrrtsubjecfstbeapplicantroadvil . .hpprovala_ . er Approwd pexalty ojnal mare tGan jrre bundred Jollan(SSOOJ.J: Yoe No � ' � �� ❑ I,os owner of the property,or my employees wilh VJaier Certificate � � � , . woges as Iheir sole compensation,wilt do th�work,and � � � . ' � the strucWre is not Inlended or offered for sale(Sec.7044) HeaOhDeporiment' - , � , BesinessandPrnfessiontCodc:TbeContractor'aLicentc , - - . � . Lam doci nat opply to an a�c�ner of proprrty wba buifdr Fire Department . or improves thereon,and wbo do¢s sucb a�ork bimseJf or - � �- tbraug! bis ou�n employees,prorided tbat sueh im- Giading � . provemenls arc xot intended or offered for sale. If, � , boerec�er,tbebuildixgosinrprouenacntlasoidwitGinone � Geoto9iml - , . _ . , . year aj ronrpJetion, !Le omncr-builder wi11 Gucc lbo , � burden ojproving tGat he drd not buifd or imprort Jor tGe/�urj�ose of safeJ. Pedeslrion Protection ❑ I,os owner of fhe (Fence)(Canopy) - - � � p�operry,omexdusivelycontmc- � , tirg wilh litensed conirac�ors to construct the projecl(Soc. Special Inspection � .- . 7044)IIusinesr and ProJessions Code:TGe Cantractori (Conc.)(Mosonry)(Welding) . � , LicenteLau�doetnota/�plyManownerofpro/�ertywbo � builds or inrprovcs tbcrcort,and wl�o con[rncts jor sucG . •Lot Droinogo � . projecls uitb a contractor(sJ liceracd punuant ta !bc Contraclor's Lirenre LawJ. Parkin9 ' ' � � ❑ lamexemplunderSec. ,B.&P.C.farihis � . . . ..._ . reason Do�e Owner } '� '' ��Approvals�. . "Dato. ;� Ir.spec!or's 5igna!urc � � INSPECTOR'S NOTFS . T Location— . . . . (Set6ack 8 Yardsj ' - �� Foandatians . � .i Slab ' ,. �.�r.; � f � - . . Froma ' • .� � - . . Encrgy insulofion � � � Lath/Drywall— Interior - � Laih—E#erior � . � � House Number— - Correcf 8 Posted - Final— � � Enter on Frant ' . . ,