HomeMy WebLinkAbout1745A 7868A WORKERS'COMPENSATION DECL4RATION � �
�6y affirm that I have a certificate o,�o�5e�r,o ge�, APPLICATION FQR BUILDING PERMIT
e,or a certificata af Wo�kers'Compenwtion Insurance,
certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
y No. Company q
Cerrified copy is hereby f�m�shed. POR APPLICANT TO FILL IN ADORESS � � �- t � �•
' CeAified copy is filed wifh Ihe county building inspao- qoo2e55 .�p�n� �• A��A GPUR.7� �
� tion department.
� ! Applicant am A[,..ru ZIP {78 IODUTY ,C� .
NO.OF BLDGS. NEAREST
� CERTIFICATE OF EXEMPTION FROM WORKERS' � 5¢E OF LOT NOW ON lOT CROSS 57.
COMPENSATION INSURANCE �1 p ASSESSOR
s secfion need not 6e compleled if fhe permit Is for one TRACT �3�-7 5 BLOCK LOT NO. 3O Mqp BOOK PAGE PARC�L
idred dollars($100)or less.) TEI.
' OWNER•TASPJIP� $. (�.7C��.fkT1 N�7�y"594'36 U EZO E �P �
vrtify that in the performance of the work for which this � /� �'
�mit is issued,I shall not em lo a erson in an monner AD�RE55�2Q&'O I Ibt�A GOU�T PECIAL r �' Y
P Y . Y � ' CpNDITIONS ��Y v`�' a
ps to become s�bject to the Wor r'Compansation Lows. � O
� C�TY W�l4At U� � Z�p �►78
,�e Applicanl - ARCHITECT OR TEI. �
�TICE TO APPL�CANT: If, ofter making ihis Certifimte�of ENGINEER - NO. DISTRtQ GROVP N�PN ZO E �«ESSED BY �
emption, you should become subjecf to fhe Workers �� � � � �
�mpensation provisions of ihe Labor Code,yoo must forth- ADDRE55 W
Hh com I with such rovisions or this � �
p y p_ permit shall be TEL STAiISTICAI CLA5�4FIC!}TION APT. CONDO, N
remedrevoked. mNiancioa OWN6 No.S9 '362
Z
' LICENSED CONTRACTORS DECIARATION � uC. a.o.ss No.��j_DWELI.UNITS
iereby affirm Ihat I am Iicensed under provisions of Chapter 9 ADDRE55 NO.
ommencing with Section 7000)of Division 3 of ihe Business LIC. SEWER Mna � � �
hd Professions Code,and my license is in full force and affect. ��ry ��u gK, pG. VALIDATION
I . SQ.FT./ NO.OF NO.OF CHECK �
tense NVmber Lia CIa55 SIZE v� S70RIE5 � FAMILIESs�u ONE . �I G'1 .7�5.a
� � . ` VALUATION
�ontracror �pate � DESCRIPTION OF WORK �t�b� 1 Dil/ NEY✓ ❑ s #� • • �'L v
�I am exempt�nder Sec. OF A RO�M �,f�f nf �.}.p(�gE � �noo � � ��� �'].�8 g
, B.BP.C.for fhis reason - �S'Ac'TN ILDc"M � I�aAl20Ny'EN�loS A�TER ❑ ; , , �� ��,�g g�
JREPAIR❑
Date: - EXST�INGBLDG. Q�SJ b�NTIhL � DEMOI❑ ��'� 7"�9
. Signature APPucAN7 J��Sf3�� ���+ULATI�� FINAL
� OWNER-BUILDER DECIARATION . fPRINT} NO.s -3G� /1.�-C�j)
hereby affirm that I am exempt from the Confractai s License � 2P(00 � �./�L-T�/�.C� DATE
cw for the following ieason(Section 7031.5, 8usinass and ADDRESS G J> FINAI
iofessions Code): PRe5EN7 � By .
BUILDING
� I, as owner of the property, or my employees wiih AopRE55 .
wages as iheir sole compensation,will do the work and ��TM � , �
the structvre is not intended or offered far sale(Section . �
7044,Business and Professions Code.) � MOVING �TEI. �����A
� I,as ownar o4 Ihe property,am exdusively confrocting CONTRAQOR ND. � . �
� with licensed coMratron to consirocf}he projecf(Sec- ADDRESS ' �t•' • ° •�
tion 7044,Business and Professions Code.) � .
�� CONSTRUCTION IENDING AGENCY . �7�BA�� �AR� HWY T�TA pROP.�IINEFROM � EXIST. � Q •2 8 b 2 5
''�hereby affirm that there-is a construction lending agancy for FRONi • � '
�e performante of the work for which this parmit is issoed P.�. � r �2�f:.�S i
ec.3097,Civ.C.). - SIDE .
' hION� r� � � G612�S4
ender's Name `�]
' � N,A - P.0 Fee E /' Permir Fee � ���Re4.M .
9nder's Address
'cerfify that I have read this applimtion and sfate that the iss�ance Fee �� � LDMA P/C N ►
ove information is correct.I agree to comply with all Counry �nves�igation Fee � ^ c
dinances a�d State laws relating to building canstruction, Total Fae �d�-� LDMA Perm.M
nd hereby authorize representatives of this County to enter
pon ihe a6ove- tion property for inspection purposes. � � � �
� �'( ��(R Q' SEE REVFRSE FOR EXPUNATORY IANGUAGE
/ � Signaturo of Appliconf or Agent �Date ' � . .
�`
� PLAlIS TO ARPLICANT � � IN$PECTOR"3 NOTES - � '- OWNER•BUILDER DECLAFATION
. , I hereby affirrn that I am exempt from the Contractor's
70: Rrtum�d _. � License Law for the following reason. (Sec. 7D31.5)
�� � � .� A{qror�A � � BusinessandProlessiansCode:Rnycrtyarwuntywhich
Ra. Dala No. Dtle • � � reGui�es a permlt to consfrucf,alter,Imprave,demoli-;h,
�---- --- , - � orrepafranystrecture,priottolfaissuanos,afsor�7vves
- � . ,.. . . -����•`� • � � � • . � . 7he eppficanf!or such permli to/r!e a slgnatl sfatement
7hat be fs!lcensed pursuanf to the provlsions o/the Con-
. � - _ t• �� � � � �� • � =� � . � tractoYs LiceRSF Law Ch� trr
.. ., .. . - . ( p �(commencing wrtHl�§ci=
� � fion 7C00)of Dlvfsion 3 0l tbe 8usiness and Pro7essions
. _� . - . . . CodsJ or that hr is arza�pt th�Jrom and thc basls far
� � � � � � �� �� , ,. theaflegc�exe�mptron.Rnyviolztrcno75ecfion7031.5by
� pequlrW . p�hR�� - . -� � � �� anyapplicantforapermitsutrlectstheapplicanttoacivil
- AgF{onmh.' � Y� �Q � �.�.«A�� � . .. . . penalty ol nof more fhan five hundred dollars($500J.):
- �� . � ❑ I,aeowneroftheproperry;ormyemployeeswith
..__.__._._—_ ----- -...... .. • . . ,_ .
Water Certlficate - - � . . � . , . - . � � .wages ae thelravle compensatior,will do the wcrk,and
� - the stfucture is not Inter.ded or otfered for sale(Sea 7044)
� '�' � ��- � -" � ' Sustnesa and Prolesslons Coda The Contrsator's L(cense
Health Department � � � ' . � . Law daoa not aFP�Y fo an ownar of props�ry who builds
FireDepartment � . . _. ._ .. . . � O!lmproveatherean,arMwhodoessuChworkhim.ssllor
� _ �.through h!s cwr, employees, prcvldetl that suoh Im-
Grzding" � � � . .. . '��provaments a�e not inta�ded or ollered/or sale. !f,
�� � '�.1��� -however,the building or impiovement is sold v�ithln one
Geotogical � yearo/complsfion,theownar-builderwillhave,the6urden
o!proving thet he did nat bulfd orlmprove for the pmpose
Podestrian Protection oisaleJ, �� �
� {Fence)fCanopy� � � ❑ �.a�o'�+�af the properl�,am excluelvely can-
. � tracting with licensed contractors to construct ths pro-
�' .. . . ject(Sec.7044)6usfness end Pro/esslons Cade:The Cart-
Special InspeEion ' � trscfor's Lfcense Lawdoes not apply fo an ownero)pro-
- (Con<.}(Masdnry)(Welding) � , �
perty who builds orimproves fhereon,and H�ho contracts
� � Jor such prolacts wlfh e contraator(s,�fice�sed pursuant
Lot�rainage �� . � - " . . . .� � ,- � - to the Conlractor's Ucense Lanq. . -
Pz�sking ' � . . . . � . . ... . . . ❑ I.am.sxer[tpt uader Se¢. ,6.&P.C.}or this
, _ . . . _ . . . � . reason
- �- � Dat¢ Owner
Approvss; Detn Imp�etar'a SlpnNun ' . . � � �
� . � � � � - IN56��CTOR'8 NOTES .
Locatlon— '_--__ � . . . ' , . �J
(Setback&Ya�ds) � � �
Founda:ions � . .. . .. . . . . � '� . . ..
SIa6 � !� K"1 I V'`C.�.� _..... . .._ . .. . . . . . , .. .
Frame f U� . . . . � � . �
Energy InaulaUon 4� �� � . _. - � � .. .. �. � � � . � � .
LathlDrywall— � ._ . . . .. .. .... .. � .
Interior
Lath—Exterior . .. � . .. - _ . . . . ..�}�...�.� . .
House Number— - � - � -- � . < � .- •� .
Corrett&Posted ���� � " �� � � �- �-
Final— . . . .. . . .
Enter on Froni � � - -
� . � .. . . � � � . �. � - .
; _ .
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