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Home My WebLink About0848A 0869A _—_ \ WOHKERS'C07vIPENSATION DECLARATION . �� I hereby affirm thot I hove o terfifimfe of[onsenllo 5e�f . APPLICATION FOR BUILDING PERMIT insure,or a certificote of Workers'Compenstion Insuronce,ar �a�fc�eJ�t�/e�j��Jt/Jyereof(Sec.3800,lab�.[�f�/`J�� -gq—� COUNTY OP LOS ANGELES BUILDING AND SAFETY 761'cyffNo. O Company `�'��I%/7LL/[.i � Certifed copy+s hereby furnished. FOR APPLICANT TO FILL IN BWLDING a/i✓7 G ADDRE55 /J V-d � Certified copy is filed with��he county building inspec- BuiLDINc � � tion department. ADDRESS LOCALITV � . NEAREST . . Date Appliconl CITv ZIP CROS55T. CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLOGS. ASSESSOR � � COMPENSATION INSURANCE SIZE OF LOT - NOW ON LOT ' MAP BOOK PAGE � PARCEL (7hi5 section need not be wmpleted if ihe�permit is for one r USE ZONE MAP hundted dollbrs($100)Or less.} . TRACT �J�/�'d . BLOCK LOT NO. � �� NO. �� } TEL��p��y � CONDITION$ � I certify ihat in the performance of the work for which�his OWNe NOYJ 5`✓/� � permif is issued,I shall�not employ any person in any manne� 915TRICT . GROUP TVPE FIRE PROCESSED 6Y V so as�0 6erome su6jecl ro fhe Workers'Compensotion Laws. ADDRE55 - CONST. ZONE � /O �c� . / O Date ApplicaN CITY -ZI7 S7ATIS1IGAL CLASSIFICATION APT. CONDO. (~j NOTICE TO APPLICANT:�If, afler makin9 Ihis Certificate af ARCHITEGT�OR � 7EL , � .�y Exemption, you should become subiecf to Ihe WOrkers' ENGINEER NO. CIASS NO.�DWELL.UNITS�� . y Compensation provisions�of the Labor Code,you must forth- � ' qpDRE55 SEWER MAP � Z with tomply wi�b such�provisions or ihis permit shall 6e � � deemed rewked. . � .� � TE�' ��f�,�� BK.�PG, .Zl� YALIDATION CONTRACTOR NO. UCENSED CONTRACTORS DECLARATION ��, y , I hereby offirm thot I am licensed under provisions of Chop�er 9 A�DRE55 N J yp�UAiION 4�Q[��A (commencing with Se<fion 7000)of Division 3 of the Business and �� /J n tj p P�ofessions Code,and my li�ense is in full fOrce and effeci. CITY CLA55 �,i � $�v .�� #�• • � '2� Q (� �+�,('''� � SQ.FT. � NO:OF NO.OF CHECK LiCenSe NUmb@r�v�Q3] Lic Class�,j� ' S12E SiOR1ES FAMIUES ONE . � • •4�.� � - �J $ Coniractor �+ ��/� �2,""Z f DESCRIPT N OF WpRK �l�i'LfLY�Date� ADD � •-s e(i';.� 2? ❑ u I am exempt from�he licensing requiremenfs as I am a licen5ed architect or a registered professional enginear- . AiTER � DATE`��"�"` ' �'�G`�'� acling in my professional tppatify (Secrion 7051, � Business and Professions Code). u5E OF � REPAiR � � EXISTING BLDG DEMOI � BINAL . �� ., /��. lit.orReg.Na� Da�e APPLiCANT Y ,,�� OWNER-BUIIDER DECLARATION PRWT O. I "q j,//�p I hereby affirm that I am exempt from Ihe CoNracfor's license r p�� G�� 1� �'"��'�"��"� Law for�fhe following reason(Sectian 70.31.5, Business and � ADDRE55 !i/O � ��(/"'"� � Professions Code): E . � - �� ❑ . BUILDING ��t��,v�,f�� .. I, ps owner of the properfy, or my employees wifh A�DRE55 wages as their sole compensation,will do�he work and � the structure is noi in�endad or offered for sale(Saction . �OCAiITY ,. . �� p 7044,Business and Grofessions Code). MOVING � TEL. M��y�J,J�� '�'c�� I,as owner of�he ro erl am exClusivel ConhaClin CONiRACTOR NO. - . - P P Y, Y 9 � S`� `OH69Fl � with licensed contracbrs to construct ihe project(Seo qoDRE55 tion 7p44,�Business ond Professions Code). � �O #s • � . o � � '1 ' � REQUIRED TOTAL SET6ACK FROM E2fIST. � CONS7RUC,TION LENDING AGENCY � SET BACK YAR� HWY 7R07.LINE WIDTH �� I hereby offirm thot�here is a conshudion lending agency for fRON7 Q� �� ° •�d 5 S� � rhe performonce of 1he wo�k for which�his permit.is issued P.L � .(Sec.3097.Civ.C.). . �. Sioe . � • '� ��''�r.;.:.'�.� . P.L. Lender's Name � p 9� t�f� � 2.Q 2'-�� Lender's Address P,C Fee S ✓�l f/ Permit Fee \ 1 Q� � � � I certify Ihat I have read this application and stme that the � Issoance Fee /�J� - - above informarion�s mrrea.I agree to compty wi�h all Counry � io�ev��go�io�Fee �� ✓� � ordinances and Sta�e laws relating to b�ilding constroction, To+al Fee � � and hereby outhorize repre%entatives of ihis County to enter � upbn Ihe qbo�e-mentioned property for inspection porpoaes. � . . L '� .-„�`�i SEE REVERSE FOR EXitAHA70RY'LANGUAGE � Siqnolu.e of Appli ant or Agent Dote —� � 83 � � RLAAfS i0 APi.LICAt1T INSPECTOR"S N6iE5 � OWNLR-$UIL17�R 17ECLARATIUIV - 1 hareby affirm�hat I cm exempt from the Contracior's To: � lielurned �/-�//�_ �'�'�r��,,�,`�,,,� �n A�,,��'M�...�,..,��.��„mUcense Law for the following reasan. ($ea 7031.5j ApR�a�ed �-�'j. Bessiness and PraJessions Code:Any city ar comndy whitl✓ No. Date ho. Dafe � ,'7 �. � requires¢permit to consYruct,alfer,ine�rove,demolish, or repair any structure,prior to its issuance,adso requires � , �� $�;�,! tfie applicant far sucb permit to file a sig�ed sSotemeat . that be u lrceraed pursuanl to tHeprooisions oj tbe Con- � �� : ��.r„Y, � ��,,,,� trattor's License Law(Cbnpter 9)(crommendng-with Seo- tion 7000J of Division 3 of ibe Busi�ess and Professions � � . � CodeJ or tba0 be is exerxpt tberefrom and lbe batis jor the . nl(eged exempNon,Any viobtion of Sec6ion 7031.5 by - . Rpalr�d Dala R�xeOved � � � axy af�pl£cantJora permit sv�bjoe#tbe applfcaf�i Eo a ctivll ApproVals rs. Na or Apprawd � penalty oJ not more thax Jiue bundned dollan(dS00J.Jr _ ,__ � - , � � ❑ I,as owner of the property,or my employeea wtth Woter Certifitate - � , woges as iheir sole rompensotion,will do ihe work,and �- the structure is not intanded or offered for sale(Sec 7044) Heahh Dapnrtment , , Susiness ard Profeasions Code:The Coatrxtar's Licease Laeu doos aot apply to an owner of propsrty wbo buiWs Fire Deportmant � os i,nprovea tbereox,and mha does such work birrraslf or - thraugb his oum empToyees, prooided tbai sncb im- Grading � provem¢xts ore wot ineended or offered for sak. If, � � � � bowever,�bebutfdsngorimproverweetiasoldrrritbinoae Geo(ogical � � . - � . year of compktson, tl�e ownervdkildes will bave ebe . � burden ojproaing tbai be did not bn!!d or£mproveJnr Pedeshian Proroe6an . . � the purpose ojsafeJ. (Fence)(Canopy) - � - ❑ �,as owner of the property,am ex<lusively conirao- � tirg with licensed contractors to construtt the p�oject(Sat. Special Inspection � _ '�i)44)Bwiness and Profes.alFof'3'�'od�q:Tbe CoxMoctor's (Conc.J(Mosonryj(VJetding) ' License I.au dnes not af�pCy ro dn owa¢r of frop¢rEy wbo . � ��..buil�ic or improues.:lFiere�n,ndd�:;f(rbo';cbeilrrces for sutb Lot Drainage � . �Qrojects�witb¢caaEractor7sf��Ticensed�us.suaet to tbe � Controcior's Licenae LawJ. Porking - �� ' � ❑ I am axempt undsrSec. ,B.gf�.C.forthfs � � � � ' � reason � , . . . ... .., . . , Dole Owner . . ..:.._., . � �. ......,- . . .. ... . -- . - . Rpprovatz Datc � Ins�oclor' Si�nature � ' � � � INSPECTOR'S NOTES � Locatio— . . . (Se .Yards) � ations � Slab { Frame . ' - . � Energy Insulation � � . Lath/Orywall— . ' Interior � Lath—Exterior . - House Number— _ Correct&Posted � Final— Enrer on front �