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Home My WebLink About1000A � . WORKEFS'COMPENSATION�ECIARATION � � � - �� I hereby affirm that I have a certifimte of�o�5e��,o,e�f .� qpp�,�CATION �FOR �3UI�.DING PERMIT � inwre,or a certifimte of Workers'Compensation Insuronce, , or a certified copy rh�er+eof(Sec.3800,Lab. . COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo.��o.3�O Company � BUILDING � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AODRESS �7 2 � 7�j7� � � CerNfied copy is filed with ihe coonry building inspec- gULLoirlG ' � fion departmen�. ADDRE55 � � — �—C7^Applica � CITv ZIP LOCALITY CERTIFICATE OF EXEMPTIO OM WORKERS' - NO.OF 6LDG5. � NEAREST ��.!' .x� � � COMPENSATION IN RANCE � SIZE OF LOT NOW ON LOT � CROSS ST. 3 A (This section need not be completed if the permit is for one � � � � / ASSESSOR .� � �� hundred dollars($100)or less.) .. TRACT BLOCK LOT NO. MAP BOOK' � PAGE. PARCEL ' TEL. US 20 E MAP p f certify that in ihe performance of the work for which ihis O`NNER � Ci NO. "�S r NO, df7'��3 � y permif is issued,I shall not employ any person in any manner qDORE55 Z. h�d � �V�� (�QGO SPECIAL� - � --� -�0- so as to become subject�o the Workers'Compensation lows. CONDITIONS u . . CITV . ZIP . . . . .. . . . � Date Applicant � qRCHI7ECT OR nEL 4QI � NOTICE 70 APPLICANT: If, ofter making this Cartificate of ENGINEER �,f,� DISiRICT GRqUP TYPE . . '-PIRE PROCESSED BY Exempfian. you should become su6ject to the Workers' e� � CONST. ZONE Compenwtion provisians�of the Labor Code,you must forih- qpDRESS 1 n• �Tf17� . �O _ �- with comply with such provisions or ihis permii shall be lI� •{ � � h deemed revoked. CONTRAROB I �� NO.��V��{ STATI$TICAI CLASSIFICATION � APT. ONDO. - � Z IICENSED CONTRACTORS DECLARATION - �i�. C1n55 NO. bWEtl.UNI75 I hereby affirm Thot 1 om(itensed under provisions of Chapter 9 AO�RE ,� . NO.�j� e� �� (commencing with Se'pion 7000J of Division 3 of the Business and _ �� SEWER MAP � Professions Code,and my license is in full force and eNect. CITV 01./11} CLA55 I BK- � � � - VALIDATION�� ^ p�� SO.FT. NO.OF �f NO.OF CHFCK . � Litense Number��-I� Lia Class ■ _ SIZE $TORIES 4 FAMILIES � � � � ONE +/'��,.� 1 VALUATION Canfrattor�/�+'��Y�.� 1� Dpte �a7��S DESCRIPTIONOFWORK �)( �jO NEW � _ %Q ry 1 �� , � pV(/ ,i' O A� � ❑I am exempt onder Sec. � � ALTER B.&P.C.for this reason REPAIR � � _- � � -, �� O O�O A Date: USE OF DEMOL EXISTINGBLDG. 1� ❑ #• • •.�'�1 .. Signature � APRICANT /� TEL. FIN y �y . . OWNER-BUILDER DECLARATION , P2iNT V)�l/S � NO.� D J S � � • •9�,O O 1 hereby affirm that I am exempt from the Contractor's License . Low for ihe following reason.(Section 7031.5,Business ond ADDRE55 � � (?�� FlN - • • •9�j,Q�� Profeuions Code):.. . . . . By. " . . . � .. . � .❑ . . BUILDING . . . . . . . .. 0(1`2 7••�}Jr.. I, os owner of Ihe property, or my employeas with ADDRE55 wages as their sole compenwtion,will do the work and ' � ihe sfructure is nol intended or offered fo�sale($edion �aa`��T� � - �7044,Business and Prafessions Code�. MOVING �-�� TEL. � � -�� -� � � � � � 1,as owner of the property,am exclusively confrotling COnITRACfOR NO. _ � �wilh licensed contracton to canstruct the pro�ect(Sec- ADDRESS- � tion 7044,Business and Professions Code). � �� CONSTRUCTION LENDING AGENCY � � � SE7�BACK YARD- HWY T�TAp OTP,LNE WIDTH� � � � � I hareby affirm ihal fhere is a mnstruction lending agenq for FRONT � � � fhe performance of�he work for which ihis permi�is isaued �� P.L - . � � (Set.3097,Civ.C.). SIDE � P.L. Lender's Name �-7� . S . .�. ,,,)v IDMA Rat.M � � � � �� - - P.C.Fee§ � Parmil Fee �� - >= Lenders Address / iF I certify thal I have read fhis application and sinle fhat the ._ . . . . . Issuance Fea `�� O IOMA P/C N� , � � � � � a above information is tonecf.1 agree ro comply wifh all County Invesr�garion Fee 9¢ . g ordinances ond Smte laws relotin9 ro b�ilding construction, . . � imal Fee /d� �O iDMA Perm.N � -� � � � u an ereby aurhorize representatives of fhis County to enter � � a th above- en� n ro ty ins ecfion purposes. , a ,�� /;,��}'�}�. SEE REVERSE FOR EXPIANATORY IANGUAGE ///// �{ � /� // �� y� � �..�.irr�y�— V��•G-t-$RJ O� �i p i Signah�re of Applimnf a nt- .. .. Date .. - . .. . - . . .. . J . . . . ( d��e Co�� !v-2 7�'� _ '�-.�_ PLANS TO APPLICANT INSPECTOR'S NOTES O�VNER•BUILDER DLCLARATIDN � . . I hereby affirm that I am exempt from the Contrador'S To: � - ' Relwned � � � � � � License Law for the following reason. (Sec. 7031.�� Approved Bsssiness and Professions Code:Any city or couary whicb No. Data Na � DoTa�' � � �� - � requires aPerrnit lo coxstar�ct,a[ter,imQroue,demolish, . . or repair an.y structure,prior to ila issearzce,okn requir¢s �� , ,� -. . � � . the applicant for ssstbQermit to Jile rs signed statemeat that he is licensed pssrsaaat to t6e prooisrons of 6fie Con- . . - . - _ tr¢ttor's License I.aw/Cbapter 9J(ca»iroxencing witb Seo- � tian 7000J of bivi3ion 3 of tfie Busdness and Professions � ... ,.,, - , ,. ,,, , ' CodeJ or[bat Be is exempt therefrom¢nd the basis/or tbe � � -� � ¢1leged esemptiox.Any violation of Section ]031.5 by ..- . � � Requirqd " -�- Dafe Recafred � . any applicattt�or a permit subjects tlse applicant to a civil Approva1s or Approvad pe�alty of not mare than five hundred dollars($S00/.J: Ya� No �� " - _ � ❑ I,as owner of Ihe properfy.or my emplayees with Water Certitimte ��. �� . � . , . _. � . wages as their sole compensation,will do ihe work,ond - � - �� - - � � � . � the siroctore is not intended or offered for sale(Sec.7044) Heahh Department . � -. _ . � �� `'� � � ' - • . - � Business a�d Prof¢ssinns�Cad¢:Tbe Coatrador's License � Law does not applry�to on owner of property who builds Fire DepaHment _ - or improves tbereon,and wbo does such work bimself or � - throagb his ourn employees, provided tbat rucb lm- Grading � . ' � - pmoem¢nts nre xoe ixterded or of/ered for sale. If, . � � � �bowever,tbe building or improvement is sold uritbin one Geological ' . . _ . �. �year of completion, !be owner-beilder tuill bave 15e � i-�, . „ .. . -. .,, � burdeu of pravixg tbat be did aot build ar improve for Pedesirian ProFaction -� - � _ _ tfie purpose of salef. � � (Fence)(Canopy) - � ` ` ' � �� ' � � � ' � � ❑ I,as owner of the property,om ezclusively contrao . , iing with licensed conhactors�o conshuct the project(Sec. Speciallnspection � � 7044)Business attd Professinns Code:-Tbe Cotttr¢t[nr's �Conc.)(Masonry)(Welding) � - , . -� , , . Licefu'e Law does not apply.to'af�otan8r ofQmperty wbn - buiJds or imQroves lhereoa;and�mbo'coxhacts for sucb Lot Drainage � � -- �� - ,- �.. . projecss weth a rontractor(sJ.lecensed parsuant to the ' � �- Contrattor's License Lau�J. � � - � Parking . .. ' . . . . . . " � ❑ I am exemp�under Sec. ,8.&P.C.for this reason �� . . Date � Owner , .i` . �-. . ., � . Approvals Dafa Inspedor's Signature , , � , , - � . �. . . - � � INSPECTOR'S NOTES - � Location— (Sefback 8 Yards) � - - � Foundarions - Slab . . . � -� � Frame . . - , � � Enargy Insolafion . � � � � � � . . � , Lath/�rywoll— . . . . -... .. . � . Inlerior - � � - Lath—Ezterior s � � � � -- � � � House Number— � - � � . . . . . Correcl 8 Posted Final— . . . . . . � Enter on front � � - �,