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HomeMy WebLinkAbout1352A _..��-____,__ __ ,WORKERS'GOMPENSAiION DEQARATION - ' '<' � � � � a,,�e�.eb� affirm lhpt I have a certifiwte ot�o�se�„a��f � . qpp�ICATION F4R BUILDING PERMIT insure,or a cer�ificate of Workers'Compensation Insurpnce, or 6 ce�tified copy�hereof(Sec.3800;lab.C.) COUNTY OF 40S ANGELES BUILDING AND SAFETY Policy No. � Company� ... . BUIIDING n J,,� � Certified copy is hereby furnished. FOR APPUCANT TO FILL IN o�3zp S� �/�+••-�^� � AD�RE55 �t•� � .Certified copy is filed with the county building inspeo- �� gUILDING - tion depariment. ADDRE55 � � � E,(�` 1^ �_�j� Date� � Applicant -- CITY ZIP J LOCALITY � � � CERTIFICATE OF EXEMPTION FROM WORKERS' � - � � � �� ���B��S- NEAkESi - .. .. ...._.. � � �COMPENSATION INSURANCE . SIZE OF LOi NOW ON LOT CR0.55 Si. y,� i (iFis section need not be completed if+he peimit is�for one � -� � - - ASSES50 � �� � bundred dollars(5100)or less.j , . . TRACT BLOCK LOT NO. � pnp,p � , pqGE PARCEL TE�' USE ZONE MAP I tertify that in the performance,of the work for which fhis OWNER � � /' "NO: r0�•� 7 pp !� — �y/� � . . ,r parmit is issued,��shall not employ any person in any manner A�RE� ,.F,I � - � SPKIAL - �� � � - � d so as lo become sobjecl to the Wor rs'Compen ion ws. � CONDITIONS v bate�-�` R F .Applicant � �. CITY � ZIP . � .. .. . . . . . p� NOTICE TO APPLICANT: If, ofter mpking this Certif' te of ARCHITECTOR TE�. DISTRICT _ GROUP TYPE FIRE . PROCESSEDBV._ G Exemption, you should become subjecf fo ihe Workers' � ENGWEER NO. CONSi. ZONE Compensation provisions ot ihe lo6or Code,you must forth- W wifh comply ifh�suth provisians or this permi� shall be .. ADDRESS �l � � .. . � daemed reVoked. STATISTICAL CL4551i1UTl N APL DO. Z �`� � CONTRACTOR NO. . UCENSED CONTRACTORS DECLARATION� � ���� � � - - � � � �-���.� �� � CtA55 NO.�DWE«UNITS � I hereby affirm tha�I am licensed under provisions ot Chapter 9 qDDRE55 n10. �R� , (commen<irg with Section 7IX10)of Division 3 of the Business and . . . . . . . .. . pC. , � ' - Professions Code,and my license is in full 4orce and effecL CITY CtASS 8K - �: � . � -VALIDATION � �� � SQ.PT.n NO.OF Np.OF CHEIX .. . license Number Lic Closs 5¢E J� STORIES � � FAMILIES ONE� ... ' . . ... - . . . . O .VALUAAON . .. . _ .. ��� CoMracfor .. . Date � . . DESCRIP'f10N OP WORK.. . . .. . - . .NEW � s �q�, . ,, �P � Acw� PAT�� ADD ` , �I am exempl under Sec. � - ❑ � ' ALTER B.BP.C.for fhis feo5on �V REPAIR '� �� � � � � � � -'135.2A .. . . . . Date: u5E OF DEMOL � . . EXIS7ING BLDG. . �� �.�'� ,� . �$ignafure . . ... . . . � APPLICANT TEL. FINAL � . OWNER-BUILDER DECLARATION PRiNi NO. 1 hereby offirm that I om exampt from lhe Contractor's License ��� �� ' � -0ATE � �-s�a[J.,'��,0 Q Low for the followin9 reason(Section 7031.5, Business ond ADDRE55 FINAL � � � s �Vrofessions Code): - - �- - �� � � N - gy . . � � "�'� �4`^0�u. � BUILDING , � I, as owner of}he property, or my employees with AD�RESS / . �'�,.2 7`8[� wages as their sole-mmpansation,wili do the wark and ' ' � � ��� � the struc�ure is not intended or offered for sale(Section ���m � � � �� 7044.Business and Professions Code). MOVING � � �� � � iEL. �f � - -�- - ��--� - � � I,as owner of fhe proparty,om extlusively caMracting CONiRACTOR NO. 1 i i., LI `f� J � ,.`...a�.�_V v with licensed contractors to constroct Ihe project(Seo ADDRE55 . . .. . ... .. �. . .. . . . . �. .. _. . . tion 7044,Business and Professions Code). - � . . -� � " � CONSTRUCTION LENDING AGENCY - � REQUiRE� rnRD � Hwr i07n�se7ar.CK .. . . . . . .. . SET BACK PROP.IINE WIDTH I hereby affi�m thot ihere is a consirvction lending agenty for FRONT � � the performante of the work for whith ihis permit is issued ��-� � � P.L -�- � � � � � -�� � � � - - � - (Sec.3097,Civ.C.). SIDE . � � . � ._ . .. _ . .... . 7.L. ._. ... . _ . . .. _ . � . Lender's Nome � $ ' LDMA Ref.R ' Lender's Addrass � � - P.C:fee E � ' � �' Permit Fee �Z_�� � � � � � � I certify thut I have cead this applicotion and atate that 1ha -. Iesuance Fae ����� -�- LDAN4 P/C S � ,- �� � � � above informatlon is torrecl.I ogree b comply wi�h nll Coonfy ���eziigatlon Fee V V . $ ordi nces and 5}ate laws relo ing to building construction, .. . . .._ �� � ' � pod ereby autho�i preseM tives of this County fo eMer Total Fee � LDMA Perm.M � � - � � - � � � upo e above-m ti ed pro erry for inspecrion porposes. _ � a . . —�f /� . . . .. . . . . _ . ._ . . . . .. .. ^ �. —�/—�k7 SEE REVERSE FOR E7(PLANATORY LANGUAGE , � � Signar�re of Applican� gant. . . Da�e . . . _. _ . _ . . . ... ... . _. _. . .. .. _. _. . ..... . .. . . . �.p i PLANS TO AVPLICANT INSPECTOR'S NOTES OWNEft•BUILDER DECLARATION I hereby affirm�hat I am ezempt from fho Co�,tractor'� To: Relunred � � � - � . License�Law for the following reason. (Sec. 7C�1:L'; � - Approvad — ��' � BusinessandPr%ssionsCade:Anycityorcourttymbicb No. Dafo No. Dafa � G - ..� �l reqssires a permit to construct,alter,irrtproce,demolisb, _ or repairany strucdure,prior ed iis issuance,ako requires .. - . . . . t5e applicant f r sucb Qermit 6o file a sigaed statement � � .tbot be is licensed pursuant to the provisions o,j Lbe Con- �}��� � tractor's License�Law(Chapter 9/(comraencing with Sec- � tiort 7000J of Divisiort 3 of!be Busixess and Professions � - � , . CodeJ or that he is exempt tberefrom and Obe basis for tbe � � � � � � alleged exemptios..Asy violalion of Section 703 LS by Raqulr�d Dafs Receired - . . . axy app[icana for a permit aubfects ihe applicant to a cirti/ �Approv6le � ersalt o not more thax :ve bundred dnllars 5500 � � Yos No or Approwd P Y l .f� I 1•l+ - - ❑ I,os owner of 1he prope�ty,or my employees with Wafe�Certificate . � � . . � . wages as iheir sole compensation,will do the work,and - �the strocture is not in�ended or offered�for sale�Sec.7044) Mealth Deportment. . . . . Business and Professioxs Code:Tbe Coatractor's I.icense Law does root apply[o nn oumer of property wbo huilds Fire Departmeni. . . . . • � - or improoes lhereos,and who does such work hineself.or � througb bu.owa��employees,previded tbat sucA im- Groding . �� � provemeaRs are not intended or.oJfered Jor aale. If, �� bowever,the baildin,q vr improuement is sofd within one Geological.-. � - � � . yeor of completion, the owner-builder urill have t6e bu+r/en of proving Lbal he did not bei�d or improve for 7edesuian�&oroc+ion� �� . � � theQurQoie of saleJ. � . . (Fence�(Canopy)� � � � - �- -� C." I,asownerofihe property,am exclusively�contrac- . ting.witH licensed contractors to wnstrucllhe projed(Sec. Special�nspection � � � - - - 7044)Business and Professiorzs Code:Tbe Contractoi's (Cont.)�Masonry)(Welding) � � � , Lice�se Law does not apPly to aA oeener oJproQerty who � - � � � ��-�buikls��or lmproves theseon,and wbo con6racts for ssch lot Drainage � , „ . .. . . . . projects witb a contractor(sJ licensed pursuaaa Eo tbe . - Contractor's lirente Law). - - . , Parking . . . �. ... . , � ❑��I am�exempi unde�Sec ,B.&P.C.for this reason � Date .. . � .. . . Owner Approvals D te �+' ped rSignaloro - - . . � . . � � � INSPECTOR'S NOTES � � location— � � �� .. �Setback&Yar J � '�`` ' r,,q,p " � � �1 '..t - . . . _. . . � Foundations ,k�„o- � - . Slah ._ . .. _ .. . . . . . � . .. . _ . �, .. Frame . . . � � . Energylnsulm�on , . � . - . � � � -.� �- . . Lath/Drywall— . . . . .. .. . Interior ...� . ... � Laih—Exterior . . � . . � . � - '� . -.. ..... . .. . .. - � . House Number— ' � � - -- � � _ ... . . . � �� ' Correct&Posted � � � Final— . . . _... . . . . , . . . � Entar on Froro � "