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Home My WebLink About1176A 1351A i WORKERS'COMPENSATION DECLARATION . � I hereby affirm �hat I hove a tertificate of consent to,e�f � APPLICATION FOR BUILDING PERMIT 4 insure,or o certificafe of Workers'Compenwfion Insurance, or o cert�fied copy thereof(Sec.3800,lab.C.) COUNTY�F LOS ANGELES BUILDING AND SAFF�� N� PolicyNo. Company BUIL�ING � Certified copy is hereby furnished. FOR APPLICANT TO FILL IN � ❑ ADDRESS - . Certifiad copy is filed with the county b�ilding inspec- BUIIDING � l �,,1 tion depariment. qooRE55 LpCa,u'fv / kY�� - NEAREST Date � ApplimM OTY ZIP CRO5557. CERTIFICATE OF EXEMPTION FROM WORKERS � NO.OF BwGS. n55E550R - COMPENSATION INSURANCE � SIZE OF LOT NOW ON lOT MAP BOOK PAGE PARCEL (This section nead not be complefed if ihe permit is for one � USE ZONE Mt�7 �L hondred dollars(5100)or less.) TRACT BLOCK � lOT NO. NO. � ��T T l, SPECIAL I Certif that in the OWNER CONDI710N5 d y performance of�lhe work for which this �iSTRiC7 .GROUP TYPE FIRE PROCESSEDBY 0 permft is issued,I shall noi employ any rson in any m r qDDRE55 S° ' ' CONS ZONE U sa as to become subject to the Wor em pen ' Laws. : ��fQ�q� � f �� O ��'-9ate�L� Applic CITY • Z�P STATISTICALGLASSiFiCATION APT. C p. ARCHITECT OR TEL. NOTICE TO APPUCANT: If, ii Cartificate of � ENGWEER NO. � V Exemption, you should become sub�ect lo the Worken' C1A55 NO. DWELL.LINITS W� Compensatian provisions of}he Labor Code,you must forfh- ADDRESS SEWeR MkP � with compFy with such provisions or this�permft ahall be �� Z deemed revokad. � � CONTRnCTOR ' Np, BK. PG, YAUOATION — LICENSED CONTRACTORS DECLARATION - LIC. I heraby affirm that I om licensed under provisions of Chapter 9 ADDRE55 NO. VpLUAT10N (commencing with Section 7000)of Oivisio0 3 of the 8usiness and LIC. � Professions Code,and my.license is in full fwca and effect. CITY CLASS -F ► � SQ.FT. � NO.OF NO.OF CHECK Licenae Number Lia Glass� � SIZE STORIES FAMIUES ONE �ESCRIPTION OF WORK NEW ❑ � r� � 7�6 A Contracror Daie ,q,`'� �,�7 ��}/� ADD � �a• •• +2� ❑I am exempt under Sec. � � Trt'^'�'"-' "`�"""'"�� ALTER Q FIN _ (u O � I •9?S.�G 8.8P.C.for this reoson �� REPAIR DA Dote: USE OF DEMOL F�N '` ° �'t'J Q O"c�i ExISTING BL�G. ❑ Signature � . AP�P NTT NO. By �r.2��s b � OWNER-BUILDER DECLARAT�ON � I hereby offirm that I am exempt from ihe ContraUor's License Law for fhe following reason(Saction 7031.5,Business ond ADDRe55 _Professiana Code): p . , �� BUIIDING' �_ ; I, os owner of ihe proparly, or my employees with ADDRE55 � wages as their sole compenwtion,will do fhe work and / �'� 3 5.1 A� tbe strucivre is not inrended or offered for sale(Section IOCALiiv 7044,Business and Professions Code). MOVING TEi. �� o � ♦� � I,os owner of the property,am exclusively Coofrociing NTRACTOR NO. wifh licensed controctors to consirucl fhe projecf(Sec- qpDRE55 � � �G z 5� -tion 7044,Bosinass and Prafesnions Code). , CONSTRUCTION LENDING AGENCY � �QUIRED yqRD HWv TaTAI SETBACK PROM EXIST. �'�e�d+�:C.J G o � SET&4CK PROP.LINE �✓�DTH I hereby affirm thot there Is a construcfion lending ogenry for FRONT �he performanro of rhe work for which this permit ie issoed P,L. � ��2 7��5 6 ZSe[.3097,Civ.C.)• SIDE ... - � � � �F.L. � Lender's Nama /�,(\ � � � P.C.Fee� �},> Germit Fea /�•v� Lendei s Address � I certify�hai I have read this appliwfion ond atate thm the � issua�ce Fee �a'�� a above information is correct.1 ogree to comply with.all GooMy Investigo�ion Fee q g � � ardinances an State laws relating to bullding consiruclion, TotalFea /.�Ci.S� G rind hereby a t rize presentatives of this County to enter � upon e ntioned proparty for inspectian purposas. � � � � � - �-`Z� � � SEE REVERSE FOR EXPLANATORY LANGUAGE ignal re o App M or Ayenf pule .m� .. FLPI�f6 � I t0'R3 MpteS . .O�t'\F i .UIS.I' C.-r71.e#P^4'I'IOi�.'`: I hercby a;f�r i Ih_.)I ai -.� mp?front 1he,Contracror's� To: . RaPurnid _ Litens� Loti� for ihv iolloviing recvon..(See 7031.5) � A��nwd L'ruieessa::dpn.c."��.':�--C�,;�.::.Lm,:c:Ycrcnaqtywbleb hio. -�c8s ho. Data rcyuires a�e;,-:il 10 c . ..cFt�:-�r,rhrnvr.�c_:v�olesh, . -, ..-�-.--_.'_ __ . nrrc.,r.irccv.t�.t:.._,/�r. ,_ .alsarequ[res Y � ti e app/rccnt f r .cJ/ r�at[ f.e�a cr,�ned atutement � . . . . . , . . . tl�at kr rslirc� z�yar.:e:,,.t to tbo f�roe�isior�s af thz Con- �4 - ,j tradnr's Lrrcnsc L��u(Cl,.�1cr 9J(co��+rrrcxcir.,q wdth Seo- � _ �' �� xenx 7000/of Dretisio+�3 of 1.5s Snss+eers and-FroJessrons . � - Cndc)nr�b.rt i�c is c•.•.r.n;7•':sr�frun.nrrd the hos+x for the _„^,____,� n!l:ned es:r!.�^di;v.�.Ac}�v�i:=7rtrnn o7 Srctio;: 7031.5 by - Ra��lrod � .. ariy� l��c�,z/ 1.. cP-t/ c.aE icuxttoaciael F.[':ro°rc!c Wt�R�e�Fv�d � t ., r_.�r Lt�;;:';c �..>liars 500.: � �r Appnv�d pe-, .�oI nn , (," l� Yes No ... . . ��. , . , , .. .;.., � . �.� ..�:'`�- • . t' ,� �� . ' '�4 -�I I,ds own,;o'tf•..,properfy,or my Employees with . . . ._._—_..--.. __ . � . . . , . Woter Ce f ficete . .��.�. wc- c t��.� s � _�n;�en ��,o�,will dc the work,end .�� .: �. ,. �, . .-.^.. ' ' • . ,• ,�'1 .. the sinctur�a is r� n�.i:ir d�.r c�rered for salcn(Sec.7C4d) . ; : : � ti � � :1�. . ,� �,�� t"1: . Uus� ,es a•-._'t �• .�(,,,_;( .:.: �t r C .�•ra'ctnr's Licens¢ Haalth�epertmcnt . . ... � - Kj., .� . � " � . l,au�rdxF;�;�ot ro�+(.1v.le��ael n•. .,fjnAAerty u�lm bral�s nJ i Fire Derartmcn� ar irr.provc�.c tt�:�rr� ,,':d:-..n �Y,:ee�f�u�arw bimseljor - . . _ . iGr�u:ti�I l+i_: o_,,. �.:��h4.t'�._.�E,>.nr � ' t,iat sec8 ifn- Grading � pr � a � ir�:� . �-J� �� J�:�sal::. If, ho e� tlic b !f.�;or e u t�.snld u�itl�in one Goologlcol Ve� �, c ��::,r� . , - �'ll 1 ae e tfie t: , �,yF�r, ,�., .� , .4 f,>r Pedeetrian Protection � -.. tl� y-}• ��f ,t�� .. . -,,. .=='^�nc (Fance)(CanoPY) . . .. - L J sn, . �f�h-.Fr a.r'y,am c d s�rvely car+lro-c- � ±ir witn licensr.d c�nirr.•-rnrs to canctruct�he pro'lect(Sec. 5 eiai Ins ection � 70A�)13:;sie 1 r- __.Gr.��•. 7'!+Contrxtar's (Cone.J(Maaonry)(Welding) � — Le . -I i t � .:r�.:�,<,Jpmnerty wbn . . , bne(da or::i.r-o�...._�. . ��v�l��contracts for sach LotDraina,qa -. . . ' .,: t ., . ..t. •. . proj,xl.v :aiti� r. �-,�at:��ra,::(:�:J 1::�•r.s.-:.+frr.cu¢r:t M tic � Covtructn%S�I.ice::::, L,.�.:;�1. Parking . � � •`.. . � I c-m exor'�;"u.�.. �.,. .G.FS?.G 4or fhis � - - _'__'. . � � reoson'____—_.._________—_ — ' � . . ' Dar� _'"_ Owne . � Rp r I Ga48 In6f�a}�r'sSfgnNun . . ..w'.. . �.^ .T��"'�� , � ' ° ' � ' � �) � ,�� . .-::,..: ..._.__.�.-.—_._,:...r.� � �- . .. , ��....Y.��.._ ..�__._... ..--�.�.v � Lomtion — — '------ � {Setback P Yards) .-'1 l �+ '.��l „1� i={'� Foundatians I .� � � � Slab . ------� ----- Frame � � � ' � � ergy Insu(afion "—�--��—_—�--`!-- � Lath/Drywall—� � Interior . . . _ .. . .. . . . Lath—Exterior � � HouseNumbe�— � � � � -� - � � Correct&Pastod - � � � � - ' � - Finol— . _ . —,'_-_,__ _"'__ . .. Enter on Front � � .