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Home My WebLink About0955A 0956A WORKERS'COMPENSATION DECLAkATION I hereby offirm ihot I have a certificote of�o�5e�f�0 5e�f qpp��CATION FOR BUILDING �'��III'� �, insure,or o ceriificafe of Workers'Compensotion Insurance, or a ceriified copy�ha^eo4(Sec.3800,Lob.C.) ' � P❑olftyNo.�� Compony ��'��UI� COUNTY OF LOS ANGELES BUILDING AND SAPETY BUILDING / �, '(� �� ^ Ce�tifiad copy�s he�eby fumi:hed. FOR APPLICANT TO FILI IN � n�oaEss 4j�.r� �� Cenifiep copy is filed with ihe county building inspec- gUIL�ING '�ry r tion artment. ADDRE55 1 Dofe t� Applicant CI7Y �� . ZIP LOCALITY RTIFICATE OF EXEMPTION F OM WORKERS' NO.OF BLDGS. NFp.REST . . COMPENSATION(MSURANCE SIZE OF LO7 NOW ON LO7 CRO55 57. (This section need no1 be completed if ihe i1 is for one � ASSESSOR hundred dollars(5�0�)or less.} TRACI' BLOCK LOT NO. ,y�qP gppK PAGE PARCEI TE�' USE 20NE 1�P I cartify thot in ihe performanc the work for which this �WNER NO. 1-_ N� . T permit is iss�ed,1 shall not e oy any person in ony manner MN . 1 � SPEQAL Q so as to become su6ject 1 e Workeri Compensotion laws. A�DRE55 � W CONDiTIONS � Dafe Applicant CITY 7^"�_ ZIP '� � NOTICE TO ICANT: If, ofler moking ihis Certiticate o` ARCHI7EC70R 7EL. �O ENGMEER 7 `�Np, DISTRIQ GROUP TVPE FiRE PROCESSED BY Ezemptio , you should become subject to �he Workers' ,n �N�`r� ��Z� V Com sarion provisions ot the labor Code,you must forth- qD�RESS �} � jf+ . 0. ' comply with such provisions ar ihis permit sholl be y deamed revoked. � ' TE�� , STATISTIUL QASSIFICATION AP7. CO � CON7RACiOR � K M NO.S e'� � . UCENSED CONTRACTORS DECLARATION 7� ��. C1A55 NO.�_DWEtL UNITS_ 1 hereby affirm that I am licensed under provisions of Chopter 9 ADDRE55 � r �' F f. NO. 3� 7 �commencing with Section 7000)of Divisio�3 of�he 8usinessand �� (� ��R� _ Professions Code,and my license is in full force and eHetl. CRY � CIASS (� � � BK � VALIDATfON SQ.FT. NO.OF NO.OF CHECK License Numher �93 8d7 ��, loss � / SIZE � STORIES FAMiLIES ONE � � s / V IUATiON Coniractor , a�e �T DESCRIPTION OF WORK NEW � wo s � �I am ezempt under Sec. AITER 8.8P.C,for ihis reason <- � REPAIR s � USE OF Dote: EXISTING BLDG.�/�{/ O,J DEMOL ❑ ;"[;�'�,�� Signature � APPUCqNT �.{�� FNAL g 6 .- OWNER-BUILOER DECLARATION PRINT ��^'�� DAT6 S/j�� #' " �G`,' I hereby affirm ihat I am exempi from the Cantr tor's License Law for Ihe following reason(Section 70 . , Business and AOORe55 pNq� ) « �>2 j,(i;� Professions Code�: 6y c.u.a.�/ � _.i OBUILDING c �'. �.� i�C..c I, as owner of ihe pr rty, or my employees with AODRE55 i /�7� wages as their sole pensation,will do the work ond 1�Q�l G'�G�"U:� the structure is iNended or offered for sale(Section iaA�IN 7D44,Busin and Professions Code). �MOVING 1EL � c n CONTRACTOR NO. 3 Z�� =.U S'J.E F 4.J I,os o er of ihe property,am extlusively contracting wi icensed conlractors�o co�struci ihe project(Seo- qDDRE55 *�° ° ` • °1 T on'7044,Business and Professions Code}. REqUIREO TOTAL SETB CONSTRUCTION LENDING AGENCY SEi BACK YAR� �Wv pROp.LiNE WIDTH I �� T'�!�5.C O I here6y affirm that there is o construction lending agency for FRONT � the performance of tha work for whi h lhis permi�is issued � P.�. c a e 4;'�'t,_ (Sec.3097,Civ.C.). SIDE P.l. (��+_i:�J�C:j lender's Name f� � P.C.iee S }. � Permir Fee � � ��ReF.N Lender's Addreu , . I certifiy that I have read his applicotion and state that the issuonce Fea LDMA PiC M ¢ e6ove information is correcr.I agree to comply with ali County Invesiigotion Fee � ordinances cnd Stote lows relating to building construction, To�al Fee � ` Q LDMA Perm.M and here6y outhorize representotives of Iryhsis Couaty to Mer m upan ihe abova-mantionad ro rty for i pection pur ses. . ` .ZL � �" ¢ SEE RFVFRSE FOR E%►LANATOIIY LANGUAGF Sig aowe of Applicant or Aganl Date � �� OWNER-BUILllEN DECLARA7'ION PlANS TO APPLICANT INSPECTOR'S NOTES 1 hereby afflrm ihat I am exempt from Ihe Coniractor's 70: . RWurrrvd � - License Law for �he following reason. (Sec. 7031.5) Approwd 6usrness and Professions Code:Any city ar couxLy wbich No. Datu No. Dari ��qu�res a pen„tr m«„srr,�cr,alner,imp>o e,demolish, , or repuir uny struciwre,Qrior to i[s issuance,also requires , . , . � , . - tbe applica�ud for sacb permit tn f'le a aig»¢d stetemeat tbat he is licensed pursmant to tbe pro+�isions of Lbe Con- . � � � iracmr's Liceuse Law/Chapter 9)/commencing with Sec- tion�7000/o/Divisian 3 of tbe Business aad Professiou , � . � � � Cn6eJ nr tbat be is exenept therefrorn and thc basis for tde � alteged exemptdnn.An.y uiolation oj Sectenn 7031.5 by . R�quired . uny upplicaatjrir a perrait sazbjects tbe opplieant to a civif pProvols DWe R�ceived A or Approwd . pena[ty oJ not more tba�five huadred dollars(S500J.J: Yos No ❑ I,as owner of the property,or my employaes with Wo�er Cerlifimle � wages os�heir sole compenso�ion,will do rhe work,and the sirucrore is nof iMended or offered for sale(Sec.7044) Heal7h Depart ent . . � Bnsiness and Prnfessiows CnJe:7he Coxtractor's License Law does no1 apply to un owner of property wbo builds Fire Depar�ment or improves thereon,and who does such work bimseljor . ' t/roagh bis oum empinyees,provided 11 a2 sucb rm- � Grading Qronemends �ere not intended or njfered Jor sele, !J, howe��¢r,tbe breildinq or improe�emewt u sold wrtbin one Geologi � � year oJ rnmjiletina. the owwer-builder wi!!haoe tLe . � burden of proving thad be did nad build or improve fnr Pade on vraecrion � . . tbe purpase nJ.wieJ. (Fence)(Canopy) ❑ I,asowneroftheproperty,omexdusivelycontrac- ting with Ilcensed con�raclors�o construcf the pro��eci(Sec. Special Inspection � � 704a)8usiness and Professions Code:Tbe Contrador's (Cone�(Masonry)(Weldinga - - � - l.scexae I.¢u�does not afply to an nwner of property mhn bui[ds or improves Ebereon,and wbo cantracts for se�cb Lot Droinaqe � . pr jects with a ronEruclo+{s/litexsed pursuant ta the ' Contractor's Lioense l.aw/. Porking ❑ I am exempi under Sec ,8.&P.C.forthis reason � Dale Owner Approvals Doto Inspactor's Signature INSPECTOR'S NOiES Lorotion— (Setbock 8 Yards) Poundations � . Slab Fra e Energy Insulation Lath/Drywoll-- Inlerior Lmh--Eaterio� House Num6er-- � � ' � Covect 8 Posfed Fina1-- Enler an Fronr �