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Home My WebLink About1713A (10) WORKERS'COMPENSATION DECIARATION - � - I hereby affirm that I have a certificote of�o�5e�,fa se�f � qpp��CATION FOR BUILDING PERMIT � insure,or a certifica�e of Workers'Compensation I�surance, or o cerlified copy t/herepof Sec.3800,Lab.C.) e COUNTY OF LOS ANGEIES BUILDING AND SAFETY Poli No. Sv�A�mpany �TC �UKU ►�Ce�titied copy is hereby fomished. FOR APPLICANT TO fILL IN suuoiN� ,�� ❑ ADDRE55 Ceni4ied copy is filed with the county building inspeo- euuDING ��ion departmenf. ADDRE55 r Q 4 �(.; . Date �� 17 J Applicant_��_ CI7V � l.�. h ZIP � /�� LOGALI7Y � CERTIFICATE OF EXEMPTION FROM WORKERS' , NO.OF Bi�GS. NEARfST • COMPENSATION INSURANCE SIZE OF LOT NOW ON LO7 CRQ55 Si. (This se[fion need noi be[ompleled i4 the permit is for one TRACT BLOCK L07 NO. /�qp gppK PAGE PARCEL hundred dollors($100)or less.) TEL:Xy /� J ZONE MP.P I certify that in the performance of the work far which this OWNER Cf({/Q NO. (r�`" (6Gr� �� NO. ��a y permit is issoed,1 shall npt employ any person in any manner SPECIAL � d so as fo become subjecllo the Workers'Compensation Laws. ADORESS �� f E H� CON�ITION$ V f Dafe� � APPlicont QTY iQ�'hQU r— ZIP � � . . . p� ARCHITECT OR TEL O N0710E TO APPLICANT: If, after making ihis Certificate of DIS7RICT GROUP 7YPE FIRE PROCESSE�BY p. ENGINFER NO. CONSi. ZONE U Exemption, you should become su6ject �o Ihe Workers' t W Compensation provisians of the La6or Code,yau must forlh- qDDRE55 1� R � � d with comply ih such provisions or ihis permit shall be � TE� y deemed revoked. CONTRAC70R �� NO � STATISTICAL ClAS51FICA�tON APT. CONDO. Z LICENSED CONTRACTORS DECLARATION �� p ? CLA55 NO. �' �WEtI.UNITS I hereby affirm thatJ om licensed under provisions of Chapter 9 ADDRESS I iZ S 7 �IX��I � NO 3tS'O�.J (commencing with Section 7000)of Division 3 of ihe Business ond J_ /� �� ^ SEWER MAP Professions Code,ond my license is in full force and effect. CiTY��NE�4'J (�1'UV�E- CLn55 V� BK � � VALIDATION c� '( SQ.FT.n NO.OF NO.OF CHECK LicenseNumber �Q�^� Lic.ClassC 3q SIZE +�5� STORIES fAMilIES ONE `1^� O YAWATION Contraclor � � �+*'� po}¢ ��?G��S DE CRIPTION OF WORK � Nei" S /^q�j y.. U V , �I om exempt under Sec. �,�IQ �/S j > P.DD AITER B.&P.C.for}his rea5on 1 VhM1 � S RfPAIR � s Date: USE OF DEMOI EXISTING BLDG. � ( C•p✓ � � S'onaTure "�� APPLICANT� �S NO.'! -�Z �' FiNAt WNER-BUILDER DECLARATION PRIM � DAIE ' � - �� -�� I hereby affirm ihai 1 am ezempt from the Coniractor's license qDDRE55�2 '7 1�'1 �C"� FIN L � Law for the following reason(Section 7031.5, Business ond l� � �ProfessionsCode): � gy � �''r`�-' OBUILDING �� 7�,�J F I, as owner of ihe properly, or my employees with ADDRESS wages as their sole compensation,will do the work and �ocauiv � �j• . • • •� the structure is not intended or offered for wle(Section 7044,Business and ProfessiOns Code). MOVING TE�' � • •6 S 6 0 � I,as owner of fhe property,om exclusively contraciing CONTRACTOR NO. with lic¢nsed conlratfo�s to construct Yhe projecf(Sec- qDDRESS � g e�E�� tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY SET�&aCK VnRD HwY t�TAp p7pA�N€ wioiH S I hereby affirm ihot there is a consiruclion lending agency 4or FRONT G 7'2 f'�8`� the performance of ihe work for which ihis permit is issued a.L - � (Sec.3097,Civ.C.). SIDE P.L. Lender's Nome $ � � LDMA 2ef.M - Lender's Address P.C.Fea E Permlt Fea ► � 1 cenif thoi I hove read.this o licafion and state that ihe - _ Y � PP Iss�once Fee � LDNJ�.P/C M obove informotion is correct,I agree to comply with all County Inves+igoiion Fea g ordino s and S�ote lows reloting to 6uilding ronsfruction, Total Fee � >O L�MA Perm.# - � � and r b�orize epresematives of this County to enter m upo t a e- n aned roparty for inspection purposes. o -�., ''7-24—pS_ SEE REVERif FOR EXPIANATOlY LANGUAGi Signawra o+Applicanr or Rgen� Dafe n� � PLANS TO APPLICANT INSPECTOR'S NOTES OWNER-BUILDEt?DECLARATION . . I hereby o$irm thai f am exempi from the Contractoi s To: R�twnad� License Law for ihe following reason. (Sec. 7031.5) Apprewd Bsssi�ess and ProJessions Code:Any city or cnunty whicb No. DatQ No. Dota� myuires ayermil to construct,alter,irox/rmoe,demolis6, , or repair any strrrture,prior to iGs issuance,also reguires � - . the ppli�an.a/or such pernret Co fi[e a sigeed stateme»t - tbat be is licenseJ pursuant to tbeQrovisinws oJ tfie Co»- . tractor's License l,aw/Cbapter 9J/cummericing wiSh Sec- trnn 7�00/nf Die.�uinn 3 oJ tbc Business ond Prafessions , � , � � . � . , Code/or that be rs esempt tberefrom axd tbe basis for tMe . � olleged exem/ieinw.Any via[ation nf Section 703j•S by RetryPr�d -Dota Racoirad any a(�Qlicant fnr a permit subjects the applicant tv a tivil Approvals or APProwd penaJty of aot more than five bundred dollars(SSOOJ.J: Yac No � ❑ I,as owner of the properry,or my employees wiih Wmer Cenifica�e � � � �� . wages os iheir sole compensalion,will do the work,and � - the slruUure is no�iNended or offered for sale(Sec.7044) Heahh Deportmeni _ . . � � . . � . Busrness axd Pmfesxions Code:The Gb»tractor;i Lecease - . Law dnes rtot apply to an oumer of property w5o buifds Fire Depar7meni . , � � or improves ihereon,arod wbo does such work himselJor tbruug5 bis own employees,provideJ tbat such im- Grading `� � pruvements are nat intended or offered for�sule. If, bowever,the bailding ar improvement u sokd within.one Geolog�iml . � � � . � yenr uj rnmpletinx, the oumer-bnilder will bave t{�e . _ -. � . burden oJ prnoing that he did nnt bssifd or improoe for Pedaslrian Proaection '- , t5e pxrpose ojsaJe/. � . (Fence)(Canopy) - � � � � ❑ I,as owner of the properfy,pm exclusively confrac- ling with Iicensed coniraclors to construct ihe projed(Sec. Special Inspection - � 7044)Business and Professions Code:T5e Contractor's (Con<.)(Masonry)(Welding) Licente Lau:does not aJ�ply Lo an owxer ofproperty u�bo buiGls or improves tbereon,anJ u�5o controcts for tucb Lot D�ainoga ' � pr Jec1s witb o contractar(si 7�rensvd pura�bynt ca ibe � � . Coxtractor}Lirense Lau/. � � Parking � �- , � � ❑ I am exempt under Sec ,8.8P.C.for this' reason � Date Otuner Approvols Dafa Infpecfur's Siynafure �� - . � � - - � INSPECTOR'S NOTES� Locatian-- (Setback 8 Yards) Foundelions � Siab Frome Energy Insulolion � Larh/Drywali— . Inierior Laih—Exterior . � House Number— � � � Correct 8 Posted � Final— Enter on Fron�