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Home My WebLink About0782A i ' WORKERS'COMPENSAT�ON DECLARAT�ON � I hareby otf„m�ha, I have a<ertifiwfe at�a�=e�„o se14 APPLICATIQN FOR BUILDING PERMIT insure,or o certificate of Workers'Compenstion Insurance,or o cenified copy thereof(Sec 380Q La6.C.) COUNTY OF LOS ANGELE$ BUILDING AND SAfETY Policy No. Company `\ � Certified coPy is hereby tumished. FOR APPLICANT TO FILL IN ADDRESS �-�� _ ` O�_� � Certified capy is filed wiih the county building inspec- gURDiNG `�--- ra�departmenr. ao�Qe55 c�S ��Z .Ct e L iocAUTv J� � f NEAREST � • Dote Applicant Girv !Li^'/i^�t.C� � 1 � ZiP ��r- 4, CQOSSST. l � . .�.*-� CERTIFlCATE OF EXEMPTION FROM WORKERS �� NO.OF 0LDG5. , ASSESSOR ti� - COMPENSATION INSURANCE SIZE OF LOT , y NOW ON LOT MAP BOOK PAGE PARCEL (This sectian need noi be completed if ihe permii is for one (� U ZONE MAP n hundred dollars($100)or Iess.) TRACT l'�l.!S BLOCK LOLNO. �' �`�� SPOECIAL "� � Y C.. I certify that in the performance of the work for which this �"�'NER �C,'�.' .;.,M,�� NO. ' `r �.�� .. CONDI7iON5 V permit is issued,I shall not employ any person in any manner / / � OISTRICT �GROUP TYPE FIRE PROCESSED BY so as to become subject to fhe Workers'Compensalion Laws. AD�RE55 y" [.. ''� . h2C _ l� ��CONS� ZOIyE% �\� �,, l/ ar.,`� p /'�- L�-�. ff �� , ";� � aTv% /��:c:.- /iG. na e:. �S f- _ Date Applicanl.�—�� r1?` - STATISTICALClA551FICATION APT. CONDO. V � �P.RCHI1ECT O , -TEL. NOTICE TO APPLICANT: If, after moking this C rt�cate�r „>� ,�.�, , No. G��` � S 4� �� "' Exemption, you sho�ld become subjett to the Work�s' ENGINEEB CLA55 NO. OWELI.IJNITS d. Cam ensation ovisions of ihe labor Code, ou must forth- ,j � P p� Y ADDRE55 � SEWER MAP �• with comply with such provisions or this permit shall be l�u. �' `�� ^ '. ,.�''�'�':� , — deemed revoked. � ' TE��`��'��'2 �'z,. BK. PG, VALIDATION CONT2ACTOR , w� +�NO.� LICENSED CONTRACTORS DECLARATION ! �7 LiC �^ I hereby afflrm that I om licensed under provisions of Chopter 9 � AD�RE55 .� (..�:% NO.zG�.�7�� VALUATION (commencing with Sectlo�700D)of DWision 3 of the Business and �7 / ��. ^ ` O �+,�.} Professions Code,and m license is in full force and effect CITY / ',.��..t.i�'-<-..C�-t�..� CLA55 — � $ �� `�v � �f - SQ NO.OF NO.OF CHECK License Numher ��Z.�� Lic.Class /'�J , SIZE � L�Z� STORIES � fAMItiES ONE �_�y_6-J NEw ❑ $ Conlra[tor --+Date I �ESCRIPTION OF WORK ❑ � ' '^��' ADD � � I am eaempt from rh li nsing requirements os I om a 'iy c,,,,Lr � licensed architect or a r gistered prafessional engineer AtTER ❑ � FINAL /, '" octing in my professional mpocity (Section 7051, REPAiR � DATE «�'x� �Jj� Business and Prafessions Code). USE OF � - EXISTING BLOG. DEMOL ❑ B�NAL '� � , LiC.or Reg.No. Date APP(PR NIT) . ` '/'� .'< NO.� �' �'r}4)• OWNER-BUILDER DECIARATION � . . I hereby affirm ihat I am eaempt from the Cantractor's License �,! "� ' � � � " - � Law for the following reason(Section 7031.5, B�siness and ADDRESS �`�� '�t-��"'� �..�' Protessions Code): v I, os owner of rhe o ert or m em lo ees with AODRESS 7 � wages as their sole c mpensation,w�ll do Ihe work and :�C�� ,£'•�C F, the structure is not intended or offered for sale Section IOCALiTY 7044,Business and Grofessions Code). ( MOVING TEI. . �� c d • '� ❑ CONTRACTOR NO. I,os owner of the propeny,am exclusively controcting �.a � ��:,V�U with licensed mntroctors ta mnstruct the project(Seo qDORE55 � • tion�044,8usinessandProfessionsCode). , d � � �� e"t�,.-, REOUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENOING AGENCY SET BACK YARO HWY pROP.LINE WIDTH . � I hereby affirm that there is o constr�ction lending agency for FRONT � �.G�'�"�5� �rhe performance of ihe work for whlch this permit is issued � p.�. (Sec.3097,Civ.C.�. S�E PL tender's Name Lender's Address P.C.Fee S Perm r Fee � I certify that 1 have read this appliw�ion and sfate Ihor the " Issuon<e Pee ,�:� �/ above inform � Is mrrecf.I ogree ta comply with oll County Inves�iganon Pee '�i ^ f ordinonce tate laws relating fo building construction, To�al Fee `}',. �. \) - � and her y n thorize representatives af th��s Coumy ro enter � upo ove �en�one op ty f r pection purposes. � /� . —Z�y�J SEE REVERSF FOR E7(PLANATORV LANGUAGE {� ature of Appllmnt o�Ag Oo�e � iLAi�S Td kh'LIEANT IPi9FEf70R'S N@�T� 066'h�FiE•BUILDF,R DFCLAARTION --------- � .---.—�.—�—..�. I hare6y cftirm that I am exempt from the CoM:ador's Tc: R�vsn�d Licanse Law for The foliowing reacon. (Soc. 703l.5) �PR�a�� BHsiness and Professions Code:Any city or cosnty wbreb F.'�n. Dofe Pia. [Safa reguims a pernait to coxstruct,aFter,lniprove,delnelisb, ..___.._..___._..��.._.��,>.:��.:— .�_-�.___ . - .- arrcpairaxystractsrs.PfYOCLOtbBf%Y61t6irPIeOTB�R{T6t � tbe njy7licaRt for siecb¢srneiF to file a seg»ad staterornt that he is licexsed frosrsuant to tAe�pronisiour qf tba Gmr � tractor's License Law(ChrspSer 9J(comfrtencing with S�rc- tion 7000J of Uivisiox 3�f tha Busfneu mid Projessians � . CodeJ or tl�et 5e u a+:e�a tberefrmn aad tbr 6amis f�r ibe --- alleged exemjrtiose.Any vidadiaw af Settiox 7031.5 by R�uirad �,�e��i� a�yupplicareEfvrajwrvnidskbjretstGea�gpFieaalfewci�+11 k�rov�k o�A�Pr6� pena£ty af not morc t6an jive I�undred dol)ms(�$ppjk Y�s Na -- — ------ � - . ❑ I,as owner of ihe proper}y,or my employees wlth \"2ater Ce,-tifica!e wages as iheir sole compensalion,will do the work,and the strocture is not inlended or offered fw su�le(See.7041) Nealth Dspariment � Buseaea.r axd Prnfessio»r Code:Tbs Contsac6or's Eiceasr Law doas not a¢�I��tv an oumer of j�wperCy u�bo bniAds Fire Department , or ineproves ll�ereon,mnd uihn does sucb wor,6l.fiwAself or � througb bis au�n ernj loyees,provided thaS.swsli iw Grodin�, . Qroi�erxeAts ore wot iatexded or offered for solc. If, howaver,�be bailding or ierofxooement u soW wiihin mte Geolagical year oj contpletion, LI�e ouroer-brEelder tuill bavs ibe � burdea of pravsng dfsaE he did»nt build or imjrrove}or Pedastrion Protection the purpase of saleJ. (Fence)(CanopyJ ❑ I,os ownarof the property,am exdusively co�>rae- - � lirrg with licensed comrocrors to conslrua the project(Sec. SpPcial Insp�cfion � 7044)Brtsiwcxs awd A�v�'esriAas Codw Tba Contraciar's (Conc.)(Masonry)(Welding) License Law docs not apply to ae owwer of pr�ty m!a � builds ar imprnoex thereaq a+od wbo ro»tracts for sacb Lot Drainage [irojects with a co�2rnctor(sJ Iicenserf pursuant to lhe � Coxtroctnr's Lirense I,am/. Parkinc� � n I am exempt undv 3ac. ,B.&P.C.for fhis l� !� �l E/1l� R�- (�J L L � reason R�t, �Ob� G,� .�` Date Owner J t�.yrevsls Gcam I Ins�.�r,7ar'e�ir��:r.".ure . INSPECTOR'S NO4E5� .,.:��=_�.�.._._.�x.sy...�=�—��1__��__—__'..�._.,�._.�.�_ Location— � (SetLack 8 Yards) Fcundations Slcb Fame Energy Insuloiion Lath/Drywall— Intcrior Lath—Extwior � House Number— Correct 8 Posted . Finol— � Enter pn Frpnt � 1 ro ` G� ' .E'€.�` �LG. �'�J2�J. �r'�''. � ��