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Home My WebLink About1332A 1327A (7) � WORKERS'COMPfNSATION DECLARATION 'I here6y affirm that I have a certificate of consent to self APPLICATIQN FOR BUILDING PERMIT � insure,or a certificote of Workers'Compensatian Insurance, or o cer�ified copy ihereof(Sec 3800,Lab.C.) - COUNTY OF l05 ANGELES BUILDING AND SAFETY Policy No. Company � Ce�trfiad copy is here6y fumished. FOR AP LICANT TO FILL IN BUILDING �S� ADDRf55 � Certified copy is filed with the county building inspec- BUII�ING 1 fian deparlmeM. ADDRE55 ��p R�A L. . �, Date Applicant - CITr {� ��- ZIP �p�ALITV CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF etDGS. NEAREST � COMPENSATION INSURANCE SRE OF lOT NOW ON l0T CROS$S7. (This seclion need no�be completed if Ihe permit is for one ASSESSOR hundred dollars(E100)or less.) 7RACT BIOCK lOT NO. IAqp gppK PAGE PARCEL TE�' USE ZONE MAP I cerlify fhaf in the performance of ihe work fo�which ihis OWNER NO. /� � � ��.r��. � �. permit is issued,I sholl nol employ any person in any man�er _ •q— v�,SPECIAL a so as to become subje[t ta fhe Workers'Compensalion laws. �ADDRESS � � v�-��4W CONDITIONS u CITY .�. ZIP . OC Date Applicam O NOTICE TO APPLICANT: If, afler makin this Certificote of ARCHITECT OR TE�� DISTRICT GROUP TYPE . FIRE PROCESSED BY. C 9 ENGINEER N�� CONST.� � ZONE Ezemption, you shoold become subject ro 1he Workers' 1 y� Compensation provisions of the La6or Code,yoo must forth- qDDRE55 -Ti-A i .0 /v � w ith comply with such provisions or Ihis permit shall be TEL. STATISTICAL CLASSIFICATION APT. C DO. Z deemed revoked. CONTRACiOR NO. . — IICENSED CONTRACTORS DECLARATION �IC. CLA55 NO. DWEIL UNITS I hereby affirm ihot I om licensed under provisions of Chapter 9 ADDRE55 NO. (commencing with Section 7000)of Division 3 of Ihe Business and ��, ��R�P Prafessions Code,and my license is in fu�l force and effect. CiTV C1A55 eK �� VALIDATION SQ.FT. NO.OF NO.OF CHECK — License Number Lic.Gass SIZE 570RIE5 FAMIUES ONE �� vAwanoN CoMroclor Date DESCRIPTION OF WORK App � S �JV �`�pRIPli ' `1 3 3.2 A � �I om exempt under Sec. R�-�IS�QN (� ��'�" ALTER I _�Et � �fi ��L�1�`�,��, � B.BP.C.for this reason v�--J� �NE-� E NQ {1LL- &fpq�p = . ��Sa��l�,� Dare: u5E OF �.. -'��; oEMa� ❑ �NOER p ��?,6 3' EXISTING BLDG. -�U; � APPUCANT TEL. \ Signal�rB PRINT NO. FINAL e ._, C�u ) OWNER-BUIIDER DECIARATION 6ATE �� ` 1 qM L— "rj" � 1 hereby offirm Ihat I am ezempt from ihe Conimctor's License qD�RE55 FINA! L,�. y p y' ,JQ5 Law for ihe follawing reason(Section 7031.5, Business and +9 Professions Code): � 8Y _ , ❑ BUILDING � � � �S -+ I, as owner of the property, or my employees with ADDRESS _.�'; 4 ,,T , wa9es as their sole compensation,will do rhe work and � +s a �,.�. the shucfure is not intended or offered for sale(Seclion IOCALIrV � � 7YsET � - 7044,Bosiness and Professions Code). � MOVING TEL `� �_ � I,as owner of tha properry,am exclusively confraaing CONiRAQOR No. ' � a � o- with licensed coniractors to mnsiroct the ro'ect Sec- .�,r , � �'t�t ; P I I AD�RESS � _ �. C:c�..a;:-;'n tion 7044.Business and Professions Code). � ��'•� 3 2�7 A RE�UIRE� TOTAI.SETBACK � CONSTRUCTION LENDING AGENCY SET BACK YpRD HWV pRpg��NE WIDTH � I hereby affirm that there is a construclion lending ogency for FRONT � �, ��2'J Ihe per4ormance of the work for which Ihis permit is iss�ed P.L. (Sec.3097,Civ.C.J. SIDE � �j.Q p P.L Lendei s Name e a •�F,('j�� LDMA Ref.N m Lender's Address P.C.Fee S �3 Pe.mn Fee � ' � > 07,1 �-85 I certify thaf 1 have read this applimtion and sfate fhpt the Issuance Fa LDNvt P/C Y ¢ pkwve informafion is co�rect.1 agree b comply wifh all County Investigation Fee g ordinonces and Stafe laws relating to building cansfruclion, . Toral Fee LDMA Perm.8 - - ond here6y authorize representatives of lhis County lo enter � upon the above-mentioned property for inspection purpases. a SfE REYERSE FOR!X►LANATORY IANGUAGE �'IC �=M�I�`c � $ignafure of Applicam or Agent Dote - ' k�'��' �'S"�N�� p," n� I �E7�1u,1:LC�WAi{. INfEAP4�S '�mMi1'. PlANS TO APPLICANT INSPECTOR'S NOTES OWNER-BUILDER DECLARATION I hereby affirm that I am exempr from the Controcror's � io: � Rafwned� License Law for the following reoson. (Sec. 7031.5) Approvod Business and Profersiorvs Code:Any city or county wbicb No. Dota No. � Da1i reqeires a/iermi6 Lo construct,alter,improve,demoluh, or repair an_y strvcture,prior to ita usuunce,also reyuires , the applicaxt for sxcJa permit to file a si,qned statement . that he islicensed pursuant to Lbe provuions of Fbe Coro- , .. . traclnr's Licenae Law(Cbapter 9J(commexcixg witb Sec- tion 7UOOJ of Diorsion 3 of tbe Bnsiuess end Professioxs , CodeJ or Ehut be is exempt tberefrom and Lbe basisjor the � alleged exemptios.Any viula�iorz af Sertion 70315 by Raquirad Dafe�Raeeivsd any a(i[ificaxt jnr a permit subjecEs the applicartt to p civi! � Approvals or Approv�d penalty of not more tban Jive bxndred dnllars(8500J.J: Yo� No - � [ I,os owner of 1he propeHy,or my employees wifh Wale�Certificote wages as fheir sole compensation,will do fhe work,and �he struciure is not intended or offered for sale(Sec.704A) Health Department Business and Professions Code:Tbe Controctor's Luense Law does xot ap¢(y to¢x nwner of property who buikls Fire Deparlment or improves tbereon,¢xd wha doea sucb work iiimsel/or � lbrougb bis ou�n emplayees, provrded tbat srscb im- Grading - /�rove/rsents are aot intended or offered for sa(e. lf, _ hownver,tbe building or improvement is sold uritbin one Geologiml 1'ear nf completian, the ou.�nervbuikler will bnve tbe burden of pmving tbat he did not build or irrsprove f r Pedrekiaw W_" . � tbe purpose of sale/. (Fence)(Canopy)`. � ❑ I,as owner of the property,pm exdusively contrar ting wilh licensed contractors to construct the project(Sec. Special Inspection -� JO44)Business and Professions Code: The Contractnr's (Conc.)(Masonry)(Welding) � License I,¢w does not uppfy to un ow�er oJprnperty who beifds nr imprnoes thereon,and mho conEructs f r sucb Lot Drainoge � � pr jects auitA a coa2ractor(sJ Licensed prersuant to tbe Contractor's Licen.se LmwJ. Porking [] I am exemp�under Sec ,B.&P.C.for this reason � - - Dote Owner Approvals Dofs Inapecior's Siynal�rs INSPECTOR'S NOTES ' location— (Seiback 8 Vorda) � . Foundarions Slob Frame Enetgy Insulalion Loth/Drywol I— � Interior Lath—Exte�ior House Number— � Correct d Posted Finol— Enter on Fronf