HomeMy WebLinkAbout1295A 2074A 2075A � VJORKERS'COMPENSATION DECLARATION � �
I hereby affirm fhar� have o certifiwte of�o�=a�„o 5e�f . � �qPPLICATION FOR BUILDING PERMIT
�' insore,or o cer�ificate of Wor4eri Compenstion Insurance,or , .
o certifed mpy thereof�Sec.3800,L . �,��� � COUN7Y O!LOS ANGE�E5 BUIIDING AND SAFETY
P❑olfcy No. �2 SZ�'Comiany . �
Certified mpy is herebyfurnished. FOR APPUCANT TCfILL IN BDDRE55 l f O � `� �
Cerlified copy is filed wi+h the c erryty building inspec- BUILDING � � y�p-L. �
�IfOn deportmenl. ' AODRE55 �• n (OCALITY
/ NEAFEST /� . O_ __ _
�-Dote � ��l Applimrl ���� � � CITY � . . "�'�-p� � CROSSST. l.C"�'`�-✓�,�_�,� .
CER7IFICATE OF EXEMPT15N FROM WORKERS' � NO.!BlOGS. MAPSg�K FAGE 7ARCEl
� COMPENSATION INSURANCE � SIZE OF LOT NOK�N LOT
USE ZONE �P
(This seaion need not be compleied if 1he permit is for one � Np. •:33 . ;�
hundred dollars(5100)or less.); _ 7RtC7 BIOCK LOT NO. ���yyy
���_ $PECIAL 0.
OWNER L('�u-E� CONDITIONS � U
I cerlify ihat in the performance of 7he work tor which ihis DiSTRICT GROUP Tv7E � FIRE PROCESSED BY U .
permit is issued,I sh�ll not emplo ony person in any monner C�.S` T' j w� CONST. ZONE � . . [C
so as to become subjetl to�he W rkers'CompensoHon laws. nooRes C � �� 0
�A � CITY I '�'�� � Z�P STATISTICALQk551FICATION APT. CONDO. V
Da�e � AppliCbA ARCHiTECT OR . -TEL. � . �u
NOTICE TO APPLICANT: If,�of� oking�his Cerfitimte of � EN�iNEER I NO. CLASSNO. DWELI UNITS ti �
Exemp�ion, you should beco e subjeU lo the Workeri � ;+ :
Compensotion provisions of ihe lobor Code,you m�sl fo�lh- qDDRE55 � SEWER MAP -=
with wmply with wch provfsions or this permit shall be � i� _! -� BK. PG, VAUDATION '
deemed revaked. ' � �ONTRACTOR bP ld �.
� UCENSED CONTRACTORS DECLARATION � UC. �-�n ' �
I hereby aftirm that!om licensed under provivons of Ghopier 9 aDDRE55 �E � VAIUATION Gp ' . •
([ommencing with Section 70D0)o!Division 3 of the Business ond ���' �y I S `2��
Profesvons Code,and my license is in full force and ef(ect./ � CiTV • .{� CiAS �: / T �`�2 q,5 F� .
� c7�����7 e �!C SQ.FT. NO.OF NO.OF CtIECK
license ;r� � Lic.Class ���'� � SIZE STORIES FAMiIlES ONE f(� �r V 2 3
C ' S
Conf c�or pote r��—� DFSCRIPTION OF WORK � ` �� NEW � • • � �,n O .
❑ DD �
am exempt from Ihe licensing requirements as I am a J� � 2 � FINAL /� ` • �'� � ����
licensed architea or o regis�ered professional engineer „ UER pATE („�� /� ' '
ocfing in my professional copatity (Section 7051, REGAiR ❑ .p'q,1 3�-81 .
. Bosiness and Professions Code). � � u5e OF / FINAL � �
- ��� � DEMOI- ❑ �
EX1571NG BIDG.• By r
Lic.or Reg.No.��/1—���/�,'�''IE APPIICANi J. TEL
- OWNER-BUILDER DrSC�AKATION � PR�NT ' S IC—s� N� .
I hereby affirm that I am eacmpi om ihe Contractor's license �,00Re55��lC� (�'� /2`�S� �r E?7•C F �
lnw tar Ihe following reason(Section 7031.5, Busiaess and .� . .
� Professions Code�: FaEatNi � . �� • •+2� �
❑ BU�tUING .
I,as owner of ihe property, or my employees wifh ADDRES f��/�"�'�
oges as their sole compensation,will do the work and � -� • •°9 6 O .
LOCAIIT
� 1he structore is not inrended or offered for sale(Secfipn � � ' � ¢�
- 704a,Business and Professions Code)- � MOvinlG TE�. ��yyr,�-1 .''''' �9.�?�i`= '
� � I,as owner of 1he propeny,am exclusively tonirocfing CONTRAC7 R N�� '�0(�'r''���y} .
with licensed mMradors lo construcr the project(Seo AODRESS �
... .. tion 7044,Business and Prafessions Code�. � �
RE�UIRED TOTAL SETBACK FROM ex�sr. ��2�t 7,5 A
CONSTRUCTION LENDING AGENCY SEr 6ACK ARD HWY pROP.LWF WIDTM , � ,
I hereby affirm thm ihere is a mnsrroction lending agency for� feON� - ���•b• • ��
ihe performance oF ihe work for which ih7s permit is issaed 7 t ,.. � � '
(Sec.3097.Civ.C.). _ . .. SIDE \ � ,� r �'f[3 rj Q
P.L.
Lender's Name � � +;w�*U,z�:;Q�
a ' P.C.Fee E �D �Permi�Fee �S/ �
Lender's Addres� S-�7 � ���+� � 8�
I cenify Iho�I heve read this applim�ion and state tha��he � isw ce fee � � �
� above inf nat on is correcf.I agree lo comply wilh all Counfy inoesnga+�on Fee - o^ . � � � �,
; ordma es and Stat ws relat�ng to building consvuu�on, To�al fee �� _
ond ereby o�thori e representorives of Ihis Coonry to enter � � -
� up the above-rtee 'oned property for inspection p.ic�oses�.7/� . .
� �—�/ SEE REVERSE FOR E%PIANATORY LANGUAGE �
� �gno�ure of Applko��or Agene , Da�e . - �`
_ . _._.__. ._ .._.__.__..___.>__.__-----:w_._.._.�-----•----- -
i
� PLANS TO APPLICANT ' - � � �! �NSPECTOR'S NOTES . OLCNER-DUILL7�R DtiCLARATIO�
I heroby oifirm tha�I an exompt from Iho Conlrattor's _
To: Befarnod � � ' � � � � � Ucense taw for Ihe folowing reason. �(Sec. 7031.5}
� �� Approvvd BusinessandProfrsseons:ode:Anyeityorrounlywbicb
" No. Dote � No.- � Dote - �, . -. . _ requires u perrni!lo tnntrucl.akcr,imfrovc.demolisb,
� '. � . orrepairanystructure,piortoilsissuonce,alsorequires
�"- � � �""� �� � � ��� • � - . � � � . 11 e ap�licant for sucG p�rn+it to file a signed statemen!
. , . �tGct be u liornsed pussurnt to rGe provisiona oj tGe Con-
� , - � - - � . � lractor'sLicenselnu�(Ciapler9)(commencingwitbSec-
_ . . .. _ � �tion 7DOOJ of Drvision:of!bc Butiness and Professiane
' . �� ' � -� CadcJ or t8a1 Ge is cxcnr�t tbcrefronn ond tGe badsfor tGc
Re ulrad . ; � alleged exrn+ptron.An.violation ojSection 7031.5 by
- AFD�ovals- -- � G �etohecsivcd � . . . anyapplicantfarapernitsssbjedstbeaQQficanLtoaeivii
Yoe No or Approvod . penal�y of not morc tb�n ficc bundred dollars(SSOOJ.J:
- � . � � . � � � ❑ I,as owner of ttn property,or my employees with
� lh'ater CerlifimM � . . , . woges os their sole compensation,will do tho work,and
' � , , � � ' �� � - _ lhe structure is not interded or offered for sale(Soc.7044)
Hoolth DepvrtmeN � - Iiueirsess and PrnJeisiots Codc:Tbc ContraUor's License �
- � . . .. ' � � . . - . . Laa�docs nos of p1y toan oa7rer ofpraperty w5o builds
fire Oepartmenf -or impro+�es tbereon,and wbo does sacb work bimself ar
� � � � � � tl�rnvgG brs o�rn en:ployees, pronrded tbat arttb im-
� Groding . - procements arc not inlended or of/cred for sale. If,
�! � � � Gou•ever,tGe buildingorfrnprovc»rent issold withln one
Geological -� � � ' ,� . . yrar of completion, tbe osunenbuilder will bave tLe
burden oJpsooing tl�at be did not build or imQrorc for
Pedeslrian ProteUion - � '! . tbe per/�ose of sa1eJ. � ' �
. (Fence)(Canopy) - � , � � , . ❑ I,as awner of Ihe properfy,�am exdusivelycoNroc-
, � �� tirg with licensed comroctors�o construct the project(Sec. �
Special Mspatlion. � � . � �70-04)IIusirtrss and Projessroos Code:TGe Contractor's
(Conc.)(Mqsoniy)(Wolding) ' � License Law dors not apply to an oa•ner oJpro/�erry wGo
. � . bssilds�or improves 11 ereon,and uJ o contracts for sucG
lot Drainago� �� ' � � . projecti witb a controctor(rJ licen.*ed punuant to tLe
� ' ��� � . . . . , . -_ ' � ' Contrcctori License LawJ. ' . .
Parking � . . �. . ,
- � , � _ . - ❑ I am ezempt under Sec. ,B.&P.C,for Ihis
� � • . �- - . • � reason
Da1e � - Owner
Approvals� pete Inspeetor'a Signeturo � " , . � . .. � ,..
� INSPECTOR'S NOTES
Location— , . .
(Setback�B:Yards)� . � . . . . . . . . .. ...'
Foundoiions . � � .. . . .. .
SIa6 - , � ,. . _ . . _ . . . '
FrPme' ' - - , , ' '. , . .
Energylmulation ' . .. � , . , . . � . . . -
lath/Drywollr l . . . . . .
- Interior � • �
Loth—Exferior � � '� � � � .
House Number- . . i � � .
Cortea 8 Posled . - � �� ' ' . . -�� _ � ' � �
Final—
Enter on Front • � � � ' � -
t