HomeMy WebLinkAbout1635A I _ 2 h F�/T 2 --—- - •^+,
WORKERS'COMPENSATION DECLARATION � . ' �
1 hereby offirm thot I have a tertificate o(consenl to:e�� APPLICATION FOR �BUILDING PERMIT �
insure,or o cerfificare of Workeri Compensilon Insurante,or �
o certified copy ihereof�Sec.3800,Lob.C.) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo. Company ��/'d L'J� ,
Ce�tified copy is hereby furnished. FOR APPLICANT TO FILL IN BUIIDING
ADDRE55 I ��-
� Certiiied copy is filed with�he couny building inspec- BUiiDMG �
.—�
tion deparlmenl, - ADDRESS / J• LOCALITY / � �.
y� NEARESi
. Date_��T$/T�L_Appliconf/S/��J��GLS � CIN � ZIP CROSSST. /�' . � , .
� �CERYIFICATE OF EXEMPTION FROM WORKERS' NO.OF BtDGS. n55E550R �
� ' � -� COMPENSA710N INSURANCE SIZE OF LOT � NOW ON lOi MA7 000K PAGE PARCEL
(This seciion need not be completed if ihe permi�is(or one U5E zaNe M.47 � .
hundred dollars(5100)or less.) . TRnCT BIOCK LOT NO. NO. �� .'�J„� . Y
� � - TEL. SPECIAL C '
OWNER NO, CONDITIONS �
. I terlify�ha�in Ihe performance of fhe work for whicb�his , . O
permit is issued,1 shall not employ any person in any mannei . OISTRICT GROUP iYPE FIRE PROCESSED BY
ADDRE55 � J CONST. 20NE
so as to become subjec�to the Workers'Compensa�ion laws. � /�� � /` � •C��
Date � Applicant � CIiY Z�P STAT15T1�.41 CLASSIFICATION �'APT. CONDO. V
NOTICE TO APPUCANT: If, after making this.Certificafe of ARCHITECTOR � � TEL � � � W
Exemption, you sho�id become subje[f t0 ih9 WO�kers' ENGINEER NO. �1455 NO. �WEII.UNITS N
Compensation provi5iani o(�he Labor Co(Ie,yoV mu5f fOrlh- � qDDRE55- � SEWER MAP � ' �� Z
winc �omply with such provisions or this permit shall be
deemed revoked. � . TE�' BK. aG, � VAUDATION ',
CONTRACTOR O / NO. �
- LICENSED CONiRACTORS DECLARATION � �i�,
I hereby affirm thot I am licensed under pravisions af Chapter 9 ADDRESS ' S. NO�d�� VALUATION
(commendng wi1Fi Section 7000)of Division 3 of ihe Business ond - ��� ��� LO � , .
Professions Gode,and my license is in full force ond ef(ect. CI7v .N /r CiA55�i`�r s
� /��/ SQ.�FT. NO.OF NO.OF CHECK
LiCCnse Numbe� �h7; Li[.Class `� /� SIZE STORIES FAMILIES ONE � ' �
�,y�r,��'j6N� � DESCRIPTIONOF WORK NEW s
CoNrot�or _ Date S/� Y -. . .� . ._
� I am exemp�from�he licens�ng reqoirements os I om a � noD . �
� licensed archilect or o regislered professional engineer .. . . . . . . ... ALTER � �FINAL� -/�O � � ;
acting in my professio�al capocity (Secflon 7051, REPA�R � DATE �
Business ond Professions Code). • u5e OF DEMOt �FINAL -
EXISTINGBLDG. ❑ BY �� ,
Lic.or Reg.No. �afe APPII�'.4NT , TEI. �
� �� OWNER-BUILDER�ECLARATION �. - PRiN71 J� N09�9 9.�i �� �/M, �
I hereby affirm thot I om exempf irom ihe Conlracror's License r1�J . .
_ Law for ihe following reoson(Setlion 7031.5,6usiness and AD�RESS ��' „S yi4.��/ � • _ �
Professions COde): � PRE ENT j�"/ y/]j Z
❑ . . BUILDING � �I I� / �O/(!I ��-l'.�A:',F,� .
I, as owner of the praperty, or my employees with ADDRESS
wages as their sole compensation,will do the work and • �
fhe strucrore is not intended or o(fered tor sale(Section i�`i�TY � � ' t��' •4-° • �
7044,Business and Professions CodeJ. rnOvwG � Te�. f�I��; ��j O �I ;•�J�,�� ��,
❑ GONTRACTOR NO. ��,"' , -
I,as awner at the properfy,am exdusively conrracting F c e.`�.�^'
with licensed coNroctors lo conslruct ihe projed�Sec- - �
ADDRESS f.',.-,�J;'.: � C�.21:'-��
� lion 7044,Business and Professions Code). - - . _ . _. . ��1(,%j j`j-- �
REQUIRED TOTA4 SETBACK FROM E%IST. � 3 •
. CONSTRUC710N LEND�NG AGENCY SE7 BnCK YARD HWY pROP.IINF WIDiH � .
I hereby offirm lhat Ihere is o mnstrucuon lending ogenty(or ppoN7 � �
the per(ormonce of Ihe work fo�which fhis permil is issued P.l � �
(Sec.3097,Civ.C.). � . . .Si�E . � �
P.L. '
Le�der's Name n7 .
tender s Address _ P.G Fee 5 �-� Permir Fee .1�l -� ' �
I cenify thm I have read fhis applicotio�and stafe�hot the Issu e Fee a 'S � ,
above informolion is correU.I agree to comply with all Counry . i,,.,esrgoro�Fee � ��� g � -
ordinances ond Sla�e laws relating to build�ng consrruUion, Toiol Fae a.J I• ..�U
and hereby authorize represen�atives o(this CouMy lo enfer , _ - . . ��
� upon the obove•menlioned property for inspettion purposes. . . . •
� ��y. h �j �/ - SEE REVERSE FOR EXPIANATORY LANGl1AGE
� Signowre of Appl�<ont Age Oaie � ' �s .1�
_
i
� - - pLANS TO APPtICAC1T • � � � �INSPEQOR'S NOTES . OWKER•BUILDER DLCLARA'flOti
I heroby affirm that 1 am oxempt from tho Canfrocfor's �
To� � Retvrnod� � ' -� � � ' � Ltcense Low for the following reason. (Sec. 7031.5}
' � Appreved . 13usinrssandProfessionsCode:Ar.ycityorcountywbicG
N � -Dato � Na �Date . . . � � � � reguires a pern+il to mnstruct,aUcr,improur,dc»:olisG,
. , . , orrepairanystnsclurc,priortoiuusuanre,aGoreguires
- .. - • ' . . - � . . .. . . !be applicant for sucG permit eo Jile a signed statenrent
tGat Gc is Irtensed punuant to 1be ptovuions af tbc Cox-
f . �-� � � � - � � ' � " ' ' � tractor'rLicrnseLam(CGapter9J(commencinguithSec- '
eiqe 7000J oJDivision 3 oJtGe Dusiness and ProJossions
� 1 -- - . � � � � � � � � � � CodrJartGatGcisexcrxpttGerejron+andtbebuisjoriLc
� , . , alleged exemptron.Any violation oJSectiors 7031.5 by
Roqufr.d� � D110F�CCCIYfL� � . Prt,yG�J'T(CGf!lforaperniitsabjecxsebeapplicanttoacioiJ
_. Approvols_ �- �Yas No , or Approvod pen¢!!y af not more tGan Jivn Gundred dallan(SSool.l:
� �- ❑ I,as owner of the property,or my employees with
V:ater Certificme - ' . woaes as their sole mmpensalion,will do the work,o�d
" � � �• � " the svuuure is nm imended or ofiered for sale(Sec.70d4}
� Healih Department . - • � � Business and Projessioas Codr.TGe ContracJor's Litense
- . . ' ' , l.aw docs not apply to an owncr of property wbo bu!!ds
- Fire Department � , or inrprovice tbercort,and wbo dorssucb uork bimtelf or�
� � � - � � tbsoagb bis ou�n emyloyces,(�ranided tbat such im-
Grading , � , f�roe�ements arc not intenJed or offrrcd for ralc. !f,
- � Goa•eoer,tbebuiWingorin�j�rovemerstisaoldwitbinone
Geologicel � , . . , . .. � . ycar af comQlcliars, tLe oamenbuilder�uill Gove ibe .
burden of proiing tbat bc did no!build or improve for �
Pedestrion Pratection ' � .. . . tbe yurpom of saleL- � �
(Fence)(Canopy) _ . ❑ I�asowneroflhepropeny,amexclusivelymnlmc- ,
' , , , ting with licensed contractors to construn�he prajen(Sec. '
Speciol Inspection � � � 7044)Busrness and Professions Code:Tbe Conlractor's �
(Conc.)(Moeonry)(Welding) � � I.fcensc Lau�docs not oJrply M an osr.cr ojf�roprrty wbo ��
� . � builds or imfroves!/crcon;and w1 o mntracts for such ,
� Lot Drainoge . . � , "projects witb a�cantraclor(sJ liceased punuant to tGe ,
� . .. . . . . .. Contractori Licensc Lau�/. �, ��
Parking � • - . - . . . . .
. , ❑ �am exempt under Sec. ,8.8P.C.for thls 'i
' ' , . . , reason -
. Da1v �� � Owner �
APPravals Do1e, InapecioriSiflncturo� . � . . . . � , '
� INSPFCiOR'S NOTFS
Lo�ation— . . _ . . . , .. . � . . . .. � . . ,
�Set6ack 8 Yards) � - ' � - � . - .
Foundations.. . . . .. . . . . - . .
, Slab • ' . . . -
Frame ' � , � �
Encrgy Insulalion . . . � . .
Lolh/Drywall— . . .
Interior � � �
Lath—Exlerior � . �` � . �
Housc Numbcr— � . �
Correa&Posted - �� � �
finai—
Emer on Fmnt � � . �
t ,