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Home My WebLink About0929A ,f I - --- ----,.r -____Y-�,.� , . .. _ .- - _ � � WORKERS'COMPENSATION OECLARA710N . . . ' . ' � 1 hereby atfirm �ho,I have a certificote af consen�to=e�f . � � APP�ICATION FOR��UILDING PERMIT Insure,or a tertificale�of Workers'Compenslion Insura ce,or . a certified topy ihereof(SQe�c.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAfETY VolicyNo.�7�`Cb�pany � BUILDING /�/ � �/ � Cerrified copy is hereby furnished. R APPLICANT TO FILL IN ADDRE55 ir � Certi(ied copy is filed with the munry building inspec• BUitDING 1,( t�on departmenr. � � � nooaess .�/� '. ,t -!t !� LOGALITY /Y - � ,',` � _-�J NEAREST /} / y� /� Do�e�?—��Applicontl✓f!l�� CITv - �es..�++t��-• q�ZIP GRO555T. L�� {��/�//i7 ' CERTIFICATE OF EXEMPTION FROM WORKERS' � NO.OF Bl�GS. . ASSESSOR COMPENSATION INSURANCE -� SiiE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permir is for one . g � � u �Z� MAP ' hvndred dollars($1�0)or less.) TRACTeJ.�a7.� eiocK ior N . � � No. � �, � / T � / � SPECIAL 0. OWNER (�' .L'F3 �p ' CONDITIONS I tertify ihot i ihe performance of the work for which this �t'�`� B n No � 0 permit Is Issued,I sholl nol empioy any person in ony manner G DiSTRiC7 GRf�P iYPE FlRE PROCESSE�BY so as to become subject to Ihe Workers'Compensafion Lows. ADDRE55 �a �/11e< i� /J Jt�CONST. � ZOCY� � � 'C �" J O Dafe Applicant - � CITY � Z�P STAtISTICAL ClA55iFICPypN - � AM. CONDO. (~j NOTICE TO APPUCANT: If, atler making this Certificaie•of ARCHI7ECTOR � - TEL � . � ' Exempiion, you shauld become subjec� to the Workers'. . ENGINEER �i-+.�/..[ � NO.. .c-s>. " ClA55N0. ��"�WEIL UNITS_ N Compensation provisions of the Lobor Code,you musl forth- � qDDRE55 � SEWER MAP 2 with comply wilh such�provisions or this permit shall be deemed revoked. ' CONteaci0e C NO. 7 � eK. FG. VALIDATION LICENSED CONTRACiORS D�CLARATION �O� l � UC � . I hereby affirm Ihot I am licensed under provisions of Chopter 9 ADDRE55 ril 'J�r� VpLUATION (commencing with Section 7000)af Division 3 of the Business and . �i� / DC Professions Code,ond my litense is in(�II force and effect Ci7Y ( Cta55 �'/ E�� SQ�,-'' , J O 50.Fl. NO.OF NO.OF CHEIX - - License Number J��,<�� Lit.Closs� • SRE STORIES FAM�LIES ONE � . ' ❑ $ Controclor��/UI G� pq�e� - DESCRIPTION OF WORK NEW .�, . � I om e.empt from the Ifcensing requirements as I am o ' � w .J ADD � � licensed archilect ar o regisfered professionol engineer / ALTER FINAL� / . octing in my professional copaciry�(Se[lion 7051, �.t �p�C. 2EPAB � DATE 'f ' � I` � -Business ond Professions Code). USE OF � f " ' ExISTING eIDG. �e - DEhtOL ❑ F�NA� I . Lic.or Reg.No. Dale � APPIICANT TEL 8y � . - OWNER-BUIL�ER DECLARATION (�RINiI ' ' I .c/�� NO. 17�JO �� /O I hereby affirm thoi I om exempt(rom the Contractor's License � low for the following reosan(Section 7031.5, Business and ADORESS ��0 7 � �,rlt in �.�/�/p/ � , . Proiessions Code�: � FR ENi � � � I, os owner oi the properly,�or my employees wilh q��DRE55 � . ' ;nc 9.2,g F1 . woges as iheir sole compensation,will do the work ond � .� - ihe strudore is nol intended or offered for sole(Section �«ALITY ' . H�� • •� d4,Bu5ine55 pnd Pro(essions Code). MOVING TEL. ' '• fONTRACTOR NO. � � � as owner of Ihe prope�ty,am ezdusively coNracung .�..`�G 7, � �Ih licensed contracfors lo-construct Ihe project(Seo • . (�.,,�- rfon 704a,B�siness and Pwfessions Code). />o�aESS �.N.� �-r�; � REOUIRED TOTAL SETBACK FROM E%IST. . '' � CONSTRUCTION LENDING AGENCY SET BACK YARD HWV vROP_uNE WIDTH � I hereby affirm that fhere is o mnstruciion lending agency far - FRONi ' 0(;.�'I`�� Ihe performence of the work for which this permit is issued F.t , . (Sec.3097,Civ.C.). . . . . SIOE . . . � . � � F.L. Lender's Name ) � . . � lender's Address P.C.Fee 5 � Fe.mi�Fea / �O � . � I certily ihat I have reod ihis applimiion ond stole Ihot the Issu ce Fee (7 � , `- _ above informo�ion is correU.1 ogree ro comply with oll County invesiigoron Fee � �� /� - � � � . � � ordinances and Siate laws reloting to building consbo[I�on, ' Toial Fee �� / and reby authorize representatives of this Coonry ro emer � up he ab •e-men�ioned property for inspeUi-n� pur�s. . . . . . � , SEE REVERSE FOR EXPIANATONY LANGUAGE �� .. . S+gna��re o Applican�or Agenr Dare. . . . . . .. . . �\ .� .� - �PLANS TO APPLICANT � INSPECTOR'S NOTES OR'NER-DUILDER DLCLARATION � 1 hore6y affirm t6af I am exempt from ihe Confrocror's � To: Relurned � � . I.icense Law for the fa�lowing reasan. (Sac. 7031.5) . Approvud Business ax�!Pmfessians Cude:Any�i Fy pr�Qunty wbicb No. � -�Date � No. � Date � - reguires a pCrnnt to construut.alter,im�irove,denrolish, . or reJ�air aay aeruclarc,rrior to its issucntc,aleo reguises - � �' �-� � ' - � � � - � • � � thc arp/irant for sucG perntit to Jile a signrd staerinent � tbat Gc is licensed pursuant to tGe provisions oJtbe Con- - �- � ' � - - � � . � � � �� . 'tracrer'r�licenselow(Cbapter9l(�on�mencing�t��itl�Sen tion 7000Jof�Diik.sion 3 ojtbe IIusinesi a�d ProJcuions � - �� , - CodeJ or t1�at Gc is exempt t/crefrone and!Ge basisJor tGe � - . a!leged rxempiion.tlny veolation of Settion 7031.$by � � Raqulrod � �DateRocsived � � � � anyapplicantforapermitaubjectstheapplicanttoaeici! Approvals Yos 1do� °r Approvad _ , , fenally oJnot morc tban jivc Gundred do!!an(5500J.J: , , - ' � �. . ❑ I,as owner of ihe property,or my employees w{th Water Certificate � � � � . � � wages as iheir sole compenso�ion,will do the work,and � . , . - � • � . � tha structure is not intended or offered for sola(Sec.7044) Heallh�epartment - ' ' _ . , Burinrss and ProJessinrts Cadc:TGc Contractor's Litsnsa . . .� � � ., Law does not apply ro an ou�ncr oJproperty wbo builds FireDepertmeN , , . , , , orimproucslGercon,andwhodnessacbworkbims¢IJor . � . . tbrougG Gis ou�n eni/�loyees,frronided lLat such im- Grading �� provements arc nol rnlenJed or ojfereJ far sale. If, � . . � � botucvrr,t7 e buildingorim[�rovenrent isao[d witbin one Geologim( - � � ' _ - . � _ � . . year of eoneQlclion, tbe owner-builder wi11 Gauc tGe � ,-.� ; , . . . burden of proving tbal be did not build or in�Qrove,jor Pedestrian Protec�ion , • . . . tl�c pvrpose fraleJ. � (Fence)(Canopy) , - '. � � ' �❑ I,os ownerof the properiy,am exclusiJely contrac- � ' " fi�wilh licensed mntractors fo tonstrutt the projett(Sec.- Speciat Inspec�ion � � 7044)A�siness and Pmfessions Code:TGe Contractor's (Cont.)(Mosonry)(Waldinfl) -Lrttnse la�r docs ttot apyly to an ou.�ncr nJ/�rof�crty u•Gn . � � burlds�or inrprovcs tGereon,and wGo e6rttraets for sueh , Lot�roinage � . � . projeets witb a contractor(iJ Jicensed punuant to the . . . � Contmclor's Liccxsc Lau�f. ' � .. ' Farkinc� . . � � . ❑ I am exempt under Sec. ,6.&P.C.for this � reason . . � . , , . Date � Owner � Approval: Date InspcNorsSipnaturo � - . INSPECTOR'S NOTES Location—' . . . (Setbatk&Yards) � Founda�ions . - � � Sfab � � , . � - . . . ' . Frame ' 1� `'4�� J1�, . . � � Energy InsUlation � � ' " ' �ath/orywa�l— �lS Y, r_�� Interior \9 � - � �� ' Larh—Ext r � , -- .. . U �--� House Numb� � � J - . � Correct 8 P�i�� Final— � ' � � Enter on Front � ' . �t . , . • _ , . . _ -