HomeMy WebLinkAboutNo Permit Number �� ri— �—�-� , _ . _ , . , —
WORKERS''CO�ENSATION DECLARATION . � �
�I hereby affirm that I have a certificate of consent ro 5e�{. .. .... qpp��CAT10N FOR BUILDING PERMIT �
insure,or o cerlifimte of Workeri Compenstion Insuronce,or �
a cerlified capy thereoi 00,Lo C.)
p��o���an COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cerrfied copy is hereby furnizhed. . FOR APPLICANT TO FILL IN ADDRE55 Q ' � �
� Certified copy is Tiled wilh the co nt bu Iding inspeo BUILDING % 1 .
tion deporlment. ADDRESS I tOCauTY r��y.
NEAREST 'I l
Date_lF�Applicont .� I � � - [iTY � ` ZiP GRO55 Si. �Y�. 11 t' �d -
�CE TIFIC TE Of EXEMPTION F OM W KERS' � NO.OF BtDGS. ASSESSOR .
COMPENSATION INSURANCE . 5¢E OF LO7 � � �NOW ON lOT MAG BOOK PAGE PARCEL
(This setlion need not be compleled if the permif is for one USE ZONE MAP � �
hundred dollars�$100)or leis.) . . TRACT 1V l.� gIOCK t0T NO. { 'l NO. r
�d TEI. � r SPECIAL
OWNER � N�c,r NO. �- 4 �1 Z' COND111ON5 a
I ceriify that in the performonce of the work for which ihis , �
permif is iss�ed,I shall not employ any person in any manner { DiSTRiCT GROUP. TYPE FIRE. PROCESSED BY V
ADDRESS S -L�J Cn ti'�. CONST. ZONE
so as 10 become subjeci ro Ihe Workers'Compensa�ion Laws. . .�� I ^ �.� /, � �t/ O
tY y
Date Applicont ` ��T� � � V Z�P STATISiICAI CV'.SSiFICATION - APT. CONDO. V
ARCHITEC70R � iEl.
NOTICE�TO APPLICANT: If, affer making this Cerlificale of " � � ut
Exemption, you should 6etome subject to the Workeri ENGiNEeR M��L p NQ CtA55 NO. ��` DWEtI.UNITS N
.Compensotion pwvisions of�he Lobor COde,y0u mu5t forlh- ADDRE55 � '�� rt' sewea mwa Z
iih comply wiih such provisions or this permit shall be • .iEi. � ^
. deemed revoked. � � CONtRqCiOR .p� NO. IU.' �� BK. PG, VA�IDATION
�UCENSED CONTRACTORS DECIARATION � � � " �i�, `�r � .
I hereby affirm lhat I am licensed under provisions oi Chopter 9 . A�DRESS f4�, No. VALUATION
_ (commencing wi�h Section 7000J af Division 3 of Ihe Business and ��� �
Protessions Code,and my license is in full force and efiecf. G1Y N CtA55 s ,(((1 � . .
-� � � 50.FT NO.OF NO.OF �CHECK ' ' .
License Number � Lic Class ' S12E �. STORIES FAMIUES ONE _ � .
� � y
CorllrtlGfO� - DOte �ESCRIFTIONOFWORK NEW �
� I am e.empt from the licensing requirements os I am o • f;+ { A�D � -�� � %.i i�
Ilcensed archi�ect or a registered professional engineer Al7ER FINAI
pcting in my pwfessio�al capocity (Section 7051, REPAIR Q DATE �5.� �i re.�w e e j
Business ond Professions Code). USE OF .,/ �FINAL
E%ISTING BLDG. J � L ,!� C OEMOL ❑ I'� T�� ��
Lit.or Reg.No. ' Dale APPUCANT Y IEL. / � I A i gY � ..��•: � �1.:.� .
� � '�-' OWNER-BUIIDERDECLARATION �� IPRiNi1 - � � h i�� NO: `t 'y
I hereby affirm thot I am eKempt from the CoMratlor's license � { / � -Y� ���� � " ,
Law for the following reason(Setlion 7031.5, Business and AooRE55 I � � l. N 1.� /i�� p� (J7��
Prafessions Code): � PktcENi .
O '. . .� . BUILDING . . . . .
I, ps owner of the property, or my employees wilh qooaE55 (�
wages os iheir sole compenso�ion,will do the work and � Q �07 7�� .
- the snucture is not Intended ar offered(ar sale(Section � � �OcnuTr � � �
70aa,Bus�ness and Profess�ons Code).' � MOwNG � TEt. '
❑ CONTRACTOR NO. '
I,os owner of the property,om exdusively conlracling ��"—
- wilh licensed contractors ro mnstruct the proje�t(Sec- ADDRE55 ' '
- .. lio�7044,Business and Professions Code). �
� CONSTRUCTION LENDING AGENCY SET�BACK� YARD NWY TOT'4pROP,A�NEFROM VlIDTH . ' �1'
� I hereby affirm thal lhere is o mnstruction lending ogencY for FRONI � � �� , � � �
lhe periormance of the wo�k lor which this permit is issued � P L � � .
($ec.3097.Civ.C�. . . . . � . SIDF . . . . . . .
� P.L.
Lender's Name �
� Lender's Address P.C.Fee E Permir fee 3"—� ' '
W I cerllfy that I have r a �his applico�ion and stote that the i..�a„ce FPe 0 � U �
obo�e i [ormrrtion is on 1.I ogree lo comply with oIl.County , Inves�igoiio�Fee . _ . .�- . - . � � �
� ordina ce an Stat la s reloting to boilding co�strucfion, Toial Fee � .5 �
and h re a ihoriz r pr s.nlatives of Ihis County to emer
� . - upon 1 e o e-men i n properfy(or inspection purposes.� � _ - -
- �J � �'Z � . SEE REVERSE FOR EXPLANATORY LANGUAGE ' _
- S�g i�re af APPl�cant or Agenr Dat , �s
� ... . . . . .. . . . .... , . ...... . .
_. . . . .. .. . . . . . . `
, � _ :
PLANS TO APPLICANT � - � � INSPECTOR'S NOTES OR'NER•IIUILDER DECLARATIOY
I hereby offirm�hat I am exempf from tho Comrocror's
To: � � �efurned - Liconse law for the 'followin9 rcason. (Sec. 7031.5)
Approvod , . , L3usenessandProfcs:ron.r�Codc;Anyeityoreountyu•Gic4
ko. Dnte No. Date � requires a pern:it to-consiruct,alter,improac,demolrsl,
, , , �,orrepairanystroctuse,priartoilsissuanre,alsoieguirer
- � � tGe applicant jar sucG permit to Jile c signrd rtatement
tbat Gc is liccnsrd punacnt to tGc provirioni of thc Can-
' . .� � tractor'sLrcenseLaw(Cbapter9J(commencinga�iebSec-
, tiow 70001 of Division 3 of tbe Dusiness and ProJessions
� � - � � - CodeJ or tGat Ge is exemptlGerejrom and 1be basisfor tGe
. ., . a!leged exemptiom.Any violation of Section 7031.5 by
� � Roquirad peteRocolvod anyapplicantjorapernritsubjectaebeapplicaxttoaeivil
. �Approvals . or Approvod penalty oJnot mo�c tbaro fivc bunJred dollars/SSOOf.J:
Yes No
� � ❑ I,os owner of iho properfy,or my employces wHf�
Water Cerfificafo � . wages as their sole compensa�ion,wtll do the work,�and
- . � the structure is nm imended or offerud for sale(Sec.7044)
Health Deparlment� . - �Business and Projessronr Code:Tbe Contractor's Licrrac
. . . I�rw does not apply to an ovmer of property wbo bailds
Firc Deparimenl . � � orimpsoves thcreon,and a•bo docsaucb work bimse f or
- � ' � - tbsougb Gis oa�n.emJ�loyces,f�ronided lhat asstb im-
Greding . - provements pre no! intended or o/fereJ for sale. lJ,
1 oa�ever,tGe buildirtg or im(�rovemenL is sofd wit!irt onc
Geolo�icol� �� - . , year of compklion. JGe oumer-builder wi11'Laae tbe � �
- burden oJproving tba2 be did not build or improrc fos
Pedestrian ProtecHon � � ' . !be purpose o,jraleJ. '
(Fence)(Canapy) . . . ❑ I,as owner of the p�operty,am exclusively contrac-
tirtg with licensed contracfors to construct 1he project(Sec.
Spedal Inspection 7044)Busineas and Profcssions Code:Tbe Contiattor's
(Conc.)(Masonry)(Welding) License Lau�dnrs'not apply to ax owner ajysoper[y a•bo
_ builds or improucs tbcrcon,and wGo conlracts for sucG
Lm Droinoge � , projeclr wilG a conlroclor(iJ lirensed'pursuant ta tbe +
' � -. �ContraGlor's Giccntc LattJ. '
Parking
- . Q I am exempl under5ec. ,6.&P.C.forth(s
� . � reasan �
Date Owner
Approvals Dato Inspoetor's Sfgn�wre � - - '
INSPECTOR'S NOTES
Locauon—
(Setback 8 Yards) � � � - -
Foundot�ons . - .
Slab ... .' �
Frame �,..I_G � .
1
Energy Insvloiion � ,
Lalh/Drywoll— . , - .
Interlor
Lath—Exferio� - ' � ���
House Number— • , �
Correct&Posled - - � . �
Final— . . . .
Enter on Fronf ' � - �
' I