HomeMy WebLinkAboutNo Permit Number - - -_ ___ _ __ __-..
JORKERS'COMPENSATION DECLARATION � � � � � ✓'�U � � � �� �
' APPLICATI�N FOR BUILDIN� PERMIT
n's dfirm lhat I have a cerlificme of eonseni to self �
,g� �cenificme of Workers'Compenstion Insuronce,or �
�b 'capy�hereoS.(Sec.3800,Lab.C.) . COUNTY OF LOS ANGELES BUILDING AND SAFETY�
,b, Campany -
•es ti{ied copy is hereby Surnished. FOR APPLICANT TO FILL IN AD�RESS l�.r j`� �. ��
°t '�tified co s filed with the count buildin i s
n_ . PY� Y 9 �Pec- BUILOING .
� eportment. ADDRESS . tOCAIITY �AL-.
iN
�f p NEAREST �S� /'L�G�j�O
� 0 ApplimN CITY — 2iG � CRO555t.
S� NO.OF BLDGS. ASSESSOR
ERTIFI ATE OF EXEMPTION FR RKERS' S¢E OF�OT �NOw oN�oi
'Y COMPENSAiION INSU N �v� MAPBOOK PAGE PAR[El
'+� � tion need not be completed if the permit is for one� � `/J�q.�. USE ZONE, �P �t 1 � �
k I dollors(8100)or less.) . � TRA�7 �/ oT • � ��7�7 3��
T .
fi ; � TEL. n ) �I Y SPECIAL � L.
,thal in the performon[e of fhe work for which this . �NER NO. d� S 1 CONDITIONS Q ,
d � � � OISiR1CT G UP iYPE.. fIRE �PROGESSED BY V '
s issued,I shall not employ any persan in any ma�ner
7) � AODRE55 � � CONST. ZOyE , / �
�become subject fo the Workeri Compensption laws. �(/ ,�(/[�
s , .. .. � � � CITY TI " ' . � � � .�� �'LL7 �
AppllCant STATISTICAL QAS FI TION AP7, NDO. V
r ARCHITECIOR - TEt. �I �y
i TO APPUCANT: If, a4er making Ihis Certifimfe of ENGINEER NO. � M� CLA55 NO. �� DWELL.UNITS_ a
�ion, you should 6ecome subjeu to ihe Workeri y
rnsotion provisions of Ihe Lobar Code,you musl forlh- qDDRESS SEwER MnV � _
a 'omply with such provisions or �his permii shall be tE�
� . !drevoked. � CONTRAQOR NO. ��j P BK. PG. VALI�ATION
' � IICENSED CONTRACTORS DECIARATION � ���, 7^�� .
oy afflrm thot I am licensed under provisians of Chopfer 9� nDORE55 � NO.a0�0 0� VAIUATION
iencing with Seclion 7000)of Divislon 3 of ihe Business and . . IIC. �Q/�/�
� isions Code,and my license is in full forte and ef(ect. CITY ��e C1A55 E c�uv -
' S�.FT. NO.Of J NO.OF CHECK
se Number lic.Class SRE SiORiES 1 FAMILIES ONE .
b
faCfor Date �ESCRIPTION OF WORK �r-� NEW � , _ �
. � I om eKempt from tha licensing requiremants oa I am o - � � � ADD �� .
� licensed archirecl or o registered professional engineer . . . . AIiER � FINAL ,✓ (�
j acting in my professional capacity �Section 7051, - REPAIR�� DATE L.D "/ ��- � .
; Business and Profeesions Coda). u5E OF DEMOL � FINAL �
j . E%ISTING 6LDG. h i � BY� vt� .��� � ;`�t �;7! f�
.orRag.No. Dcte /PPLICANT TE�. _ � '
' i OWNER-BUILDER DECLARATION - - . PRMT NO. � j!• •4 G.�,
ereby offirm that I om exempt from the Coniroctor's Ucense J�� - �
. u for.the following reason(Section 7031.5,Buslness and AooRess rl� . W��1 � •�•Cj 2 h,�
lfeieions Code): " a N � �
. � - BWL�iNG - •.� e L'?C;(1= �
I,�as-owner of tha property, or my employees wiih nDoaESS
. woges as iheir sole Compensation,will do tha wo�k and �O�ALITY � � �4.� 5"8�
� 1he skuUure is not intended or offered for sole�Setlion
� 7044,Businesi and Profesiions Code). . MOVING Te�. . �1 3 7.9 R
I,as owner of fhe property,om exclusively contratling CON7RACTOR NO.
. with litensed conirocfors lo consirocl the project(Sec- qDDRE55 - � � - � �
- � .tion 7044,Business and Profeasions Code�. � � . `' .
REOUIRED TOTAI SETBACK FROM EXIST. ' � I •'°li�.r O
� CONS7RUCTION IEN�ING AGENCY - set eaa YARD HWV FROP.IINE WID1H � � �
hereby affirm that there is a construci�on lending a9ency for FRONi o �t�i.r G�
�he performance of the work for which ihis permit is iszued v.i. �
(Sec.3097,G'v.C.). � � sioe � . �C^1 �—�°.7
v.i.
Lender's Name � �
� P.0 Fee S �O Pe.mlt Fee OG .
lender's Address �
� �t cerlify Ihot I have read Ihis applic4tion and state that the � �ssu ce�ee '� �
.abave inform6lion is mrrecL I agree to comply with oll County Inves�igaiion Fee . �^ ` � - - ,
�ordinonces ond State lows relming to 6vilding conslractian, io�d Fee b �
� -and hereby av�horize represeNatives of this County to enter .
. upanlh bove-menlioned proper farinspecFon orp ses. � �
j� �� u �� SEE REVE0.5E FOR EXPLANA700.Y IANGUAGE ' � ' - � �
�g e oF Appli�ont or ngem Doie / �6
. pLAF15 TO APPtICANT � � INSPEQOR'S NOTES " � � O�CNER-DUILDER DL'CLARATION
�hornby affirm ihm 1 am exemp�from the Coniract<
. 70; � FMorned � � - � Llcensa law for �ho following�reason. (Sec.�7031
ApprovCd Business and ProJ ssions Coda:Any city or coun ey wGi
ha OQ}a No_ pate � � � , reguhes a pernrit fo ronstruct,akcr,improvc,dentolk
or rc/�airanystrucJurq prior to its i.ssuancc,also regrsi�
� .' � � � �. �. � � �� - � � - tl c app/ican!far avcG pern:it to J'!c a rigncd slstcmc
, . . lLa1 Lc is liccnsedQursunnt to dLe provisions of tbe Co
. - -. . . ' . . � � . � � � trnctoh Liccnic Law/Cbaplcr 9J(commencing wftb S�
., tion 7000/ojDivuion 3 o/tbe Duainess and Projessio.
� - - � ' �- � � � � � CadeJortGatGeiscrenpltbercfraracndtGebasetfortl
ulleged rsen�fio�.Any viola[ion of Seetion�031.5 1
Requtred De�sReceivod � ' � � anY°ppltcanljorapermltsubjcct.ctbcapplicanttoecic
Approvals � or Apyrpred � . Qenafty oJ nat morc tba��Jit�e l�undred dollars fSS00J.�
�- - � Yes No . . .
.. � - . ❑ I,as owner of the property,or my employees wii
Wmer Cenificnte � � � , wages as their sole compensation,will do the work,an
. � - � the s+runure is no�In�anded or offered forsale�Sec.704�
HealthDepartment � - BusinessandProjesseonsCode:TbaContractor'sticens
� , � _ Law docs nat apply to an oroner oJproperty wbo buik
Fire Deportmcnt ; . , . � arin�rmrs thrreon,and rnhn do�s.sucb u�orb himsaljo
� . � � � , � .. . . - JGmegb 1 is own enrployces,/�rovided tbat trtcb im
G�pd�n� ��. - _ _ provcmena are not intended or oJjered far sale. I/
� � � � �� - - .bo:ncner,tGcbuildingorimprouementissaldwitbinon�
Geological � " . . � . . year ol aon�pletion, tLc menenGuiJder u•i7J baoc eG�
. , brsrden oJ proving tbct Ge did not baild or improve fa
Pedestrian Protetlion .. , . �� . . . . !be purpnse of saleJ. '�
(Fence)(Canopy) � ❑ I,osownerofiheproperry,amexdusivelycontroo-
' . - . firg wifh licensed mntractors to construct Iho project(Sec.
Special Inspeclion � � � ' 704d)Dusinest and Professioxs Code:TGe Contractor's
(Conc.)(Masonry)(Welding) - �Lirnnse Lau�dors no1 np/�fy tn an ownrro/firoperty wGa
� buifds or inrProocs tbereon,and eobo contrattsjorsueb
lof Drainogo , . � . � projerts u�itb a rontractor(sJ liceased pursuant to tbc
� Conlruclor's License Lau f.
Parkinc�� , � � � ❑ I am e.empf under5ec. ,D.&P.C.for Ihis
. , , ' . rcason
Date� - �Owner � � �
Approvals � Dafe Inipoctor's5l�nalure .. . � .. . ..' . .
INSPECTOR'S NOTES -
Locotion— . .
(Set6ack&Yards) � � � � - �"�
Foondations . - - ' �
SIa6 . . . . � - ,
Frame� . �f/� /�f .�/.� ' . . .
Energy Insulalion , � �
laih/Drywoll— . . '�
Mrerior
Lo�h—Exlorior � - � . . '
Hovse Num6er— ' � � , .
Corretf 8 Posted -
Final— . . . . . .
Enter on Front �
a