HomeMy WebLinkAboutNo Permit Number I WORKERS'COMPENSATION�ECLARATION , � Qj
!hereby afFirm�hor 1 have a tertifico�e of coneent to 5e�� � APPLlCAYION FOR BUILDING PERMIT � �'
nsure,or a certificate of Warkers'Compenstion Insvrance,or �
i cenified capy the.eof(Sec.3800,Lab.C. � � COUNTY OF LOS ANGELES BUILDING AND SAFETY
'olicyNo. Company �� �
�, Cer�ified mpy is he�eby fu�nished. FOR APPLICANT TO FIIL IN nooeEss �� � .
� Cerfified copy is tiled wirh the o ry bu'd� inspeo - �UILD�NG � /
tion depar,lImenl. ' � ' ' ADDRE55 � �� , � ��1 LOCALITY ,� �/�
(� 5� � �. ���1 NEAREST
ote -i Appiicanl . � GTY 1�i_�� - Ziv N CRO555T.
� CER��EXEMPTION FBOM WOR �RS' ,� f \ NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE . SIZE OF loT . ,r��, NOW ON l0T MAP BOOK FAGE PARCEL
his seclion need not be compleled if ihe permit I5(Or one USE ZONE MAN
mdred dollors(5100)or Iesi.) , TRACT )�f �AN. BLOCK LOT NO. ' NO. }
� TEL�V ' SPECIAL .
;ertify thai in the performance of the wo�k for which this OwNER �.`, r' ''' NO. i - CONDITIONS' Q
irmif is issued,I sholl nof employ ony person in ony manner qDORE55 �rQ ( 1 ;,,1 /1, y DISTRIQ GROUP iYPE FIRE 7ROCESSED BY V '
�,as fo become su6jecl lo the Workers'Compensalian Laws. � CONST. ZONE n,
��T� r.L� � Z�o ' �G �r". 3 � �� o
te Applicont $TATISTICAL CtA551FICATION APT. ONDp,
)TICE TO APPIICANT: Ii, afier moking ihis Cer�ifimte o( ' ARCHITECT OR TEt. �
�mpfion, you should betome subjfcf to Ihe Workeri fNGINEfR NO.� C1A55 NO. DWEIL.UNITS_
G
mpensa�ian provisions of fhe lobor Code,you must forth- �
h comply wi�h su[h provi5i0n5 or Ihii peimif shall be ADDRE55 �/� �, SEWERAMP z
fined�evoked. CONTRACTOR �� � NO. bK. PG, VALIDAiION � �
LICENSED CONTRAC70R5 DECLARATION ' r. �i� � � '
•reby af(irm fhat I am licensed under provisions of Chapler 9 ADDRESS /�A.1. NO. CI� VALUATION �
nmencing with Section 7000)of Division 3 of the Business and ���' ��/�
`essions Code,and my license is in full force a d ef(ecf. CITY CLASS S � �
!1(/� 50.FT. NO.OF � NO.OF , CHECK - .
�nse Number J 7 � C Lit,CIa55 n�J� 5�2E � $TORIES FAMILIES ONE , .
S�� DESCRI7TI OF WORK NEW � S �
Iroctor � Date___t�� / ❑
�� I am exempt from ihe licensing req�irem ts s I am a � ,���I/ Y C A��• .
' licensed architett or o registered professionol engineer _ � ,_ , .�� ALTER � FINAL
� oc�ing in my professionol capocity (Secfion 7051. � �ATE �^.�'�� "
� � Buslness and Professions Code). � REvaiR
USE OF FINAI �� Q Z�P.
Ex15TING BIDG. OY I L, � � OEMOL � ,
rt Reg.No. �ole APPII(;ANT NO. G /I J By �;'• •b •C.v
- OWNER-BUIIDERDECLARATION --fPRiNT� n R .0 �
'�^by altirm Ihat I om exempt from�he Contractor's License / �/ � / ,I ^�"��,t Q
�, Ior fhe following reason(Section 7031.5,Business and ' ADORE55 6�f. lTi^ilr. �I� �
'ssions Code1: �. FRE�ENi . • '"�'��G(1�
_ euuowc
. �,1, as owner of the properly, or my employees with-� nDDRE55 � ,� C.Gj q_�1
'�wages os their sole compensmion,will do the work ond ' .
-� �rhe srructure is not intended or offered!or sale(Section tO�AtIiY
• .70d4,Business and Professions Code�. MOVING � TEL �"� (`,`j.C�',,
— �I,as owner of ihe propeny,am exdusive�y wntracting � cONien�i0e NO. . �
�wifh litensed conrraciors to constrvct the projecl(Sec- ADDRE55 �� �� � � �
_ rion 7�44,8usiness ond Professions Code). � � '
' REOUIRED TOTAL SETBACK FROM E%IST. , 'I G��'�5�-D �
CONSTRUCTION LENDING AGENCY� SEi eaCK YARD Hwr vROv.LiNF WiDiH
— �y offirm that there is a wnsfrvctio�lendm9 agency for� FRONT • Q F!�}�Q v
vformance ol the work for wh�ch�his permit is issued P i . �
_ iov�,r�.e.). s�oe , C 9.f'9—�1
P.L.
's Name
V,C.Fee E , J Permit fee � �
's Address . ,
i�hat I have re this applicotion ond state�ha�the issu e Fee .�
�ntormorion's c re r.I agree to comply wNh oll CouMy , i„�esrgai�o�fee �v \
�c d S t law relaring to build�ng constroction, Toiol Fea '7I U
y th riz rep s niorives of ihis County to enter , �
' e me Iio d roperty for inspeclion p rp�ses.� -
— � � SEE REVERSE fOR EXPLANATORY IANGUAGE � �
natvre o Appl�<ani or gent Do�e ' ' �a
� . . .. I - � .. . . .
l
PLANS TO APPiiCAM - �� � INSPECTOR'S NOTES - OA'NtiR•BUILDER DLCLARATION
I fieroby affirm that I am exompt from the Controctor's
To: 6cfvmed � � � License Law for the following reason. (Sec. 7031.5)
� Approvod IIusinessandProfeisionsCode:Anyeilyoreounfyu�bicl
120. Date No. Date�.� - - � . reguires e penr�it to ronatrect,efler,inzprove,demolisl�,
, or repair aay structure,prior to its issuance,ako reguires
- - � - - � - - - , tbe efJ�lkant for sucb f�ernril fa filc a tigned statenient
tbat Ge is licensed pursuant to tbe procisions oJ t!e Con-
- traclor's Liccnsc Lew(Cbaptcr 9J(comnrencing mitb Src-
tion 7000J of Divisiox 3 oJtbe Businrss and Profetsions
- � � . � � Codr/or[ba!be is rxcmpt tLcrejrom and fLe burs jor tbe
allrged exempfion.Any oiolation of Scction 703l.S by .
Reqvirvd - DatoReceivod � anyapp(icantJorapennitsabjeUrt6eapp(icanttoac4vi!
ApprovCis� or Approvod penalty of rsot morc tban fivc Gundred dollars(SSOOJ.f:
Yos No
. ❑ I,as owner of�he propeny,or my omployees wtth
Wafer Certifimte � . woges as their solo campensalion,will do the work,nnd
� the structure is noi intendetl or offered for sote(Sac.7044�
HealFh Departmanl OusinessandProJessions Code:TGe Contractor's License
. Law docs not apply to an owncr oJproperry wbo builds
Fire Department . � , or improves thercon,and wbo doessucb work bimseTjor
- - . � . � 'tb�oug6 ,Gis ou�n cmployecs,pmt�ided tbat ssscb inr-
Grading � � � prorcrnentt arc not inlended or offrred Jor sale. If,
� - - � � �bowevcr,tbebuildingorimprovenicntissoldu•itbinone
Geologica!� � - � year of conrpTetion, tbe ownenbailder will bece tGe
. barden oJ f�rouing tbat he did rtot b¢iJd or inrpraveJor.
Pedestrian Protec�ion tbe purpwc of raleJ.
(Fence)�Ganopy) - ❑ I,as owner of the properly,am exclusively coMmc-
. ting with licensed comroc�ors to constrvct the project(See.
Special inspedian � 7044)$usiness and Professions Coder T'be ConiracJor's
(Cont.)(Masonry)(Welding) , � Liccrtse Gau�dnrs ttot ap(�Iy 1n an oumcr of proQcrty wGo
� � � buifds or inrJ�rovcs tbcrcon,and who contrncts for sucb
lot Drainogo . projetts witG a tontroctor(sJ Iicensed rursuaxt to ibc
� . Conerattor's License I,awJ. ' .�
Parking � ' �
. . . ❑ 1 am exempf under Sec. ,B.BP.C,for this
. ' . � reason
� Dme - �� - � Owner
Rpprovols . Date fnspecfor i Sipnoturs ' � .
� INSPEGTOR'S NOTES .
locotion— . . . .
ISet6ock 8 Yords) � - - -
Foundations
Slab
Frame �
Energy Insulation . . - -
Lelh/Drywol�— ,
Interior
lath—Exterior � �
House Number— . . .
� Correct 8 Posted
Final—
Eroer on Front