HomeMy WebLinkAboutNo Permit Number (232) I � WORKERS'COMPENSAiION DECLARATION � `IJ`��j� � ' ��^" `� � � `
insureborafclertiicatela(WorkerseCo'mpens�tion�ln�°o�°e5o'� � APPLfCATION F�R BUILDING `PERMIT
a certified mpy ihereof(Sea 3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PalicyNo. ' Company
� Cer�ified copy is hereby furnished. FOR APPLICANT TO FILL IN ADORE55 .� .S LT
� �{ � Certified copy is filed with the covnty bvilding inspet- BUILDING I''yy
�X-� tion ep �1meM. _ � ADDRESS 721 Brea �. .�.11t.2 1. LOCALITY VV/T L �
��/� NEAREST
Date � ApplimN "LU� arr Wa1t1Ut , ZiP 91789 � ceoss sT. GV S L�7'0/1�
-CER IFI ATE OF EXEMPTION F� RKERS' Srze oF�oi Pr1Yt Of SWi�I1NOW ON`10T5 MAP BOOK 7AGE PARCEL
'COMPENSATION INS R NC
(This seclion need not 6e tompleted if the permit is for ane- .�1�1V15 �IOtS 3 & � USE ZON MAP � �p
hundred doilars(5100)or 1e55.) TRACf LTE NO. J�1/� � SPECIAL ' �/J a "
I certify Ihat in Ihe perfarmante.of ihe work for which Ihis OWNER .�'12d Hanes N�98-1841 ��� CONDI7�ON5 Q
permit is issoed,I shall not employ any person in dny manner DISiRICT GR P TYPE FIRE .PROCESSED BY V
so az to bemme subjecl to the Workeri Compensmion Laws. Aooeess6$$ BY2d .C3ri II� �. � CONST. ZO y
aTv Walnut Z1P 91789 a a /l � o
Date �AppliConl STATISTICALCLA FI TION AFT. CONDO. V
NOTICE TO APPUCANT: If, oiter makin this Ce�lifimte of /RCHI7EROR . TEt. � ��
� 9 ENGINEER Sttea Hanes No.598-1841 ClASS NO. � DWEIL.UNIT$ r-
Exemptian,y ouu shouid become su6ject lo the Workers' �
Compensotion provis�ons of the Labor Code,you must forih- qooeess SC7IIIE SEWER MAP �
with tomply wilh suth provisions or Ihis permif shall be TE� �
� deemed revoked. � CONTRACTOR 'Sh2d HQSles No 598-1841 BK. PG, VALIDATION
� � LICENSED CONTRACTORS DECLARATION i��, . �
I hereby oHkm thot I am licensed under provisions of Chap�er 9 ADDRESS 5�7I[lE' �NO, VAWATION
(mmmencing wi�h Section 7000)of Division 3 oi�he Business and ��� � ' �
Professions Code,ond my license is in ful�force and effecf. CITY � S�� CtA55 S 3�]0� . . �
. SO.FT.S20 NO.OF 1 NO.OF � Q ' CHECN �
Li[ense Number liC.Clpss SIZE ��STORIES FAMILIES ONE ,
NEW � s
Contra[for Dale DESCRIPTION OF WORK . �
� I om exempt from the licensing requiremenls os I am o AD� �
licensed architect ar o registered professional engineer . . AtTER � FINAL C�
aUing in my professional capaciry (Section 7051, REPAIR � ��ATE S��` p �
Business and Professlons Code). . U5E OF ,
EXiSTING BIDG.OfP1C2�IRC1L1StY13�. DEMOI ❑ I FINAL
� By �� �Zl�i
Li[.or Reg.NO. Date APPUG4NT �� Hanes. . .. rE�.598-1841 . . .
� OWNER•BUILDER DECLARATION (PRIM� NO. j _ N��• t a • �
- I hereby affirm thar I am eaempt irom tha Controclor's Licensa 655 Brea �.'3II OIl wdlIlllt.
Law for�he fallowing rea5on�Section 7031.5, Business and ADDRE55 Y � �� •�•L{j rj�
Pf0IES5iOn3 COCJCJ: ' . PRE EN �C'u
❑ BUiIDiNG • � e,w��e((j` �
I, aS owner of the properly, Of my employee5 wilh ADDRE55
wages as iheir sole compensation,will do the work ond .,
�he structore is not intended or offered for sale�Seuion �OCAuiv Q�� �,,_�'
7044,Buziness nnd Profe55ions Code). � � � MOVING TEL.
O1,os awner of the properly,om exclusively contracling CONTRAC70R No. I �
with licensed contractors to construct Ihe project(Seo- ADDRESS �
rion 7044,Business and Professions Code). � . �
REOUIRED TOTAL SET6ACK FROM E%IST. � .
- CONSTRUCTION IENDING AGENCV SET BACK YARD HWY - 7ROP.UNE wi�TH �
I hereby affirm Ihat lhere is a consfruclion lending agency for FRpNi ' � �
the per(ormance o(rhe work(or which ihis permir is issued v i
(Sec.3097,Civ.C.�. � - � SIDE ' ��
P.l. I
Lender's Nome - � . ��OO � � � ,
� tender's Address � P.C.Fee E Permu Fee . � �
_ � �
W 1 certify�hat I have read this applimtion and sraie thai ihe . iswan<a Fee � �. ' - '
� obove information is correcl.1 agree lo comply with oil CouMy � . i,,,,es��gar�o�Fee /�^� �J � � � � �
$ ordinonces ond State laws relating to building construdion, Total Fee '!tJ� . � � �
� � ond hereby ou�horize represen�o�ives of t is Counry to enrer , . �
� ��,pon the ab ve-mentioned property for i specfion pu pa es. .
<' ` � � � � SEE REVERSE FOR EXPIANATORY LANGUAGE - ' , � � f
I '� . Sign %e f pplicont or Agenr �e . � . . �'I
- PLANS TO APPLICANT � � -INSPEC70R'S NOTES , �OL1'NEK-BUILDER DECLARATIO^I
I hvreby afiirm that 1 am exempt from the Contractor's
To: � Rotumod - � � . � . � Llcense law for Ihe followin9 reoson. (Sec. 7031.5)
Approvcd Burinras arsd Professions Codc;Any city or county wGicG
llc. .Datc . No. . D¢tc. . . . . , rcguires a ycnnit fo corsslrucl�alOc�improvc,dcmolisb,
. . . _ , D/ICrOtJ'6RyS�ILCtY/C.f)ffOf LO 11SlStLpfJLC�A150 fCgYlIC3
� � � ��- �� - � -- . - � � � - � � tbe applican[jor sucG pernart to jife a signed statemen!
, tbat bc is licenscdQunuant Lo ibc provisions oJ1L¢Con-
� � � � . ._ � � . � . lractor's License Lau�(Cbapter 9J(commencing a�itASen
. , . �tiox 7000J ojDicv:rion 3 o/1Ge IIesiaess and Professions
- - � - - � � � � �� . - - � - CoJeJ or tGat Gc is excmpt tGcrejronr aod tbe basujor tbe
_ aJleged exenrptrore.Any viola�ian ojSection 7031.5 by
� P.oqulrod DafaP.ecsivod �� �� � ' . � anYnpplicaxtforapernr&subjectstbeapplicantloaticrl�
Approvals - Yes No af AapfOYCd _ QQRa1�)'Of nol mnrc 1Gars firc brmdrrd dollars(5500).f:
' .-_ � . � ' ❑ I,as owner of the property,or my employees wi�h
Wafer Certificate � ��- wages as their sole tompensotion,will do the wark,and
� � � . . . � -, . � fhe struauro is not intended or otfered for sale(Sec.7044)
Heolth Departmant � � �., �� Iiusincu and ProJessions Codr.ZGe Contractor's License �
. �� � � "' . - � � Lau.�docs aot apply to an owncr oJpropesty uibo bai[ds
Fire Deportmnnt . � . . or in+prones lbercon,and wl�o docssucG rvork bimse f or
. " . - ' . _ lGraugb Gis own eniJdoyces,proeided lGrst sueG ino-
� Grading � . , pronemexn arc no1 intended or offered jor.sale.Ij,
- � � - , . .bomercr,tGebreildingorimprovemcntissoldartGinone
Geological' � ��car oJ conrpletrox, tGc orvncrbuifder u•i11 bave tGc
� � - � burdea oJproving tbat Ge did not baikl or improa�e jor
!Gc ur os¢o sale. � ' �
Pedestrian Protenion � � � .. .. . . . . . .. P P l
(Fence)(Canopy) � ❑ I,as owner of�he properiy,am extlusively confroc-
, � . , , . tirg with licensed contractors to constroct the project(Sec.
' Special Inspecfion - 7044J Buarnras artd Professiaxs Code:TLe Contractor's�
'�� (Conc.)(Masonry)(Welding) - I.itrnseLa�ndoesnolapf�lytoanou�nerofpropertywGo
6uilda or inrproves tGereon,and wbo�ontracts Jor sucG
� Lm Drainago , '� �projects a�itL a eontractor(aJ licensed punuant 10 tGe
i
' � �� ' � �- � � � Contrrsctor's Lirense LauJ. �
Parking � � , � ❑ I am exempl under Sec. ,B.&P.C.for this
. ��--� - --. -• reason
� , . � . Dote Owner
J Approvals ' Dato In�pactor's Signaturo
� INSPECTOR'S NOTES �
Location—
(Setback 8 Yards)
i Pound6tions
�
� Slah ; � ' � � , �
IFrome ' , � , -
� Energy Insulation � . . � .
Lath/Drywall—
Interior
I
'� Lalh—Exterior , - . � � .�
1 Housc Number— . - � .
I Correcf 8 Pasled � �
! Final— . . . . .
� Enter on Fronl - � � �