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Home My WebLink About1517A 1991A i WORKERS'COMPENSATION DECLARATION � � � � hereby affirm thai I have a�e,,;f,�a�e ot�o�se��,o=e�f .- � APPLICATION FOR BUfLDING PERMIT � � Insure,or o certifitaie of Workers'Compenstion Insuronce,or � . ' a certified copy thereof�Sea 3800,tab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolityNo. Company � � Certified copy�s hereby fum�shed. FOR APPLICANT TO FILL 1N ADORESS � � � ��/�G�� 7'�f�� Cenified copy ls filed with the coonly building inspec- BUR�WG .] ,-r f]/ fion deportment. • � � A�DRESS a�� P� QW. LOCALITY (/'/� ��"�— �7 [�� NEAREST L �Oote ' � APPIicaM . ' � CITY / 21P � /�J CRO555T. . ��/ �T''�`��1� CERTIFICATE OF EXEMPTION FROM WORKERS' � / V / NO OF BlDGS. ASSESSOR �G7�� pqGE PARCEL � � ' COMPENSATION INSURANCE � � 111��y��. SIZE OF LOT O b �l CCO NOW ON LOT MAP BOOK '(This section need nat be mmpleted if the permit is for one� USE ZONE �P , a � �. hundred dollars(5100)or less.) n TRACT BLOIX LOi NO. �f NO. �. I /� EL. I(7� SPECIAL a f� OWNER O I� /�.' F O. �ONDITIONS �I certify tho�in the performance of iha work for which thi£�" � DISTRIC7 GROUP TYPE FIRE PROCESSED BY 'permit is issued,I shalt no�empio person in y manner CONST ZONE U ADDRE55 : so as to become sv,jett to the orker'C mpeas tio q s. . rO � 3 ��s�n�lt� p Date Appli n • � �C/Y✓ CITV Z�P S7ATISTICAL CLASSIFICATION - API. CONDO. V 0.RCHITFCT OR - TEL. � NOTICE TO APPLICANT: If, a ter oking this Certificme of ENGWEER NO. "�'�✓�� W Exemption, you should become subject to the Workeri ClASS NO. wELL UNITS_ N Compensation provisions of the Labor Code,you m�sl forih- pOPRE55 ' SEWER MAP � .Z � with comply wifi such provisions or this permit shall be tel. �� deemed revoked. CONTRACTOR � N NO. BK. PG. VA[IOATION � LICENSED CON7RACTORS DECLARATION �i�, � - � I hereby affirm thor I om licensed under provisions of Chapier 9 .. aDDRE55 NO. VAWATION � 6h �� ,rj�.']A ' � �(mmmencing wilh$ection 7000)of Drvisiop 3 0�the Business and LIC. �7 � Professiom Code,and my license is in ivll force ond efSeU. _. CITv C1A55 E�j�O`-^" +� � �r� � ��2 3 � � � 50.FT. NO.OF NO.OF CHEIX . jicense Number Lic.Class � SIZE � � S70RIE5 fAMILIES / ONE f � �1 �4 O , �N��GSP NEW b � . ' DESCRIPTION OF WORK z Conlractor � � Date .. �� /� AOD � � • • • � $'4 Q , � I am exempt from the licensing reqoirements os 1 pm a r7 f/b . U licensed orchitett or a reglslered protessionol englneer .. ALiER � FINAL n Q Q,p(�—$2 � acling in my professional capacity (Section 7051, REPAiR � DATE� (/ �,/� � Business and Professiom Code). USE OF �+ � - ExISTING BLDG. O G � DEMOL ❑ FINAL By ' Lic.or Reg.No. Dote APPfPR N1�0 T�O. � . . � . � OWNER-BUILDER DECIARATION � � ' . 1 here6y affirm that I am exempi from the Contractor's License � ApoRe557�� L 0 �/1�� OW �r�i4 ' � � low for the following reason(Section 7031.5,Bosiness and � , ', � Professions Code): vae etvi . � , i � � . O . B�RO�NG � . � .. . , . � . I, as owner of the property, or my employees with nooRess� -�1 9 9,1 R - � wages as their sole compensmion,will do the work and � �- ' ' the structure is nor imended or offered for sale(Section � �«A��TY � � � ' � '� -�'� ��•�,�� 7044,Bus�ness and Profess�ons Code�. rnOwnlG � � Tfl�. �� ' � � I,as owner of ihe ro ert am exdusivel [onlractin CONTRACiOR�� ' � '� '� NO.�' - � � P P r, r s . �I�• •37.5.0 . with licensed controclors to canstrucl the projecf($eo qDDRE55 tion 7044,Business and Professions COde). � • •3 7.5.0� - . REOUIRED TOTAL SETBACK FROM _EX�ST. ' � - CONSTRUCTION IENDING AGENCY � SEi BnCK ��RD HWY � pROP.LWE � WI�TH � 'O Z��p� I hereby affirm thm thera is a consironion lend�ng agency for � FRONT • � '� ••� �. � the performance of the work for which this permit is issued a t -' � � ' (Sec.3097,Civ.C.). . SroE .. . . . .. . � . � . . . P.L Lender's Name � p � . ' . - � . � lender's Address P.C.Fee 5 D �— Perm��Fee � ,j�� I cenify t6at 1 hove read this opplicotion and slote Ihat the isw ce Fea / ��L� � above informalian is mrrect.I agree lo comply with oll County .. inves�igaea�fee � �n, ) � . . .. � ordinances ond S�ate laws relo7ing to building mnstrucrion, Toial Fee ✓ ��i � � - ' ; by autha' representatives of�his County tq enter ._ , . i upon�lh a ov me oned p operty far inspec�ion purposes. -� �� . � < , � �� SFE REVERSE FOR EXPLANATORY LANGUAGE - ' ^ ignalu�e o�Applicant or AgeM Dote ' 0� - PLANS i0 APPIICANi � � � INSPECTOR'S NOTES� � OZVNER•BUII.DEA DECLARATION I hareby affirm fhat 1 am exempt from the Gontractors � To: � Retornrd � ' � ticanse Law far the following reason. (Soc. 7031.5) ��'� � Approvod Basiners arsd Pr j r..ions Code:Any eity or cou6ty mbFcb . Nm - -- Doto � No. � Oate -- . . � � � -reguires a pe�n+it to construcJ,alter,imf�roue,demalisl, .. , , _, or repairanystructrere,prior to its issuance,aJso requires � � � � ' � � � � � ,� - tGe appTicant jor sutb pern�it to Jile a signed ewtenrent , . , , , . . . tGae be is licensed parsuani to tbe provuions of tbe Con- - � - � -_ , - . � ` lractor's Lirense Law(Cl�apter 9J(commcnteng udtb Sec- , , lion 7000J of Divirion 3 oj tLe Dutinesr and Projeuions � . � � � CodeJnrt/aEbcisexemfrtlGerefrornandtGebasis,�ortbe - � nlleged rxemption.Any s�ioJalion of Settion yo3t.S ay �RequGed.'. OoteFecetved � -� -� �- . anyaJrpTicantfaraperntilsubjectslGea/�filicanttoacivrl - '0`Fprova1s ' , or Apprevod;� pennity of aot more tbero ficc banJred dolfars(BSOOJ.J: Yos � No _ , � � � _ - � .�. . ❑ I,as owner of the property,or my employees with VJoter Certifica�e . � � ', wages as their sola compeneation,will do the work,and . the structure is not intended or offerod for salo(Sec.7044) � Health�Departmeni .. . � �� - • _ � BusinessandProjes.rionsCodc:TbrCotttractor'sLicexsc . . ' . .Lau+docs sot appfy So an omrter ojproperty a�bo buildr Ffre Deportment _ . . orlmprot�e.r ihercon;and who docs aacb rrork 6imrelf or � � � � � � � � . tbrougb bu own employees,prorided that surl im- Groding . � provenrentr¢re not ineended or offered for safe.�If, � � howevcr,tbebuildingorineprovementissoldu�ithinone Geologicaf � � . _ � . . - _ ycar oj rompletion, tGc omncrbuilder will Gave tbe � � burdon of praving tbat be did aot baild or impros�c for Pedesfrfan Protection � - - tbe pury ose of:arel. � � (Fen[e)(Canopy) ' � �� ❑ .I,as owner af Ihe property,am exclusively toMrac- � " � � , . _ tirtg with licensed coniroctors to construct the project(Sec. Special Inspetfion � . - � 7044)Lfusiness axd Professions Code:Tbe Contractof's (Conc.)�(Mosonry)(Welding) . , Licexse Lau•doea no1 a/,(�1��to an ncxcr of p�of�erty mLo � . � . . -. . builds or impmves t/ereon,and u�Go tontroct.c J r sµcG Lot`Drainago _ J�rojects wirl�a contractor(s)licensed persuant to tbe � ' Caafraclor's Licensc LaaJ. Parking � � , � . . . ❑ Iamexemptunder5ec ,B.&P.C.farthis � � � � reason . . . Date Owner � l SSUuhcu Approvcls Dato Inapcc}ar'a Signafuro - a, ."O INSPECTOR'S NOTES � LocBtion—. � .� • , . � . (Setback E Yards) � � � Foundations`. . . �1,1 r1.�� . . • L!J `2 Slab... � " � � . . �L �S i a ' � � Frame � � , . . Enerpy Imulatian Q,iai h t{1n (11�1 fhiQK�`�! . . � Lath/Drywall— � ° Interior � t Lath—Exlorior . '�t �. �,�,1._ J . � wi,v.9N� . Housc Number— � � . � Correct&Pos�ed �� - � Final— En�er on Front -