HomeMy WebLinkAbout1517A 1991A (8) 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 -