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Home My WebLink About1711A 1769A (10) WORNERS'COMPENSATION DECLARATION � � I hereby affirm �hof I have a certificate of consent ro�self A�PPLICATION FOR BUILDING PERMIT insure,ar a certificoie of Workers'Compenstion Insuronce,or �p��ert'fied topy thereof(Se�3800,lab.C.) � ' . COUNTY OF LOS ANGELES � BUILDING AND SAFETY po��N�'J�/'/2 S.�C'ompany �'h� '� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS e2 G�� BRo-k�ti F�:�r/fs� (5(1 Certified copy is filed with the coumy boilding inspeo- BUaDMG .7/ G y / �/� q � i��'� fiondepartmeni. ADORE55 iC-Y �Q /P.9�1� ��'��7�� LOCALITY I�,�(, �c+1/ . � . ' .D �•u n /��. NEAREST I1w�„w Date ApplicaM C�TY � e' o ZIP CROSSST. /1t�ctiac.� CER7IFICATE OF EXEMPTION�iROM WORKERS' NO.OF B1,DGS. .455ESSOR I COMPENSATION INSURANCE SIZE OF LOT NOW ON l07 MAP 600K PAGE PARCEL" '(This section need not be completed if the permit is for one p p U Ne MAP TRACT ,JG.r 7 7 BLOCK LOT NO. !� � ND. � S .hundred dollars($100)or less.) ��ry �' ' =JY�TEL. � L v�o yO.W' SPECIAL 4 � I ceriify ihoi in the performance of the work for whlch this OWNER �C ,s��E N0. � CON�iTIONS Q ��.permit is issued,I shall nof employ any person in ony manner - DISTRICT GROUP TYPE FIRE PRO�SSED eY () '.so os to become subjecf ta the Workers Compensafion Laws. P.DDRE55 S r-- •� /{b� ONST. ZONE /� �, � N � o �'�,Dafe Appli[anf CITY ��-�- Z�P STATISTICAL GLASSIFICATION APT. CONDO. V I NOTICE TO APPLICANT: If, after making this Certificate of . aRCHI7EGT OR TEL � �' / W 'Ezempfion, you should become subject to fhe Workers' ENGINEER NO. CLASS NO.�(_DWELL.UNITS � 'Compensalion provisions of the labor Code,you musf forfh- ADDRE55 SEWER MAP � wifh comply with such provisions or 1�permit sholl be � TE� �deemed revoked. CONTRaCTOR (��/t'F ec�4� Np. 6,Z7� eK. PG, VALIDATION IICENSED CONTRAC?ORS DECLARATION A �I hereby affirm thal I am licensed under provisions of Chap7er 9 aDDRESS G r' /�(•�f/Cl:�£ NO.��S�0�' VALUATION (mmmencing with Section 7000)of Division 3 of the Business ond �q LIC. / Q p� � � Professions Code,and my license is in full force ond effect. CI7Y ` ��N`'� CLqSS C-S 3 5 d SO.FT. e NO.OF NO.Of CHECK ' 'LicenSe Number li[.Class SIZE O� STORfES FAMIUES ONE _ . '.Coniractor Dafe �ESCRIPTION OF WORK �O L NEW § ❑ ADD I am exempf from the litensing requiremenfs as I om o . licensed archifeGf or p regislered professiona�engineer AITER � FINAL� /� O� ��. acting in my professionol capaciry (Sec�ion 7051, REPAIR � �ATE o �1 7 L 1 A � � Business and Professions Code). USE OF . oeMoi FINAL Ex15TINGBLDG. ❑ g �,� ��•�•'Z� Lic.or Reg.No. Da7e APGUCANT iEL. - � OWNER-BUILDER DECLARATION �RMT NO. � I •�•3 9,7 6 I he�eby affirm that I am exempt from rhe Comractor's license � �Law for ihe following reason(Secrion 7031.5, Business ond ADorte55 •-• •3 9,7 8� Prafessions Code): , GR ENT 2 � . BUILDING . . O.A O 2`S Z I, as owner of ihe property, or my employees with ADORE55 ages as their sole compensarion,will do the work and � . . .. the structure is not intended or offered for sale(Secrion �OCt uTv - , 7044,Business and Professions Code). MOwN� 7E1. . ' .., � � I,os owner of the property,am exclusively conirocfing CorvTRAC70R N0. � . with ticensed mMroclors lo Construcl ihe prolect(Sec- ADDRE55 � tion�044,B�siness and Professions Code). - � REOUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENOING AGENCY � SEt BACK VARD HWY PROP.LWE WiDTH �� 6,9 A I hereby affirm thot there is a consfru<tion lending agency for FRONT . . Ihe performonce of Ihe wo�k for which ihis permit is issued a.l (Sec.3097,Civ.C.). . Si�E �.� • • ` �}� P.l. Lender's Name � �) �'� •7 9.5 0 P.C.Fee S � Permit Fee 6—(1 �7(�5�x Lender's Address ' �� • � 1 certify ihat I bave reod this applimtion and sfale ihat 1he Issuance Fee �'�U 0 3,0 E`8 2 above information is mrrec�.I ogree 7o mmply with all County invesrigot�on Fee � ordinances and Stote lows rela�ing lo building construction, ' 7o�al fee t S�� and hereby authorize representatives of this County to enter � upon e bove-mentioned properfy for inspetlion purpases. . , . � ��' SEE REVERSE FOR EXGLANATORY IANGUAGE � . Signoture of Applicanr or Agenl Dote , , . . �� j INSPECTOR'S NOTES OWNER-B!]ILDER DECLARATION � PLANS TO APTIIfcANT t hereby affirm lhat i am exampt from Ihe Confractor's Ta: � RNurn�d Licanse Low for the following reason. (Sec. J031.5) Ap frovw! Bruiness and ProJessiona Code:Any city or county wbrcb Wo. DaM No. Dufe - reguires a persreit to construct.alter,improve,denmllsb, or repair uey atnrctrre,prvor to ixs issuance,aTsa reqaises . � � - �� eke applicaxt for sucb permit!a file a sig»ed amae.naat . - _ tbat be is licensed pµrswnt to tbaprauisiwas of tbe Con- ' � � � � - � � ` � �- tractor's I.icenac I,aw(Chaptsr 9J(rormnencing witb Seo- � , tion 7000J njDioision j of Lba Businass and Profeasiofu � Cod¢J or that be u exempt therefrom and iha basis for tbe olleged exemption.A�oy violatioro of Saciion 7031.5 by � R�quind � . axy afiplicant for a permit subjcctr tba(yDplicant to a civll kpProrala ` Y�a No D�fa Rxs3y� � . .. _ penalty of eot more tbae ffue hu»dred JoJJors(d$00%J: � a:Approv�d_ . . . , ❑ I,.as owner of fhe proparty,o�my employeea wifh . � Wofer Certifimte � I wages as their sole compensation,will da the work,and the struaore is not intended or offe�ed fw wte(Snc.7044) H��'��n�� , , + Bresiness and Profesaioas Code:The CaatrocEor's License � - . . La,v does not apply to an omner of proparty wbo bwJdr Fire Departmenf , . .or imQrovas thereo�,and mbo doea sucb u+ork binxte�,(or � tbrougb brs awn ernplo.Nees,provided that s/acb im- Gradinp. � provements ore eot ieteadrd or offered foi sale. If, � bowever,tbe building or irxprroveurent is sold witbin one Geologieal� � year of cornpletron, tbe otvnenbuilder urill baue tbe burden ojproving Ebat be did uot bwTd or improve fer Pedesirian Protectian . � . tbe purpose of saleJ. (Fence)(Conopy) . . " � ❑ I,psowneroflheproperfy,arnaxclvaiwelytonhac- . Iirg witb licensed convactoro to construd the project(Sec. Special Mspectcoa � � � 7044)Basinesa aad Professions Code:Tbe Coalracta✓s (Conc.)(Mosonry)(Welding) - Liconae Law does not apply to an owner of property mho _ . builds or improves lbereon,and who contracts for sucb � Lot Drainage . projects with a contractor(sJ litensed pµrsaant to tbe - Coatractor's LicensQ Law� Parking, ,�� , ❑ �Inmexampfunder3dc. ,B.&P.C.forthis �-, � • � a . . � . �. reason . r;\.`;.-. ., ' Date Own�r � y Appr6v�l� �� 6afo Inspactors iy�nafurQ . . . . INSPECTOR'S NOTES Location—. -i � --'— � (Setback&Yards) � Foundatioos 3 .. Slab Prame Energy Irmolafion - Lat6/Drywall— _ � - , �Interior . � - Lath—Extarior - Housa Number— � � Corraei 8 fbated � Pinal— Enter on Front � .� �'g 5 � �