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Home My WebLink About1731A / WORKERS'COMPENSATIONDECLARATION � 76M444� ' � � � �E$,g,Z-$o, MISCELLANEOUS APPLICATION {� � �1 heroby efPirm that I�heve 8 certificate ot consent to sete � � � ��COUNTY OF�LOS�ANGELES�, � � �BUILDING AND$AFETY DIVISION �� Inaure,ot a eerHficate of Workers'Compensation insurance,ar � , . .. . . , � e cer[ified copy thereof(Sec.3800,Lab.CJ � � � � ' �.�Policy No. � � Company � FUR APPUGANTTO FILL IN ' � eu�Lmwo - � � woueses. h� � ��Cettitied copy is herebY fumished. � � .��.�. � Aon�esi p(j. � C./�{ES �� I�� oc��rr � . �(�•�G.. , .. . .�- �. � � Ceitified copy is filed with the county bullding lnspectltln , �EwResT. �. � . deQartment. � � . tocwurr r� � � � . . ertosssr.`. . e,CJ O . �Y�' � D8�8 ApD��C811S�� NEArtEST DISTRICT NO. ��6ROY�� Tv�6 �ROCQ63CD'6Y ' ' � - . . �� . eeoaser.��TR�!`1NOE�' ��p �y �g/!� .. �.Q . .. coHar.�� .�, �CERTIFICATE OF EXEMPTION FROM WORKERS' «a^� �� _ � , COMPENSATIONINSURANCE�� oseca�rr�oN �orno. � e�ocK �i- � wi�..x.. �� -� � �� } - � NO'70�� IRCL6) . 8TAT6 MAJOR f6CON OC a NO.-OF�GL➢G!. � �� ('fhis section need noR he�compl�eted if the work imolved TR�cr � wow or+�or � '� us�so�e BPEC AL�CONDITIDNS � ; � �� by the�pexmit is fo: one hun&ed dollars (5100)�or less.) . . . _ . . useoF �� . . � - � ,... s�ze or ior. jf 6 b �xisnna s�oc.�¢ I � [certify tAat in the performance ot the work�for whish this . .!� 0� ' O '�. permit is issued,I shall.not employ any peraon in any manner � ow��p�� r,y �O C Y3�R�E�TT ' � '� ' �"_�,L-J ,�� . so es-to become subject to the Workere'Compansation Laws. M�� . . � OCCUPANCYGROUP , w 2I�#(d C+tE57lUU1'�pF6= a � �� '� ��,�. ' FDOR65! �� Date - � Applicant n � ' '��. NOT[CE TO APP.LICANT:]f;after making this Certiftcate of .cirr�`��Q�;D v'j N°L �: � � � OCCUPANT LOAD �� ? Exemption, you should become subJect to the�Workers' qpp��CATION FOR � � � EXIT HARDWARE: � � � � ' � Cornpensation provisions of Rhe Labor Code,you must forth- � -- _ . •� , !� J with�comply with such provisions or this permit shall be rRwi�ert use� �, OEOLOGY IN3P6CTION� � �yD SFICC.K(IOWL � � , deemedrevoked. � � -� � � ' ' � L[CENSED CONTRACTORS DECLARATION�� cccurwHcr�nsrr,cr�oN �n e, �� Panic Oevices � ❑ �� [hereby afflrm that I em licensed under provisions of Chapter - � . s�e¢r*PERMIT[� i�� 1 � rvo.ov exiTs . o �, - I . 9 (commencing with$ection 9000)of Division 3 of thC B�34 - ( _ � ' ness and Rofessions Code,end my license is in full foree and � � � � ' �' -� � �� j .effect. . . . .. . � � � PwaK�� neo'o C� •Rov�oco C� sewcca � - License Number �� Lic.Class � � � � � . L�M�TE� T�ME U$E � ' Contractor �� - Date' �� ` - � � � � �� o.re . wr�� . . � � � �� •o:� � � ', �,i am exempt Rom the Iicensing requirements as.{am a � �� '� . . . . licensed architect or a registered prolessional engineer� ers¢ov , � wo.oF . +ws�ees re's ' ecting in my professional capacity (Section 7051, Bus- ex�snnc B40G. � ' BTORIEB � S�GNK�nc �; � inessandProfessionsCode). � � � , - FINA�RPPROVAL �,i/e�� . . . � PRESHNTUDE.OFlUILOING �� , Lic.or Reg.No. Dete � . . . . . � � HOME OWNEK-BIIILDER DECLARATION . . Na:os�.cz�erixc eui�niwca �- �� ', ��, � � . . . ox�or wnn uss . . �- I hereby affam that•I�am exempt from tfie ContractoC's - - � �� . . � � � �� _ - �- � � . � � � � .� �� License Law for the following reason (Section 703L5,Bus1- . .__ � .�. .. . ��. _... � � . �. ness and Professions Code): . � � � no.��.Ki�ae. _ .. _ , , . i SPAG6S PROYl06b � � . � I,es owner of the property,will do the work and the . . , � , � � - � �� - � �- �� - ' � - ' , atructure is not intended or afPered for pale(Section � - � � � � � � , ��?��.,,� - , ' . '1044,Business and Protessions Coda): . . . � ' .� . . � .. . . . . � � . . ��. . � � �ROPpSEO U56 O�'6U1401NG .. . � .. � . . . . � #•.•i� ��1�0 � CONSTRUCTION LENDING AGENCY :' � � � . � . .._ � ,' . ' [ hereby affirm that ehe�e is a construction lending agency� �' � � � � '.��,��,�b�.50 for the performance nf the work for which this permit ts � . . � . � . � . 16su0d(Sec:3097,Civ.C.). � . . . .. .�. . . . . . . ... . �'��•�6 2��O 2��. . LenQer's Name ' � � � � - � � . � , . . •WOiO9fiOMAX.00C.� . .. �Lender's Address . � . . � � � � .. . . .�� n^�'j'0 4�8i 2 • � PERMIT FEE � � �/ ' [certify [hat 1 have read this application and state that the� . >. . . . . . .. ` /�7��f{��V � �� '� above information is conect.I agree to comply with ell CounTy 155UANCE FEE �((J , �Nd �" � , �� ordinances and State laws relating to building construction, ror��Fee - � � � � J � � and y authoriae representatives of this County to enter � ..s� � � - � i pon t above� nY ed p�ty f r inspection purp�� SEE RHVERSE FOR EXPLANATORY LANGUAGE �... . . .�. -,�- � � � �� - � Si ature of Permittee � D�� ~. ,�.. � � � , . _ . . . . .. . .. . . .. . .. . .. . . ...� .. . � I � Hu�s�x'E��ssoc. C714�7�l0// ` � _' ��NSPEeroRS rvoTEs aWNER-BUILDEF DECLARATION � '. � . �, . .,-_. . , � , , � . . y.: �� _ — . - .. _ . . .. , -. -,_. . � � . . . . I heteby affirm that Y am exempt from the Conttactoi s � ��, � � - ��License Law Por the following reason�/Sectioa 703]_S,. ' ..,_.._. ..�_ ..__._. _ _.._ . ._. .. . .. _ ..... . ._ � .. . . ., ., . . . . _.. . .. .. .. . ... ,,. .�. ...... - � Business ond Professions Code): AnY ci[Y or county, ' �-� "' ` �' °�''� ��0 I�iSP6cTOF1'S whech�iequires'a�permir�ro consrruct.--alteq imprave,� ��,4�I�OVaLS�'- � -DArE - ��cNq7uRE .� -`�� ' �� , � demo�ish,or re air pn strucra�e,.prior.ro i1s issuance. ' 7RAiter�uSe .. ..�...�'. :-��- : . . �' �' ':'�f:� �� , r, 4,.��I J �. .. �� aJso requires rhe aPPI'canr for such perrnir to jile a�- � ,:...�� ... ... J .., ' � - �1 ��, .,.,:�. � { , ., ,.,..., � . 'st at-ment thoi he'is licensed�pursuam to'the : � gned st e SAFETY PERMIT - .. -- - � � t� � �� . provisions of the Contmcfor's I.icense Law�(Chap[er 9 TEMRQ aq��v �-,i t� ._ - - ` � , i; . ' 'i (�� ` � � ;i, ' � � -� � "��(rnmmencing with-Section 7000) oj Division�3-of�the�� . . .� . . �.;: STRUCTURe aFVROVEb ��-�� '- . �.� . , . Eusiness and,Professiona-Cade) or.that he is exempt TE nnAtlabiti� .. .., .. . .,,�.,. . ,... -. . _ ��... � ,'j.: .. ' - therefrom and fhe,�basis,for the alleged exemPrion.Any .�., STR C7URE REMOVED - � " - ' � -° � �. .� � � ( -� vlolation of Section 703I.5 by any applicunf forp permif � . - w y ,.;.- � -:"� ....� ;..? .�:i ;�. � .: �.. iubjects the applicant to a civil Penulty'ojnofmore tharr - �.. . ... ._ ._. _ ._ .. .. . _. � `-`` � _, ' -five hundred ddlars-($SOOJ.: �� '� � ' ,, � � ;.. ,.. .., �' .. _ . . °. -� �„�.��., .. . � , _� . . .., ; . . .. . , . . .. . . . � ,p l,as owner of the property.nvill do the,work,and . � FINAL APPROVAL.... , ..... .`. : � � . .. ., -� ' � ' ,:�; � .,�„,. . � ''-,.,. � : .. _ �, .� nacJotr's�icn sc�law dce�n�tf a��lyCtod an owner�oJ ' . PP _.. , ._, , .� .-; . � � . �""� � �� . �� "� �� .. �-- properry-who builds ar improves rhereon,and who does-� :. ��, � � � � �� .,. � � � a.;��. �. � �- � auch work himself �rovided that�such improvemeiva � f � _._ .__. . . �:�� . . .. . .. . . ..... . ..�. ,... ,... . _ �.'... ... , . � k �, _ � . . . ... � � � are not intended o�offered for sale. /f, however,�the� f '.. . . .. _. � ..- . .-.- .... .. . .. -�....-.. -. . . - . . . . . building'o� improJement.is sold wirhin one Ye6r oj� � ' �,.i .. .. . . . . - �- -�' � ' � � eompletlon, Jhe owner-buifder wil! hare !he bprden� , � . _ , �. .� � ,+ ' � ,^. ; � , of proving that he did not bui(d or rmprove jor the , ' ._ i .....' .�, :... ., . . _.. . ._ . . ._ . _ . . . . purpose oJsa(e./ � . . . . .. � : .:-. �.� . ,;, � , : , . .. . , . . . . . . ,. .,� ., . ,;.,,. , .,;; . • - I arn exempt under Sec. , _ __ _ B&P.C.for this reasan ' ' _ _ _ ._ _ Date. _ '_. . , - � I _ Utvner , ; . , , � _ _ _. _ , _ �', ,� .' ... . . �.r - .. .. . � . � . .. . . � . . .. . . . . . . . . . . � � INSPECTOR'S NOTES , . .. . . .. . .. . . . . � - . . �' . .. ., - i . . . , ... . . . . � _ . . . . . '., ., . - , � . . . . ., . , . . . . . . . . �., i��; � . . � . . _ . .. � .. . _.. , . : .`. . _ . . .' . ,, , ' . ... , 1 ; . , �.. . .� . �.. � .�... � , _�� . . �,'�.f _ . .. . . . . , � . ,.. � . � �� : . . . . ; . ...�_ , . . � �. �.-. � . .. ...� .. ., , . . .. ,, . . , �, � . � . . . .. : , . . .. . , . . . '. _.. , . , . . . , . _., .. : �. � _ .- . 1\'� . .� � . , 5 t . .. . E . . .a i. ... �( { `'. i! �� , _ � . . 'i��.' `F1 `:i_��'�.1�� ... 1.� .�� i'. .�i J'S J 1�_'. .