HomeMy WebLinkAbout1683A 1732A (10) WORKERS'COMPENSATION DECLARATION . � � �
� I hereby affirm�ihat�l have a certifimte of�a�5e�„o 5e�f . - APPLICATION •�OR BUILDI NG PERMlT
insore,or a tertifimte of Workers'Compenstion Insurance,or �
a tertifi��px�ie�e�f�(�ecrJ3800,lab. COUNTY OF LOS ANGELES BUILDING AND SAFETY
6
Policy o. � Company
� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUIIbING ��
ADDRESS
Certified copy is flled with the couNy building inspeo BUILDING '
' ��tion departmenL ADORE55 C LOCALrtY ,
/ p NEAREST /
' Date���b�Q�-.Applicant CITY ZIP CRO55 ST. '"��+.e.c
� CERTIFICATE OF EXEMPTI FROM WORKERS' NO.OF B�DGS. . /+SSESSOR ,
i ' COMPENSATION INSURANCE � SIZE OF LOT NOW ON LOT MAV BOOK PAGE PARCEL
. (This seuion need not be completed if the permi�is for one � u5E ZO E riwP
hundred dollors(5100)or�ess.) TRACT BIOCK ior No.� � .�/ No. —33 3 }
TEL SPECIAL � a �
� OWNER NO. �OC�C� CONDITIONS
I certify ihat in ihe perfOrmance o(�he work for which this DISTRICT GROUP TYPE FIRE PROCESSED BY O
' permir is issued,I shall noi employ pny person in any manner - V
AODRESS CONST, Z
so as to become subjecl to Ihe Warkeri Compensa�ion Laws. � C
�_�, C �O �O t� � � �p-c,�v:cJ Q
Date�•'ay Applicant ' CITY ZiP STATISTICP.lCtA551FICATION APT. CONDO. (,~,)
ARCHITECT OR TEL.
'NOTICE TO APPLICANT: If, aN aking ihis Cerfificote af ENGiNEER NO. CtA55 NO. ��DwEll.UNITS ' G��.
Exemp�fon, you should become subject to the Workers'
Compensaiion provisions of�he Labo�Code,you mvst forih- y
A�DRE55 SEWER MAP Z
ilh comply with such provisions or Ihiz permil shall 6e —
deemed revoked: . . CON7enCiOR Ep_ BK.n u✓ . VAL�OATION
LICENSED CONTRACTORS DECIARATION ' iC
I here6y aFfirm Ihal�om licensed under provisions of Chapter 9 AODRE55 VALUATION �
(mmmencing with Section 7000)of Division 3 of ihe Business and LIC. � !.` pQ �1 6&3�A
Professions Code,and my license is in fvll Torce and etfect. _ Ciry Ctq55 e/ 5 � '��?�� � �2�
�/' SO-FT. � NO.OF .OF CHECK - �
license N�mber��Q�y �iC.C�aSS� 512E n STORIES FAMI�IES ONE ,
5 � � • •43.�2
� �� ��,�, �j' ����,�',y , DESCRIPTI OF WORK NEW � _
Contractor�eQ /n.qL. Date Apo ❑ •;,•
❑ •43.12�
I am ex�mpl fram the litensing requiremenfs as I am a
licensed archifeU or a reg�siered p�ofessional engineer. . , . . nLTER � FINAL �O 2 2(�—$2
� acting in my professionol mpatily �Settion 7051, REPAIR � DATE � �
Business and Professions Code). USE OF � � F�NAI
EXIS7ING BIDG. � � ' � UEMOL g '
liC.or Reg.Now Date � APPLICANi TEL Y -
'-'� OWNER-BUILDER DECLARATION IPRinIT) � - - - � NO. �/� , •,'
I hereby affirm Ihol I om exempl from Ihe Contratlor's License y}�y�^`"�'"�`t��'`��'� .
. law for the following reason(Section 7031.5, Business and .400Re55 � �
�� �
Protessions Code): �Ri EN �� ���
❑ . BUILDING _
I,�as awner oi Ihe properfy, or my employees wilh A�DRESS +• �
� wa es as�heir sole com ensation,wiil do�he work and � ' �- �
- �hes trocture is noi intended or offered for sale(Sectian �OCnuiv ' - L rn�L , '' . . � "s� 7�2 A
7044,Businesz and Piofessions Code). MOVING TEL. '�� �,� ������
� I,as owner o4 the property,om exclusively comrauing CONTRACTOR NO. � � �
with licensed coniracfors lo construcf the project($ec- qDDRE55 '� • •8�5� •
� lion 7044,Business and Professions Code�. - � , � . � - ,
REQUIRED TOTAL SETBAIX FROM E%IST. •8 5.5 0�
CONSTRUCTION LENDING AGENCY 5ei EaCK YAR� HWY veOc UNE WtDiH �.'
I hereby affirm ihot there is a construction lending agency for � ppONi �
the performance of�he work for which this permir is iss�ed o i �0'a 0 4—8 2
. (Sec.3097,Civ.C.). . _ .SIDE .. . -
P.L. .
Lender's Name 9 /��7
$ Lender's Address D.C.Fee E L J• �� Permir Fee //• �/ ,
W I certify that t have reod ihis appGcoiion and stote rha�ihe is:� re Fee O•.S �
= above information is correct.I ogree to comply with alI County �' Invesr,goiion Fee � �n . . .
ordinonces and Sta�e lows reloting lo boilding consiructioa, I �S(J
� and hereby aurhorize representarives of this Counry to enier Total Fee
a op n Ihe above-mentioned property for inspecfion porposes. � . , . �
< � '!���rf SFE REVERSE FOR E%PLANATORY LANGUAGE � , ��
� �' SignoWre of A pliroN or Agent «�� . �+ �
. � . . . . . . ��
\i
� PLANS TO APCLICANT � ' � � INSPECTOR'S NOTES OZPNEF•BNLDEK DLCLARASION �
., I hare6y aifirm that I am exempf from the Contra:for's
� To: � Balurnad � �_ Lkense Law for the tollowing reason. (Sec. 7031.5)
tiPF��Y�d ,� 13usinessandProJessioiuCode:Anycrryortountyu�Gith
. No. - - Dafe - No. Datc - - . seguires a penuit to construcl,alter.nnprovc,deroolub,
or rrpair any struct um,prior to its issuarsce,a&o requires
� � � � � � • . � ' tGe a/�/�lica�f for sud�/�erntit 10 file a signed statement
, tbat Ge is[icensed�unaant to tbe provisions of!Ge Con- �
- � - � -�-� ' � - - • - ' ,- � �. ' ' ' , , � tructor'sLirenseLaw(CGapter9J(ronrmrncingu�rtGSen (
, _ , tion 7000J of Draisron 3 oJlbe Busrness and Projcrsions
CodcJoribatbeiscxenepttLemfromarcdObebarisjortbc {
� � , a!lrged exemf�tin�.Any violation ojSection 7031.5 by �
. Goqvlred DefoF.ocelvcd aayapplicant/orapermitsubjecutbeapplrcantroac7vU i
.Approvals � ��' enalt o not morc tGax ac Gr+xdred do!lara 5500
Yes No arApprovod. 1' Y I 1�' ( )•%
� - ❑ I,as owner of fho property,or my employees wifh �
Nioter Certificote . ._ woqes as fheir sole compensalion,will do the work,ond �
'•�`'� �.i fhe structura is nof in�ended or o{(ered for sale(Set.>044)
Health Departmam� � � - Dusiness axd Professrons Code:Tbo Contrac0ar's License
. Law do¢s not dpply to an oa�ner ojproperty wbo bailds
FiroDepartmenl ; � orimprocertbercox,andwbodoearacbworkbimselfor
' � ibrough bis ou•x rmployecs, /�rocided tbat srtcb im-
Grading � . , pravements are not intended or of/ered Jor salc. IJ,
hoa�ever,tbe building or im/+rovement is sold uilbin one
, Geological - � . , � _, year oj eompletion, Jbe owner-builde�wi11 bae�e fbe
burden of provrng tbat be did not bulld or improve jor
Pedeeffian�Protecfion . .. .. . .. tbe furfote of sakf. ,
, (Fence)(Canopyj -- � � � ' - ��� ❑ I,as owner of 1he pwperty,am ezdusively wMroc-
� � �� - � - . tirg with licensed contractors to consfruct ihe project(Sec.
' Special Inspedion � . 7044)Business axd PmJessians Code:TGe Contractas's
(Conc:)(Masonry'f(Weldinp) � LicenreLa¢�dnrsnoeupplyfoanoumerofpropertywGo
� , buifds or inrproves lGcrcon,and wbo canlracOs for srocG
, LolDrainago � , f�rojects udtb¢aonrractor(r)�(icensedFarsuant to.tbe
. � . • ._ �� . . � . . . Conlractor's Lrrense LauJ. ' • ._
Parking . . . .
. _ _ _ . . ❑ 1 am exempt under Sec. ,B.BP.C.for Ihis
reason
Dam Owner
Approvcis Data Incpoctaia5l�ncturo � .
INSPECTOR'S NOTES
Lomtion—
(Serback'&YQr s
Foundaiions � ,
� .�
SIa6
� .
Frame � , � � � �
EneFgylnsuldfion; . � . �� �
Lath/Drywall— ' - � �
Interior � -� � �
Lath—Exterior � �� � �
House Number—
Correct 8 Posled -
Finol— ' � - �
Emer on Front - -