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Home My WebLink About1255A 1256A (6) , � . .. . .. � WORKERS COMPENSATION DECLARATION - . . . .. . - : . . . .. ... . .. � I here6y affirm �ha, I fiavep certificate of consenf to self qpp«CATtON�-FOR BUILDING PER11711T� �� insure,or a certificate of Workers'Compensation Insurance, or o certifled copy thereoF(Sec.3800,[ab.C.) COUNTY OF LOS ANGELES BUIIDING 10.ND SAFETY Polity No. Campony � ' - - � Certified copy is hereby furnished. FOR APPLICANT TO FI�C IN " ' BuuoiNc� ADDRESS �� Cerlified copy is filed with the counfy building inspec- eUaDING } � �� tion deparimenf. A��RESS �". � � � � Date Applicant CITY �$ ZIP LOCALITV � CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF BiDGS. � NEaReSi .. . . _ COMPENSATION INSURANCE SIZE OF lOT NOW ON LO7 CRO55 5T. p (This seciion need'not be completed if the permit is far ane P.SSESSOR ' ' hundred dollors($100)or less.) TRACT BLOIX LOT NO- �y,qp gOOK PAGE PARCEL �� TEL. . ..3 USE ZONE MAP " � " ' I certify ihat in the performance of ihe work for which ihis OwNeR � NO. NO. } permit is issued,�1 shall not employ any person irt ony manner SPECiA� - . d ADDRE55 so as to become subject to ihe Workers'Campensotion La s. CON�ITIONS V Date Applicant i �,� ^ CiTY ZIP _ p.. NOTICE�PL�IC^A T: If, pfter makin this Cer fic e ARCHITECTp � TEL. DIS7RICT GROUP NPE FIRE PROCESSEDBY � g ENGINEER NO. ' F Ezemption, you should become subject fo fhe rk�er�s CONST. ZONE V Compensotion provisions of fhe labor Code,you must torifi- qDDRESS � [„�� i�,.�Vy {a��, �Y�Q d a wilh comply with soch provisions or this permit shall be � . N �A TEL.7� STATISTICAL QASSIFICATION APT. CONDO. Z deemed revoked., CONTRACTOR y�, NO. � �{s LICENSED CONTRACTORS DECLARATION .1 �� QASS NO. DWEIL UNITS I hereby affirm that I om licensed under provisions of ChopYer 9 ADDRE55 � NO. (commencing with Seclion7000)of Divisio�3 of ihe Business and �� SEWER MAP Professions Code,ond my license is in full force ond effec�. Ci1Y,{a(�A CLA55 �9 BK � VALIDATION �^�j�� SQ.FT. NO.OF NO.OF CHECK License Num6er �7 Lic CIasS f�Q SIZE `Cr'� STORIES FAMIUES ONE n ' ' 2" G" ' � VALUATION Controctor-'IL��4'��J� pp�e ��":l�I�O'J DESCRIPTION OF WORK NEW ❑ s Ds��/�-� . . ,.. . ADD ��P � , ❑I am exempt under Sec. � �f O AtTER B.&P.C.for fhis reason , . � REPAIR � s �ate: ' USE OF /� ❑ EXISTING BLDG. �\J_ DEMOL Signafure .......... . -. APPUCANT � TEL7�� FINAL �J7—/f C - � OWNER-BUILDER DECLARATION PRIN7� , NO. DATE fC/� 'J . - � �"�"'� I hereby affirm that I am exampt from ihe Coniroctor's License qDDRE55(I�pE I�� (�.nSV� I�iA�'I i�i'-(�.fYl�' p�NpC j^ }� Low For ihe following reason(Section 7031.5, Business and � s', � c m o C 5 Professions Code): PRE N ... . ...... ... _ ....—"-'... 8Y � � / . OBUILDING • a C S G� I, os owner of ihe property, or my employees wifh ADDRESS � � wages as their sole compensa�ion,wili do ihe work ond , m a ,'�:).�;�� ihe structure is not intended o�offered for sale(Secfion �OCAUTv � 7044,Business and Professians Code). MOVING TEL � ❑ CONTRACTOR NO. �'�'� � ��7 I,os owner of ihe property,om exdusively controcring - with licensed controctors to construct the proje<t(Seo- qDDRE55 �=`�� .b{i tion 7044,Business ond Professions Code). " CONSTRUCTION LENDING AGENCY SET�BACK YARD HWY T�TApROP LNEFR M WIDTH '{'_� a c e � c � I hereby affirm thal there is a consfruction lending agency for FRONT the performance of the work for which this permit is issued P.L. �u w o�j(�.�('1 (Sec.3097,Civ.C.). SIDE � Lender's Name �� P.L. �,/ :� ��..y��.�;,s � � P.0 Fee$ : (/(/ Permil Fee y�Q. 6?f LDMA Ref.# ;-- _,F� , U i.,:. I 7 - lender's Address I ceriify ihat I have reod ihis applimtion ond s�ate tha�1he issua�ce Fee l�-.�d LDMA P/C R ¢ above information is corcect.I agree to comply with ali Counly Investigatian Fee ordinances ond Stote lows relating to building consir�ction, 7owl Fee ��• �� LDMA�Parm.fl � � and here6y authorize represenmtives of ihis Counry to enter m upa the above-mentioned pr erty for inspection purposes. ' � � �� - �� -� ' `"-� �- � � � - ' - ' e ' � •y - �..e'S j�� SEE REVERSE FOR EXPLANATORV LANGUAGE � Signarure of Appl a o.A e r Dafe t � - ; I " �e,��S F � �J�r�.� �C�z� � P �Si�P_��` n� -�__ ��'�`��'— PlANS TO APPLICANT INSPECTOR'S NOTES OR`tiF•,R-BUILDER DECLARATION . I hereby affirm Ihat I om exemp�from the Contraclor's To: Ret�rned License Low for the following reason. (Sec. 703L5; � Approved I3usinee�s ared Profexsions CoJe:Any city or county u�fiicb No. Dofe No. Date � � reguires u permit to ronstruct,u[ter,in+prox�e,demolish, or repairany structure,prior to its usuanre,alsn requires - t)e applrcant for sucl permia to/s'le a signed sWtement that be is[ire�seJ parsu¢nd do!he pro+�isrnms of tbe Con- � � . aractnr's l,icense Luu•/Chupter 9J(commencixg¢�ith Ser- tion 7p00/nf 7Tirision 3 of tbe I�usinesr axd Prnjessions � _ , CndeJ ar ebat he ds ex�myt there/rom and tbe husisJnr tbe ufleged exemptrnn.Any vinlatioR nf Section 7031.�by Req�ired ��"Da}eReceived unya)pliranajnrapermrtsubjectstbeapplicanitoacre,•il Approvols ar Approved . pettalt1'of not more lbun(ive bundred doflars(.BSOOJ./: Yes No ❑ I,as owner of the property,or my employees wifh Water Certificate , wages as thelr sole compensation,will do�he work,ond rhe sirucf�re is not intended or offered for sale(Sec.7044) Health Department . Business and Pmfessinms Corle:Tbe Contracdor's License I.aw does ttod npply tn an nwner of property u�hn 6ui7ds FireDeportment _ nrimproe•estErereox;andicbodoessucAu•orkbimselJor . � � tl�rnugG bis own employees,pror.rded tbat rurH rm- Grading prnrements are not inlexded or ofjered for sule. 7j. , , , J nu.�ee�er,the buildireg or improuemen[u sofd adthin one Geolaqiml ,1'eUr of rompleiintt, X!e nwner-burlder wilf have tbe . . burden nJ prnx•ix,�tGat he did nnt Guild nr irnpnire far Pedeslrian Protection tfie purJiose nf sale/. fPence)(Canopy) I,cs owner of fhe property,orn ezdusively mntrao- , 'ting with licensed coniraUors to consiruc!the project;Sec. Special Inspecrion � � - 70441 Businaxv and Prq(exo�ions Code: The Cnntractnr's ;Conc.l(Mascnryl(Welding) L.icense Luu�doex nnt¢pply to an owner of property u�ho builda�ir iinprnacs tbereon,axd u�fin contracts for srach Lot Dramoge . J'rojccts u�itb a rnntrucfnr/sJ licc�seJ pursuant to t!e Coatructor's 7.icewsn l.uu:/. Park�ng ` I om exempt underSec. ,8.&P.C.for this reason .. .. . ..__. . . ....�. . � Date Owner Approvals DaTe Inspecfor's Sfgnature � . . _ . INSPECTOR'S NOTES Location— (Serbock 8 Yards� � Foundarions�� r`�/ ' � -� siob ,%' "�.�c;C %�l �'_,�c � �9� Prame Energy Insulotion ' Lath/Drywall-- � � Inierior Lath—Exte.ior . House Number -- Correct 8 Posted Finol-- .. -- -. .. . � .. Enier on Front � � - �� _.. ✓