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Home My WebLink About1784A 1785A � . ._ .�oo �� " WORKERS'COMPENSATION DECLARATION -�� . �-. . . ,. . . , .�._. ........ . .. ..... ., ,_ . . . ._. . _ _ _ .. .. � F hereby dNirm ihot I hove a certificate of consent 10 self APF��LrC/�!�'��ON F�R� BUILDIN�v��E1�MIT insure,or a certificafe of Workers'Campensofion Insuronce, . . . . _ ._. . .. ... _. ..... .... .. . .. . .. � or a certified copy thereof(Sec.3800,Lob.C.) � - � - - - � �� - -� --� COUNTY OF LOS ANGELES BUILDING AND SAFETY P�ol�cyNoPWC'�R9[C7�A�Pany Par_ Rm}1 n�rar� _..__..,........._... ._ . _ .. ...._ _ ===,__...... .........''------..._...._._..._ .._.. _..:._.,. ........._ Cen�fed copy rs hereby fom�shed. FOR APPLICANT TO FILL IN qooeEss ��7 � 'e�'`� � Ceriified wpy is filed with the county hui g sp o- BUILDING a fian depariment. ' ADORE55 � �. �� Date ~�` Applimnt � Cliv ZIP GOCA�ITV . . CERTIFICATE 6P EXEMPTION OM W RKERS' NO.OF BLDGS. NEARES7 COMPENSATION I URANCE� �` S¢e OF tOT NOw ON lOT —O— CRO55 Si. (This section need not be completed if ihe permit is for one � ASSESSOR hundred dallars�$100)or less.) TRACT � BIOCK LOT NO. /NAP BOOK PAGE PARCEL TEL� USE ZONE MAP OWNERM.J. Brock & Sons � Nm29-8170 „f�,.7j�f9 I certify that in the performance of the work for wViich this j',(�A NO. } permit is issued,I shall not employ any person in pny mqnner P,Q. $OX 35� �� SPECIAL �. so as to become subject fo fhe Workers"Compensaiion Lows. P.DDRE55 �� CONDITIONS � V cirv Brea CA Z�P 62 � Dafe Applicanf ARCHI7ECT D TE� DISTRIG7 GROUP TYPE FIRE PROCESSED BY � �NOTICE TO APPLICANT: If, after moking this Certificate of ENGINEER �'•C• Majors & Sons r.�62-8177 CON� zoNE �g � Exemption, you should become subject to the Workers' � yf, Compensa�ion provisions of the Lo6or Code,you must forfh- qDDRES51OS�F1 S. Paramount 9V@.� I�OlJBE r %V ��"� Y� � � wifh comply wifh such provisions or fhis permil shall be TEL. STA715TICAL CLASSIFICATION � APT. CONDO. Z deemed rgvoked. - CONTRACTOR Owner NO. LICENSE�CONTRACTORS DECLARATION �iC. CLASS NO. L'� DWELL UNI75� I hereby affirm that I om licensed under provisions of Chapter9 ADDRE55 NO. (commencing with Section 7000)of Division 3 of the 8usiness and �� SEWER MAP Professions Code,ond my license is in fuil force and effec�. CITV C1A55 BK P� VAL16AflON � SQ.FT. NO.OF . NO.OF CHECK ' License Number 54648 Lic.Class �� SIZE STORIES FAMILIES ONE __� '7&µ�'- � VALUATION . DESCRIPTIONOFWORKV214 sinole fa�mil "Ew /�/ Contractor pote ADp � s /J�� .' � � �C � ❑I am exempt under Sec. w1tY1 2.tt3CYled ara�e, , aireR ❑ =�i�'i d�•� ' B.BP.C.for this reason REPAIR ❑ S USE OF ' �'� I �+�v u �p� EXISTING BLDG. N�A DEMOL ❑ . Signature APPLICAM TEI. FINAL �]�`��i�M"� R-8UI ER DECLARATION PRINi)�, N DATE ,/e,,-'J— �� 1 here6y affir that I am exempl from the Contra[�or's License ADDRESSP.�. BOX 350 Brea C1� 92621 FINAL� � / Law for the ollowing reasad($ection 703L5, Business and '�` Professions Code): vRESENr BY � ;� I, as owner of the property, or my employees with ADDRE55 .. �= ��f��A wages as their so�e compensation,will do Ihe work ond � �, „ ,, A ihe s7ructure is not intended or offered for sale(Section ��/+LITv , , Y ' �� I 7044,Busine§s and Professions Code). '- ' MOVING ' TE�� . .- � �,as owner of the property,om exclusively contwcting CONiRACiOR NO. . � ^ i �i i.(�j U with licensed controctors to canstruct the project(Sec- qDDRE55 � ` %�! i:�1-�:�: tion 7044,Business and Professions Code). �� . . ... . .. REOUIRED TOTAL SETBACK FROM EX T. p L CONSTRUCTIOK�LENDING AGENCY � SET gACK YAR� �� PROP.LINE WiDTH ;2 V.�J 4�'��U CJ � I fie�eby affirm ihat there is a construction lending agency for FRONT ihe performance of the work for which ihis permif fs issued RL � (Sec 3097,Civ.C.). SIDE P.L. Lender's Name Nnnr� b �orna Ref.a - Lender's Address P.0 Fee$� Pe.�.+a Fee - ' � I certify thai I hove read this applicafion and stafe fhot fhe Issvance Fee tDMA P/C H a6ove informalion is correct.I agree to wmply wi�h all County Invas+igofio�Fee = ordin s and State aws reloting�o bul�ding mnstroction, iotal Fee' LDMA Perm.# - and here aufhor' represenipfi es of this County fo enier o upon ih abov - entio�ed pro rty for inspection purposes. _ (ycr � _ �� {J'�. J !'�9 SEE REGERSE FOR EXPLANATONV tANGUAGE S�gnat e of Applico r ar Agem Da�e y r)�_Y.) - ' � " -�� ' ' ��' `� f b f fJ•• PlANS TO APPLICANT ' .��INSPECTOR'S NOTES OWNER-BU.ILDIiR DECLARA'I'ION , , , , _ I hereby 6ffirm tha�I am exempl from the Con7ractor's To: � Returned License law for the following reason. (Sec 7037.5) Approved Ausiness und Pro(essions CoJe:Any city or rounty u�bicG No. Date No. Dafe � - � ' reqnires a permit m cons�ruct,alter,rmprnv�e,demolisb, � - �--� .--,.... .. , . . .. or repair anv..ctruceure,prror to r!�essuance,also reyaires . ._ - tbe u/p7icunt fnr sucb permit tn file a aigned st�tement - . _ . _thaa he i.�-ldcensed purs:tant to abe provisions nf tbe Cori- ,� . , ' � , � . :�tracdnr's Li<'ense,l,au�(Cl�apter 9J(commencin,q wit6 Seo- , tnn 7000/�f Diokclon 3 of tbe Busin,ess and Prn/��sslnns . ,. Cnde/ortbatbe�is�exewraptthcrc+frorh�ndlbeba.sisfort5e . ulleged exemption.{l ny+tinlation of Section 7031.5 by Required Dafe Recelved urry�plicana(r u pernut subjects tba applir�nt tn a ria•i! Approvals or Approved . penuldy�f not mr�re tbua f'x�v{uadred dalJurs(.�SOOJ.J: Yes No �" • - ' ` .. � � � � [J I,os owner of ihe properfy,or rriy employees with Water Cernficate , . . � � � . - � wages as their sale mmpensafion,wlll do�he work,and � � the snucture is not intended or offered for sale�Sec.7044) Healrh Departmen� � -�- • - Business ynrl Profession.v Code:Tbe Cnxtractor:�I.icense Lau.�does not applv tn cn owner oJ"propert��u.•hn builds Fire�epariment _ . - �- .. or impror,ax therenn,and wbo does surh wnrk J i�nself nr . throuRb Gis own employees, proviJed tbat suc{� im- Gradinq � � � � pror�ements are nnt rntended nr offered fnr salc. ff, �'� hnwever.dhe builden�;nr improvement is sold wit6in nne Geological � , t�ear oj comyletinn, the nu�xer-builder u•iJl havc the burden nf p�rnvi�nK tl at bc did not baild or improne/nr Pedestrian ProteUlon - tbe purpose q(.caleJ. (Fence)(Canopy) - J I,as owner of the propeny,om exdusively mmroc .. ling with licensed conlrac7ors ta mnsiruct the project(Sec. Speciol Inspection 7044)Business and Prufe.asinns CoJc: 7be C,ontructor's �Conc.)(Mosonryl(Welding) - - � License Lrsa•doe.v nat ayyl�'eo an nu:ner q(property who � builds or improu��x lGereon,and u�bo contracts/or suc6 Lot Droinage � � � �� -� �� .� prnjects u•itb a contractnr/sJ licansed purs+eant to t/e Contractnr's L.icense I.uu�J. Parking � � � �� ' , ��] I om exempt under Sec. ,B.BP.C.for Ihis �, r . . . . .... � `�„'L,,;'�l+,'=i��,...�, j''3<. .i��a.?,,f5—. �eason .. . ' . . �ate Owner Approvals Dafe Inspector's 5 ofure � -� � - - � INSPECTOR'S NOTES Locafion— ' �� '' � �- - � � �� (Setback&Yards) '� �'��' � —, Foundaiions �.� .�.� - � � . .. ,. �. .� .� .,,.. �. .. . Slab L`,/ � ' � • - . . _ ,.. � . ..,._. .,.... ,� .. . .,. ... . .�......... ......._.... ......, .,. . . Frame ...�l �f f . ' ,. ... . . . ., .. .....:�.. �,�r_:. : .,:.... Energy Inwlarion 7� (S✓ �, � � � . . � .. . , yf Larh/Drywall.... ., ..--- . ... ..., ... . .. ..._.... ......; . Interlor ��/��' C° /�-�/-�,...�.._�„�� .. . _. lath—Exterior & �• . . . .. ... . .... .� . . . . .�,_ y; ,�.,.._ -- - House Number— � ' � — --• ° � � ' � . Correct&Posted ' � Final— . .. .. . ' � Enier on front � � ��