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Home My WebLink About1810A 1811A (10) . SOo , � WORKERS'COMPENSATION DECLARATION . _. .. . . .... �.. -.. d .. . . . ..,. . ... . . -I hereby affirm thot I have a certificate of consent�o self App�LI�A�f�?�I��_R��BU11��IN� PE�RMIT insure,or o certificate of Workers'Compensation Ins�rance, . . .._. . ._,- .;. � or a certified copy f ereo (Sec.3800,Lob.C.) � - � _ _ .. . . . Po��y N�j�CC253824�,,,�„YPac, Emplovers COUNTY OF LOS ANGELES BUILDING AND SAFETY � Certified copy is hereby furnished. FOR APPLICANT TO FILL(N � - suito�N� o ,Q �p��, � AD�RE55 I��7 %+ ' ��/✓L's-% Certified copy is filed wiih the munry buii ng inspe gUIL�iNG y� tion departmenl. ADDRE55 � afj Dple�Applicant GTV ZIP LOCALITY CERTIFICATE Of EXEMPTION OM W RKERS' � NO.OF eLDGS. NEA.REST . . � -� COMPENSATION I RANCE 5¢e OF LO7 NOW ON�Oi -O- CRO55 ST. (This section need not be completed if the permit is for one n55ESSOR - -hbndred dollars($IOp)or less.) TRAR d BLOIX LOT NO. MAP BOOK ' `PAGE PARCEL TEL. I cerlify ihot in the performance o4 ihe work for which this OWNER � No. - �j��'{E NaP /(r�.t,�g . permit is issued,I shall not employ any person in ony monner qpDRESSP.O. BOX 35� i�`7 /_� SPECIAL - - p}, so as to become subject ia 1he Workers'Compensofio�Laws. Z`'�'r(J CONDI710N5 �� oTr Brea CA ziP 92621 � Dote Applicont � x!w.��'OTICE TO APPLICANT: If, offar making ihis Certificate of ARCHITECT OR TEL OISTRICT GROUP NPE FlRE PROCESSE� Y l o ENGINEER L C �Ia' rs & A - 77 zmption, you should 6ecome subject to ihe Workers' 1� CO�qLi�- ZsCIE ,! � �.:ompensation provisions of the Labor Code,you must forfh- aD�RESS �-� % � � ith comply with such provisions or ihis permit shall be - - -- �- - ' y cleemed revoked. TE�� StAT1571CAL ClASSIFICATION APT. CONDO. Z CONTRACTOR NO. L LICENSED CONTRAQORS�ECLARATION � � �iC. � CLA55 NO. � DWE�I.UNITS T/ I here6y offirm fhal I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP � (mmmencing with Section 7000)of Division 3 of Ihe Business and . LIC. Professions Cade,and my license is in full force and effect CiTY CL455 eK � VALIDATION SO.FT. NO.OF NO.OF CHECK � li�en5e Number SGhL�R Lic.Class p.� SIZE STORIES FAMILIES ONE . . . _. ❑ VALUATpION =- ! ��I.O A • DESCRIPTIONOFWORK � ' NEW E 1C�� .__\ CoMractor Date ADD � 1 !/f!O , �' . 6 a °C. � ❑I am eaempt under Sec. �d1tI7 3tt8CY12d ara e. ❑ ' ' B.&RC.for this reason AI�R � S i ��'-��,C t� REPAIR Da � u5E OF .��C!_`ci E.i,�t5� , EXISTING BLDG. j�,r A DEMOL ❑ Si nature APPLICP.NT TEL �C� � <.` 9 P@WT �,J. Brock & Sons No.529-8170 FINA `� m L .r� 8 h NER-BUI ER DECLARATION ___ . _ .. ,, DAT -�� (" - I hereby affirm at I am exempt from the Controcfor's License Law for fhe following reason($ection 7037.5, Business ond ADDRESSP O � X �T E� FINAL/�N - � Profes5ions Code): PRE ENT BY (/��'�_ ' ' - � A�"� BUILDING , ,� I, as owner of ihe property, or my employees wifh ADDRE55 �` � r.a ..... ..__ ..._... . z f C�'�� fi.. ,, wages as their sole<ompenwtion,wilC do the work and �� , ihe structure is not intended or offered for sale(Section LOCAUTY 7044,Business ond Professions Code). �� - MOVING � ' -� ' TEL. . '• ` " `' ' � � I,as owner of the o i am exclusivel mmroctin CONTRACTOR NO. Pr �r Y� Y 9 � °i: 1 �''��i C wilh licensed coniractors b mnstruct the project(Ser qDDRE55 tion 7044,8usiness and Professions Code). `C i C..�.i v`C% RK7UIRED TOTAL SETBACK FR M ' CONSTRUCTION LENDING AGENCY� ��'� SET BACK �ARD HWY pRpp.�ME WIDTH I hereby affirm thm ihere is a mnstruction lending agency for FRONT r ��-k U�"�)r � the-performan<e of�he work for which�his permit is issued P.L - � - (Sec.3097,Civ.C.). SIDE P.l. Lender's Name NOriE' (� O Q S LDnan,Ref.# W Lender's Address -� P.C.Fee$ O Permit fee (,.)��. - , -O y I certify fhat I have read this application ond stafe fhat}he Issoance Fee � S LDMA P/C# � ¢ obove information is correcY.I ogree to comply wNh all Counfy Invesfigotion Fee � ordinances and Siate laws,relpiing io boilding consiruction, . Totol Fee LDMA Perm.# � � and hereby autho�e representatives of ihis CounTy to en�er � upon t obo entioned pr erty for inspection purposes. �y�_� �S-� _ _ ... . ¢ � 1 �� (� SEE EVEaSE FpR EXPLANATORY LANfj�U`AG,�E-vp Signa re of Applicant ar Agent Date g`X •V v. T PLANS TO APPLICANT e INSPECTOR'S NOTES OR'NLR-BLILDF,R DECLARATION � . I hereby affirm that I am exempt from ihe Controctor's To: Returned - License Low for the following re6son. (Sec 7Q3L5J Approved Busrs�ss and Pro,fessions Cnde:Any crty nr county u�fiicb No. Dote No. DaTe . � � � reywires a permit xo ronstruct,a[ter,improve,demolrsJ, or repair any.vtrnct¢re,prinr to its rssu¢nce,ulsn reyazires . . tbe applrcant Jor rech pernsii to jile a signed sLatemend ihut(�e ic Iicensed pursuant to the provisions nj tfie Cori- ' . . -�. tracror's 7_rcense Law/Cbnpter 9/(rnmmerici�vg with Sec- `tinn 7000J nf Disisinn 3 of the Business und pro/essions CnJeJ or thgt,he is exerx�t dherejrom and ihe hasu�fnr the alleged e.xemfiaion.Any oiolulion n/Sectfott 7031.5 5y Required Dafe Received uxy applicattt for a permrt subjccu�tfie applieunt to a rdai! Approvals or Approved �.- Qen�lty oJ noi mom tbun five hundred dnllars(�SOOf./: Yes No r — � '� ' ' � _ I,as owner of the properry,or my employees with Water Certificate � _ wages as their sole compensa�ion,will do the work,ond . the structore Is not intended or offarad for sole(Sec.7044) Heahh Departmeni � � Busixess arsdProfussinn.e Cade:Tbe Contrurtor:e Licexse 7 au:dncs nnt applv tn an ou•ner nf(r heriy u•br�nu;i�t, Fire Deportmenr nr i»:proa�es therann,und u�ho Joes sucb u�ork l�imself or tbrou,qh hrs�mm� amp7nyees, prorided tUat smcl rr+- Grading prnvements ure_aot inleaded or offered fr�r sale. ho�aex�er,abe buildin�or improvement u sold wrebin me Geological �� year q(completinn, tbe ou�nnr-bv{lder :eilf hare the burden nf provin,q tbui!e drJ nnt build or rmpwi�e jnr Pedesnion P.o�e<tion dha purpose of xa/eJ. (Fence)(Canopy) - ❑ � as owner of the property,am eadusively confroc- iing with licensed contractors ro construcl the project(Sec. Speciol Inspection 7044)Busine.cs and Prnfessinns Cade: Tbe Con[rarto✓s (Conc.)(Masonry)(Welding) l,icexse Lau�Joes nnt upplq�to an nu•»er aJprnpert}'u•hn fiu8lds nr imprnves tbereon,anJ mha coxtructs fnr sarb Lot�rainage projerts u�itfi u rnatrartnr{sJ licenseJ pursuant to the Carstrertor'.s I.icensc LauJ. Porking � - � - -❑ I om exempt under Sec ,B.&P.C.for ihis r) s /' 'e'/C t-yj� —,. ..reason,. .. . . . .. . � /�<;C- �.i- sei' d�• '!' �.i'�� _ � - Dole �� "-Owner Approvals Date InspecMr's Signature • � . __ . � . INSPECTOR'S NOTES Locotion— � � (Setback 8 Yords) / " " Faundatians Slab ',T Frame 7� J, �^Y � Energy Insulorion �. _`�(' �''il�� y �, p �.'1 Lath/Drywall-- ,.j� �+ � � - � � Interior '�-�'`" t i.� f'�.�/+—.�,.-� � Lath��-Exterior � � House Number--- . ' ' � �-- � � '' � � _. . Correct R Posted '- Final-- � . � . Enter on Front , ,