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Home My WebLink About1782A 1783A - ;WORKERS'COMPENSRTION DECLARATION . . ��tJ � - � � . . . ._ -. _ . _ . .. . . . .. . i hereby affirm thot I hove a certificafe of consenf to=e�f �� APPLICATIO�V FOR �BI��ILDIN�G��P��RNI�IT � ..._. insure,or a certificate of Workers'Compensafion Ynsurance, � or a certified copy thereof(Sec.3860,-1ab.C.) - - � � � � - � "�� COUNTY OF LOS ANGELES BUILDING AND SAFETY � acyrvJ,'WCC253824��Pa�yPac. EmploXers Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �� R�'�+1 �� ,� Certified copy is filed with the<ounty 6uilding ins e- BNLDING �� ' fion deparfinent. ADDRE55 � CX� � , oa�e ZZ� Appliconi cin Diamond F3ar Z,P 91765 �o�AiiTy - � CERTIFICATE OF EXEMPTIO OM WORKERS' NO.OF BLDGS. _O_ NEARESi . COMPENSATION�I URANCE �� SiZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permii is for.one � - n5SES50R� � ' � hundred dollars($100)or less.) TRAR � OIOCK LOT NO. Mqp BOOK PAGE PAR(�L owNeR M.J. Br.ock & Sons No�29-8170 ��j,°� "'^P �� I certify that in 1hQ performance of the work�for which this r NO. y permit is issued,I shall not employ any perso�1n any manner d�9`��-� SPECIAL- � so as fo become so6ject fo the Workers'Compensation Laws. F�DDRESS P.�. BOX 350 v�.�r r7i CONDITIONS � Brca, CA ziv 92621 — � CITY � Dof,e Appliconl ARCHITEC70 TEL O E,,�.,nNOTICE TD APPUCANT: If, pfter mpking 1his�Certificate of ENGWEER �,.C. Ma'ors & Assoa.a.862-8177 p�STRICT GROUP 7VPE FIRE PROCESSEDBY r ^� Exemption, you should become subjact to ihe Workers' � CONST. zONE W Compensation provisions of�he Lobor Code,you�must forth- _ aooQess 10841 S. Paramount Ave., Downe with comply with such provisions or fhis permit shall be � � �� 3 • Z TE�. STATISTICAL GLASSIFICATION APT. CONDO. d¢emed revoked. - � �. CONTRACTOR �'ner NO. �/ LICENSED CONTR.4CTOR5 DECtARATION�� -- ��. - CLASS NO. � DWE«.UNiiS T� I hereby affirm ihat I am licensed undei provisions of Chopfer 9 ADDRE55 NO. SEWER MAP (commencing with Section 70DD)of Division 3 of ihe Business and __ LiC. Professions Code,and my license is in full force'and�ef#ect. CI7Y cV.SS BK P� VALIDATION � �� SQ.FT. NO.OF NO.OF CHECK License Number 54648 �;�.clau Bl size sTORies � " FnMiues ONE �� VALUATION_ Contractor � Dale �ESGRIPTION OF WORK f m'1 NEW ](�r� `� 7��F' ADD S I'��L' ❑I am exempt under Sec. ld�t attached ara e. A�TER � , �, e �•'�G� . B.BP.C.for this eason � S �- REPAIR ( �r��5(l j pptg: USE OF �EMOL EXISTING BLDG. N A � - APPLICANT TEL �'°C:`��.�-J J Signature FINAL NER-BUILOER ECLARATION PRIN71� N . - DATE � �G•`,�..L�� I hereby affir that I am exempt from ihe Coniractor's License qDORE55 P O. BOX 350 Brea CA 92621 FINAL Low for fhe Ilowing reason(Section 7031.5,Business and Professions Code): PRE EN7 - BY _ � BUILDING , � . ' I, as owner af fhe property, o my mployees wifh ADDRE55 waqes as their sole mmpensation,will do the work and , - the slructure is nor inlended or offered for sale(Seclion ��U'��TY ' 7044,Business and Professions Code). MOVING TEL '= ` � �"h - I,os owner pf fhe properfy,am exclusively<ontracting CONTRACTOR NO. ` V ( � � � with licensed contracbrs to cons7ruU the projecf(Ser qDDRES$ G tion 7044,Business and Professions Code). CONSTRUC710N LENDING.4GENCY -- -'� - -- REQUIRED YARD HWV TOTAL SETBACK FROM %IST. f �` / I i.C CJ SET BACK PROP.LINE W�DTH I hereby affirm lhaf ihere is a consiruction lending agency for FRON7 � �� ! I ',`��'u the performance of the work for which this permit is issued P.t. � � � (Sec 3097,Civ.C.). �/ SiDE �y.'�j�—Cv b +;f. P.L. Lender's Name None r\N . ;�V Qe/ �/� 5 IDMA Ref.# - - Lender's Address F.C.Fee$ S rJ Permir Fee �.JL/ , 1 S I certify that I have read lhis application and stale}haf ihe issuance Fee LDN1A P/C k above information is corre<t.I ogrea to comply with o11 CouMy inves�iga�ion Fee ' ordinances and Siate low relating to building construction, Tomi Fee LDMA Perm.# � and h re6y outhorize esentati of this County to enter - 3 upon e abo -m oned pro 1y for inspection purposes. t'],.^'� � � � s �6 SEE REVERSE FOR EXPLANATORY LANGUAGE � �\ ... . ._. .. . .... .r:i Signawre Applicanr or Agent Dare - - ' - - �1t;cT'+� � i PLANS 70 APPLICANT ' - � INSPEGTOR'S NOTES 04�'NHR-RUII.DtiR DF.CLARATIO\F , ,. I hereby affirm ihat I am ezempt from the Contractor's To: Returned License�law for the following reason. (Sec. 7031.5j ' Approved Bus:'ne.cr und Professinns Cnde:Any ci{y or county whrch No. Dote No. ' Date reguires a permit M construct,ulter,imhrna•e,Jennnlisl�, . ,�� ... - .._or rcpair any structure,hrlor ao its issaanoe,also reguires the appdicaxr/r surb permit to file a signed stutement . .. . tha[Ge is licensedpurxuunt to tbe pmaisions of tbe Con- . , ,, � , , . ,. , tractor5�License I,aw(Chapter 9f(commencing�with Sec- . tiox?000/nf Di¢•isioa 3 ojdfre Business and Professio�c .� - ��CodeJ.or that bc�is exempr therejrom ursd.the basi.v fur tbe alle,qed examptinn.Any riolalion f Secaion 7031J by Required Da}a Received an v ap[�licuna(nr a permit sufijects tbe applicunt to u ciri! Approvals Y¢s ryo or Approved .. .. .-.-pe�a�[Y�/nnt more dbun five bundreJ dollurs(S'SOOJ.J: � � �� - � �� ` ' �J I,as owner of rhe property,or my employees with Water Certifimte _ . .. �� wages as iheir sole wmpensation,will do the work,and � the structure�is no�intended or offered for sale(Sec.7044) Healih Department . . - �� usineas and.Prqfezsions Code:Tbe Cnntractor's License Lum�Lne.e nat app13'to an owner of propertti�u�!n builrls Fire Departmem or imprnves tJ ercon,and u�ho dces suc{u•ork fii�rsselJr�r throagh �is nu�n empinyees, pronided that sucG im- Grading - provements ure not iretended pr offered f r sule. If. �� -- !owever,the hreilding or improvemext rr sold withia nne Geological _ -= Year o/rompletion, the nu�ner-huilder u�rl!bare She burdon of prnuin,Q that be did not b:eild ur impro+�e frr Pedestrian Protecfion . !{e�urPnse nf.auleJ. (Fence)(Conopyl �, "�.. I,as owner of the property,am exdusively contrac= iing�with licensed conrra<tors to conslrun the project(Sec. Speciol Inspection 7044)liusinass unrl Professrons Code: TAe Contractnr's (Conc.)(Mosonry)�Welding) � � Licensef.uu�dnesxritu�plytoanou�nerojpropertymbn buifds nr rmpmres lbercon,and u�ho cnnWarts fnr sucb Lo�Drainoge /irojects w�itb a ontrurtor/sJ liccnsed pur.cuunt to the Cnntractnr's I.rcense I_au�J. Parking �C' I am exempt under Sec. ,B.BP.C.for lhis '� ��` y�r�� O� _s.v JD� reason'-. . f� �' ' � �ate Owner Approvals DaTe inspector's Si ture � � . � INSPECTOR'S NOTES Location— � jSetback&Yards) /� - � — Fo�ndations �i ,� �. Slab r r. ' : � . ..,.., .. . .- ' . . Frame _�1Jr1�7� r'Z/f Y . ... , .. . .... ...,.,. „. . ..,.. ...._ .,. . .. ` � . . , . . . ... ..... .. ..<...,,�.,: Energy Insulqtion � �[ ,� � � . Larh/Drywall-- j� � • . . ' . ' _. .. - Imerior ��'� �'�fy- f Lath—Exterior House Number - ��- � � ' �� Correcl&Posted Final-- - � . . . . �' .. Enier on Fronr �