HomeMy WebLinkAbout1780A 1781A _. _ . .. � - ,
� WORKERS'COMPENSATION DECLARATION . .' {_Q �
. ..... .. . ........ ....._.... ....... . . .. . .. _ .. , _ .
I hereby�affirm thot I have a certifica�e of consent to self APP�LICATION� FOR� BU�(Li�I�NG PERMIT
insure,or a certificate of Workers'Compensation Insuronce,
' or a certified copy fhereof(Sec.3860,Lab.C.) .. . " ......- """"'-...� .` .,'.. � .
.. . _ - , , . ... . '
AFETY
COUNTY�F LOS ANGELES AooREu BU�D�G AND SF - ._ - - -- m--- _^,,
acy tvd'Idf;�94��.r,paoy Pac_ Em��Prc euaow� '�j�
Certified�opy is he�eby fu�nished. FOR APPLICANT TO FILL IN / ' y[l1�vy�i �..Q,�._c,¢
� Certified copy is filed with the coanty bui ing inspe gUIL�ING � /� -
tian deparimenl. ADDRESS � � � �/.J
Date�.Q.n _ . . .._ . .._...._..... ........ ... __ . . . __.. _ _
�-�yApplicanl orv Diamo:� Bar ziP 91765 iocnurr
CERTIFICATE Of EXEMPTIO ROM WO KERS' NO.OF B�DGS. NEAREST - ...,.,. .. . . � . . . ..
COMPENSATION I URANCE 9Ze OF l07 nIOW ON LO7 -O- CRO55 S7.
(This secfion need not be complefed if the permit is for one �� ASSFSSOR � -� ' "'-
hundred dollars($100)or less.) TRACT BLOIX LOT NO. Mqp gpp�(`� ' ' �PqGE PARCEL
owNee hI.J. Broek & Sons No:529-8170 usezoNe mwa
I certify thot in}he performance of the work�for which this �� �� /`� y,
permit is issued,I shall not employ any person in any manner SPECIAL , - - - - a.
so as to become subject to the Workers'Compensotion Laws. AODRE55 3 �p'j(� CONDITIONS Q
U
Date Applicont aTv Brea C�1 zir 92621 � � m
:�'7TICE TO APPLICANT: 14, after making ihis Certificate of ARCHITECTOR TEL. DISTRICT GROt1P IYPE _ FIRE PROGESSED BY o
ENGINEER L.C. Md OYS S� ASSOIGq SOZ-H177 M
amption, you should 6ecome subject ro the Workers' .. . -. , , (� CO� 20� y
Compensation provisions of the Labor Code,you must forth- qODRESS v� �� fr,� d
with com I with such rovisions or this . . _ P Y IDOURt .�VB. Dokme � '3 1J'
PY P Permit shall be - -. ._.. . ..--. . ... . a
deemed revoked. T�� STAT�STICAL CL4SSIFICATION APi. CONDO. �
CONiRACTOR Owner NO.
LICENSED CONTRACTORS DECLARATION � ���_� CL455 NO. � DWELL,UNI75 �
I hereby affirm ihat I om li<ensed under provisions ot Chopter 9 aoDRESS NO. .
(commencing with Sec�ion 7000)of�ivision 3 af ihe Businessand ��� � SEWER MAP
Prafessions Code,and my license is in full force and effect. CITY Ctn55 BK � "- VALIDATION
Sq.FT. NO.OF NO.OF CHECK
LicenSe Number S�+fl�+c�i Lic Class B� SIZE STORIES� FAMILIES ONE "
' . ' '. ` ,... VALUATION � 7
cor,r,o��o. oore DESCRIPTION OF WORK i e Famil� "E'^' � 5 !J (� Gy,� c� I �'v A
noo , .�e.e e a�J
❑i om exempt under se�. with attached ara e. q�TER ❑
B.BP.C.for fhis reason REVAIR ❑ S � - � "����."�. `�' -
USE OF
Date: E%iSTING BIDG. �/� DEMOL ' w�J:�.G-v U
Signature p'PP���NTj�'[,J, Brock & Sons ���529-8170 FiNA� � �
O ER-BUILD DECLARATION PRINT) ......... NO...__._,__..._..... DATE� ���� �4.�'.�'`�'�'
I hereby offirm t I am exempf frpm fhe Coniractor's License qDDRE55P.�. BO� 3rJ� BT(,'8 Cf� 92621
� Law for ihe fol ow�ng reason(Secfion 7031.5, Business ond FINAL '"'"' �
Professions Code): � PRES T - � BY
BUILOING , � . . � . ... `- ..
� I, os owner of the property, or my employees with ADDRESS - � -" ��
�,, _ . _..... . .._. . _ _ =i !8.t A
wages as their sole compensation,will do the work and -
ihe structure is not intended or offered for sale(Section LOCAuiY
7044,Business ond Professions Code). - MOVING 7EL. �i p1^�� " e �
� I,os owner of the property,am exclusively confrpcting CONTRACTOR NO. '
with licensed coMractors fo construct the project(Sec- ' ` � � �.U L
X tion 7044,Business and Professions Code). ADDRESS
REQUIRED TOTAL SETBAIX FROM X T. ' ' ' / 1 i,O r� �
CONSTRUCTION LENDING AGENCY SET anCK Y/+RD Hwv PROP.LINE WiDTH
1 hereby rffirm that there is o construction lending agenty for pgp�y7 ��O�"�y,
the perfarmance of the work for which this permif is iswed P.l, � � - �
(Sec.3097,Civ.C.). SIDE
P.L.
Lender's Nqme �(+nP 1 � /�� $ LDMA Ref.R
Lender's Address �,�/�f P.0 Fee 5 ' '4 Perm��Fee w �- ---- �� , -
I certify thal I have�ead this application and siate thai theJ Issuance fee , .�J �� LDMA P/C#
above information is correct.I ogree to comply wilh oll Counfy Investigation Fee �
ordinances and Stq1e lows reloting fo building consiruction, Tmal Fee IDMq perm.�
ond her by author representativ f ihis County to enter
m upon e abo - entioned prop or inspecfion u�rposes. / �`[j '�� � " ' ' - �
a �G� �6 SEE REVER�R EXPLANATORV LANGUAGE
„ n
Siqnalur of Applicanf or Agenl Dale. . . __. ._.. . . .. . ..__.. _.. .. E �y L.j _. _ . . Qv.
� J f l: ��
PLANS 70 AVPLICANT ' INSPECTOR'S NOTES . OFSNF:R-BliIi,UF.R DCCLARATI04
I hereby affirm that I om exempr from ihe Conirocror's
To: Relorned - � License Law for ihe following reason. (Sec. 7031.5)�
APPruved ' Buainess and Prvfess¢ons Code:Any city orcount}�u�5icb
No. Dofe No. Data . . . . . requires a permit to conatruct,after,rm(�rove,demnlish,
., ,. , � or repairaxy strvcture.prior to its issudnce,also requirer
� - - _ . , _ tbe applrcan!fnr sazcb permit to file a signed staee»:ent
, . thut be Fs ficexmd pursuunt to the provssions�f tbe Cnn-
. _ .- � ? i_.. .. ',, , �,tractor's I,irense/.uw/Cbapter 91(�ommenring u�itG,Ser
''tion 7000)o/Uic•ra�ion 3 o/!hc 13xisiness and Proj sstoxs
Code/nr tbat he�is exempt therefram aril,tbe basis fr�r tbe
� � � u[(e,Qed exemptio�.Any oioluteon of Sectiox 703L5 fi��
Required Date Reeeived��� . . an y applicant jor n permit subjeces tbe upplicant 1n u cdai!
Approvals yes No or Approred ._ , - (ienafty of nat mnre tban f:�va hursdrad do7lars($j00J.f:
-- -� L� I,os owner o{�he proper�y,ar my empbyees with
Water Cenifiwte , - . , wages as their sole compensofion,will do ihe work,ond
�� the siructure is not intended or offered for sale(Sec.7044�
HeaNh Deparrment _ . . . , Dusrnz�s uxd Professrons Code:Tbe Cnntructnr's Lirense
L¢u�doex not upply to an ou�ner q(propertv u�bo builds
Fire Depariment . or improoes tbcreon,and u�bo dnes sucl work himself or
tbrmagb hix ou�tt employees, proa'uled��tbaL such ir-
Grading -� � Proce�nexts �+re not ixtended nr offered j�r srsle..
bowever,the hreilding orimprne:emena is sold wrtbia oxe
Geological . ' year nJ complelion, tfie numer-fiuiJ�ler u�il1 krave tbe
buaden ojprr�ring tbat be drd not burld nr im)rare fnY
Pedesirian ProteUion .. the pie r�sc�ojsaleJ.
(fence){Canopy)�-� � � �_� !,as owner of ihe properry,am exclusively mntrao-
ling with licensed contractors to mnsiroct ihe project(Sec.
Speciol Inspection � -- 7044)Business and Prnfe.csrnns Gnde: The Cnntrrectnr's
!Conc.)(Masonry)(Welding) Licen.ce I,au�due.s nnt applv tn an ouwer nf prnper{v u•hn
- builde�nr imprue�e.r t!erenn,unJ u•hn cnndructs fr�r.aed�
Lot Droinage . pr jectr rceth¢cantracror/aj 1irnn.ced pursuant to tl c
- � CoretratEnr'.c I.icense lau�J. -
Parking
'.-] I am exempf under Sec. ,B.BP.C.for tFis
'� /'- . - . , . .
(f^;<�J�E�' �G . �?/r.4 r`r,�i-.� reason .
� � � - Date Owner
Approvols �o}e Inspeclor s Signafure
INSPECTOR'S NOTES -
Location— ��
(Setback&Yaids) !. " �
Founda7ians /r !"—' . . ....
Slab '
Frame .�_i^✓ �:� .
Energy insulation J-? •5 � rg ��"�'\.__,/� �
0 J""
Lath/Drywall - ' " � - � � �
Interior �..�" '` -
Loth-Exterior • �. � �� '
House Num6er-- � ' � - ' � � � .
Correct&Posted "' �� •' �
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Final—
Enfer on Front � ` . . . . � ... . �� , . .�
