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HomeMy WebLinkAbout1108A (5) - WORKERS'COMPENSATION DECLARATION . . ... . �, . � � I hereby affirm thm I have a ce�tifimte af tonsenl to=e�f._ . .. -. �APPLICATION �FOR. BUILDING� �PERMIT� � insore,or a certificate of Workers'Compenstion Inwrance,or �- a tertified copy Ihereof(Sec.3800,Lob.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY Policy No. Company ' � � Ceriified copy�s here6y iurnished. FOR APPUCANT TO FILL IN ADDRE55�3.� 7� '�sut� Ce�... � � CerYfied copy is itled wiih the county butld�ng inspeo- BUII�ING - � � : , ti0n deparfinent. � ADDRE55 0�.3� � y¢4 G Y . �ocAUTv .�.`t�i,.c/,u .C�.e.�i . � � ' - NEAREST . Date � � 'Applicant � CITY 21P � CRO55 5T. .,c� � � � �CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF BlDGS. ASSESSOR . � , '� COM7ENSATION INSURANCE SIZE OF LOT.;D� X�� NOW ON LOT� VO�GAN MAP BOOK ' ' � PAGE PARCEL �This set�ion need not be completed if the permit is for one TRAC7� 'r7 d � � . � USE ZONE nto.P /����f� hundred dollars(5100)or less.) � . . BIOCK LOi NO. � � NO. T } , iEl. SPECIAL '� � . d � OWNER ✓ Y - NO. �7Z� CON�ITIONS � I certify�that in the performance of the�work for which�his . . _ V permit is issued,I shall not employ any person in ony manner . DiSieiCi GeOUa ivPE i FieE FROCESSED BY so as to become su6jecf to the Workers'Compensation Lows. : A�DRESS � �/O �� CONST� � ' O . Date � � Applicanl ��TY Z�P STATISTICALClASSiFICATION � � APT. CONDO. V - NOTICE 70 APPUCANT:�If, after making�his Certificate of � ARCHITECT OR� • � TELL.13�=LT-1S �j� � I w - Exemplion, you-should become suhject ta 1he Workers' ENGMEER 1 G ,N O\"� (1 CLA55 NO._�_DWELL.UNITS� N _'Compensation provisions of the Labor Code,you musl fprlh- � ADDRESS > � t� �G O • �' ✓�6� SEWER MAP � 2 witb comply w'th sucb provisions or �his permit shall 6e ��/� - , � . deemed�evoked. . , coNTRnCtOR � � � No. - C�BK. �"v�,' i VALIDATION � ��LICENSED CONTRACTORS DECLARATION � �i�, _ _ _ I hereby otfirm ihof 1 am licensed under provis�oas of Chapter 9 . . _ ADDRE55 .. � NO. VALl1ATION i . � . (commenting with Section 7000)of Division 3 of the Business and � . LIC. � i � �1 , Q$A - Professions Code,and my license is in full force and effect. _ QTv aASS E � �� � �9 I � SQ.FT. NO.OF � NO.OF CHECK '-� licenseNumber Lic.Class SRE 5��o STORIES FAMILIES ONE � - ' , #,� � �'�23 ' S DESCRIFTION OF WORK NEW .❑ I , � �6 2 8 8 Q s;•: CoNractor � � � Dofe ..O . . � . . s) � I am exempt from ihe licensing requiremenls os I om o . pµ�j aDD •6 Z R H O u � • licensed archifect or a regisfered professianal engineer ALTER � � FINAL I, � . . acting in my professionol copaciry (Section 7051, RECAiR � � DATE � ' ��2 2 3�$� Business and Professions Code). .. USE OF 1 . . � � � DEMOt ❑ F�NA� II � � EXIS7ING BLDG. BY � LIC.OrReg.NO. � .. � Dale APPLICANi 7EL. Z 3��pp . . -. . . ' . . �'��' � � OWNER-BUILDER DECLARATION� � � � � ' - yvewi) � • �� �NO. • I . I hereby affirm thal I am exempt from the Confractor's License n . . . . _ . , Law for the following reason(Section 7031,5,Business and � AD�aE55 >. - � Proiessians Code): � � � �kE ENi � - � ��, . ❑ . . . . . Bw�oiNG . . . . . . . . . . . , . . . I, a5 owner of the proper�y, or my employees wilh ADORE55 �wages as their sole compens6tion,will do the work and . , � '-� � the structure is not intended or offere}for sale(Settion � t0[ALiTV � - f��,p . �, � � � � - 7044,Business and Professions Code. MOVING TEL �F ' � 'I,os owner of the propeny,om ezdasively controcting [ONTanCTOR � NO.� � ', \ � . - wi�h licensed conrracrors to construct the proleU(Seo-. qoDaeSs 3��� ' � ' . - - tion 7044,Business and Prafessions Code). � - � �^' � � - I -t � �'�� - . CONSTRUCTION LENDING AGENCY REOUIFED YARO HWY TOTAI SETBACK FROM E%IST. /��. '. . , SET BACK PROP.IINE WIDTH � - i hereby affirm that there is a convruction lend�ng agency for "� peOM � � '� � � � � � the performance of�he work for which this permit is issued P l � I � � ._(Sea 3097,Civ.C.). . _ . . SIDE�.. . . .. .. . . . '�, .. . .- . � . P.L. Lendei s Name _ _ .. O p . . .. � , � . .. .. . . Lender's Address P.0 Fee S �✓�Q• O Q ve�mu Fee ��� � - � W I cerNfy thot I hpve reod thls applimtion and state thor the issua�ce Fee � '� -- Q _ above information is mrrect.I agree ro comply with all Caunty Invesrgaron Fee � . . � � ' '� � � - � - � - ordinances and S�ate laws reloting ro building construuion, Toial Fee ' ond hereby authorize represenlalives of this Counfy to enter , __ , „ . . __ _. �. � _ Q -�'oponlheabove-mentionedpropertyforinspectiodpurpose5.-�� ���� .� . . a � � SEE REYERSE FOR EXPIANATORV LANGUAGE ' ' ' ' � � Signa�ure of Appl�com or Agem '' Doie . . ' �� _ _ _ r i --� � �PLANS TO APPLICANT � - �INSPECTOR'S NOTES 0�5'NHR-IIUILDER DLCLARATION . I horo6y affirm-Ihaf I am ozempt fram the Contractor's To: � � Rolurnod � ` . � Llcense Low for Iho following�reason. (Sec. 7031.5) � ' � . Approvod . IJusinest and Projesrions Code:Any eiay or coursty u�bicG � No. - - -- Da}e No.� --Dafo �- - - -- ' � � � � ... reguires a pernait to construcl,a11er,improve,demofish, __ or repair uny atructare,prior to iu iuuance,also reguires - - - � � � � � ,tLe app7irant Jor sucb permit to file a signed atatement . , , , .`� ,, . 1Gal Ge is licensed punuant 10!be/irouisions vf 1Ge Con- � '� - --� - - - - - � ' - � . - � , " � tractor's Litense Law(CGapter 9J(commencirsg wieG Sec- _ _._ , .. , . , , tion 7000J of Divisiart 3 oj ibe Business and Professions �� � . . ' � ' CodeJor t!at Gc is esen p0 tGcrrjrom and!be bruis for tfic • � . a!leged exemption.Aay violation of Section 7031.5 by - �Raquind�� DeteRecaivod ' anyapplicantJoraperneitsubjectstbeapplicanttoadvil , _ . . ApproVals . - ' , yoa- No or Approvod persalty oJnot ntore tGan jivrGundred dallars($SOOJ.f: � . .'�� � ❑ I,as owner of the properfy,or my employees with . Vlater Ceiti(imte � � . _ �woges as Iheir sole compensation,will do Ibe work;and , � the structure Is not iniended or offered for sale(Sec.7044) Heallh�epartmenr! ��?� � � � � 6errness and Profcssians Code:Tbe Contractori Litersse � - - - - - - - ' . . ' Lam docs not rtpply to an owncr of property wbo builds . � FiroDepartment , �.,_ . �n: ���:,_. ,_,... oriinprovestbereon,andu�bodocrsutbworkbintseljor� - - � � � .tbrough bis own enrployecs,proorded tbat satb inr- Grading ��� � � � :, �•..� ,� ;..� � .. . , J+roocments are xo! inJended or offerrd for sale. If, � " � � ' � � ��� - ' � � � � - � boa•ever,tbebuildingorimprovementissolduritl�inone Geologiccl� - � . �" . . , .year oj complelion, tbe ownervbuiGler mi!/bave ihe , � ' - barden oJproving tba0 be did not build or improveJor � ' IGe parpose oJ sale). Pedestrian Profe[tion . . � -.. .. .. . .. . ' (Fer�c�)�(C�nbpy) ' _ - , . ❑ I,os owner of the'properly,am exclusively contrac- � firg with licensed contractors lo constroct the project(Sec. �" 70d4 Business and Pro essions Code:The Cotttractor's Spetial Tnspechon � � � t � � ' '" 1 f (Co�+t.,).{Mo�n�y�(Wolding) � . Licenselawdoesnata/�plytoanou�ncrnfproperLyWbo !uilds ar in+prover tbcrcon,arsd wGo rorstracts for sueG � Lot�Drainago�� .- � . . � . � , . projccls¢titG a contractor(sf lirertsed Qursuarst to tbc �• -- � . �" ' ' ..� � Contractor's License LauJ. , . , ParRing_�.;i � ' . . .. . . . . � .i':. . � ❑ lam exempl underSec. ,B.BP.C.forthis � i ' - � . . � . reason - . ' . . Daro.. . .. . . Owaer ' . � APProvats Dofe Impatlor's£Ignaturo . . . ... • . � � . �� . � � - INSPECTOR'S NOTES � - Location— . . . , - . . . , (Setback S Yards) � � � . Foundations - ,�,: . . . . . . � � - � . � • . Stab .. + ` - . _. .. . .. _ _ . Frame . ' . ;, ' �- - � . Enerfly Insulation � . � � .. Lath/Drywall— � � � - - - . . Interiar � � .. . . � Lath—Exterior . .�� Nouse Number— . � , , , , _ Correct 8 Posled � - - � - - - � ' � Final— . . . . . Enter on Fronf � �.