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Home My WebLink About1796A 1797A � WORKERS'COMPENSATION DECLARATION � _ . . . . . , . �., , � � I hereby affirm ihat 1 have a cenifica�e oF�o�=e�„o=e�f . - �APPLICATION FOR BUILDING PERMIT—� . insure,or a certifimte of Workeri Compenstian Insurante,or �a certified copy theieof�Sec. /$00,(Ip/b.C�.�)� COUNTY OF LOS ANGELES BUILDING AND SAFETY . .PolityNo!ZO/D�f�O C��"o�I_(t,��teQ�GC. Certitied co is hereb furni5hed. BUILDING ,y � . 1 ❑ av v FOR APPLICANT TO FILL IN 2— ADDRE55 � (�'�A j � Certified copy is filed with the counly building inspeo BUIIDING � ' 'I��L , tion departmenl. � � � ADDRE55 LOCALITV vri 'I � - NEAREST � Doie � Applicanf CITY -- VTalT1Ilt -'ZIP- � J17Hg -- CROS55T. �CERTIFICATE OF EXEMPTION FROM WORKERS' - � � NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE � - SIZE OF lOT �.OZ X�II NOW ON LOT O MAv BOOK PAGE 7ARCEL � � (This sectian need not be compleled if the permii is{or one U � E MAP ��y333 rRACT 33257 BLOCK lOT NO. 28 NO. Ihundred dollars(E100)or less.) 0 . Y� rei. 0 svenni a OWNER .�1P� HQI�$ � 714 NO 598-1841 0 CONDITIONS I certify that in�the performance of the work for wh�ch rh�s �DISTRICT G�UP TYPE� FIRE PROCESSEDBY O �perm�t is issued,I sholi not employ any person in any monner qppRE55 655 Brea CZ so asYo become subjecr to the Workers'Compensalion Laws. � . /f � CONST,/ ZONE � O � aTr Walriut CA zic os v 3 Date AppliCpnl 1 SIATISTICAL CLASSIFICATION APT. CONDO. u . NOTICE TO APPLICANT: If, aker making ihis Cerlificaie of ARCHiTECT OR � � TEI. /J�� ENGINEER NO. CLA55 NO._fJ1[_DWELL.UNITS�� 6. , ' Ezemption, you should become subject to the Warkers' y � Compensation provisions of ihe Lebor Code,you musl forth- - qDDRE55� � SEWER MAP ' Z � wilh mmply wi�h such provisians ar lhis permit sholl be TE� ' , — � i deemedrevaked. � � CONTRACTOR --53IC10 3$ �Wl'IP.r' NO. sK. PG, , VAIIDATION � I UCENSED CONTRACTORS�ECLARAT�ON . ��, � . I hereby affirm Ihot I om licensed under provisions of Chopter 9 ADORESS NO. BZHZ�J9 VAWAT ON� (commenCing wilh Section 7000)of Division 3 of Ihe Business pnd �i�' ��OO ' Professions Code,and my license is in full force and etfecl. Ci7Y CLn55 S � � 6 �f - SQ.FT. NO.OF NO:OF CHECK ' ' LicenSeNumbe/r �o�`�� Lic.Clqss ��/ � 512E ]_ ], STORIES 1 ' FAMILIES ]. ONE � ��, � � � �l� J/� . . . . . NEW b � , � Conlractor k � Date � DESCRIPTION OF WORK - NQW HORIE _ . , ' � 1 am exempt from the licensing reqviremeNs ps I am p � ADO Q � S 1�7 9,6 A � licensed orchirect ar a registered professional engineer . . �� --- � � � - A�iER � DAT Z�p '� oCfing in my professional capatily (Setfion 7051, REPAIR � � • •�' •�� ' Business and Professions Code�. ' USE OF . FINAI � � r� � � E%ISTING BLDG. � DEMOL Q 8 ' iI •2 P�J.� C LiC.or RBg.NO. Date A7PUCANT TEL. Y - � . ( � � � �OWNER-BUILDER DECLARATION � IPR�Ni) � - � � - -NO.� ' , ', ,+�2 9.� Y� �� I hereby affirm�hat I am exemp�from the Contracror's License qDDae55 � - ' � • . , Law for fhe following reason(Sec�ion 7031.5,Business and �� ' Q�1,i�7^8� Professions Cade): _ � , �REStNI � � �, � � BUILOING ..- . . . . � , . `� � I, as owner of the property, or my employees with A�ORESS ,. `, 'j C�'7 F� � . wages as Iheir sole compensaion,will do ihe work and - ' � �the strucf�re is nat intended or offered for sale(Setlion ' �O[ALITY� �\ , rr��"�� • • � � 7044,B�siness ond Proiessions Code). MOVING 7EL \ . � I,as owner of fhe property,am exclusively confra[fing' CONTRAQOR . NO. � �� }3�6 Cx.rJ Q with licensed conhoUors to construcr the project(Seo � �. F ` ' , . tion 7044,Business and Proiessions Code�. . A.DDRE55 , ,, ` , h e,�}�Yj,.,�l ' REOUIRED TOTAL SETBACK FROM EXIST. ' � ' � CONSTRUCTION LENDING AGENCY SEi BACK 1'ARD HWV pROG.LINE WIDTH" '' --�- _ ` ; � I hereby o(firm�hai there is a constroaion le�ding ogenty for �- - fROM �� ' �' � - � �[J,Q`7*-�� '� the performance of the work for which fhis permit is issued G t " '� ,,_, _ � . � . (Se[.3097,Civ.C.). . - ._ SIDE -. . . . " .. .. .. .. �� . ' . . � P.L. � � / � ' lender's Name � � '� � - . ..... ,.e Fee s � Pe,m��Fee ' �S�dP � ' �j Lendei s Address ' _ , ry�� . , �i� . . ' I certify ihor I hove read this applimtion and stote thot the Issu ce Fee d � � � . above informotion is correcl.I agree to comply wilh all County __ In�esrigmion fee .. . . ��. 7 I� � - •� � � � � � � � ordinances ond SFote laws reloring to building construction, � Toiol Fee t/6 � and here6y aulhorize representatives of ihis Counly to enter � _. �, . _ ,_ _, , � � opon thJ-L;bove-menlioned properry for inspeUion porposes. ' . � � - � ��` ��y�r� y� SEE REVFRSE FOR EXPLANATORY LANGUAGE � � ' . .- Signat�re'of ApPllmni or Ageni Do�e . . .. . . .. . ... . . _. . _ ' , �°� � �PLANS 70 APFLICANT � � � INSPEQOR'S NOTES OWNER•BUILDER DLCLARATION I heroby affirm tha�I am exempt from�ha Contracfor's To: ' � �oturnad � � � � � � ' Litensc law for 1he following reason. (Sec. 7031.5) , ApProwd . , . B�uirsrrsandProf¢;s�on;Cn�le't1n tit orrouttlyu�bieb No. - -� Oete No. Date - - � � . .. .�c'quircT'upe3niil to consiiuct.a'lte�lr;i�ve.daniolisG, . . _ , . orrepairanystructare,priortoilsixsuance.akoreqairrs . . . - - - ... . -- . . . - �- � tGe applicant jor sutb pern:it io file a rigned atatenrent 1Gat Ge isliccrucd punuant to tbe provisiont of tb¢Con- � - - � - � - � � - � "'� � -'�� '� lractor's License I,atn(Cbapter'9J(rommencing witb Sec- , .. _ , , ., _ _ . _ ,_ _ _ . . _ eion 7000J oJ Divuioa�3 oJ tGe Bariness and Projessians _ � � � . � Code)ortGatbeisexenr[,tiberefromandlGebasisJorthe , a!leged exemption.Any oiolu0ion oj Sectiox]031.5 by � •-Required DetoP.ocelv�2 . . . . - � anyopplicantforaperneitsubjecutGeapplicaxtJoueivi! ---Aparova16 or Approved penalt��of not more tban five buadred dollars(SSOOJ,J:. ' Yes Ne . . � ., � ❑ I,os owner of the properry,or my employees with Water Cerfifimte � . � � wages as Iheir sole compensafion,will do the work,ond �� . - • � . -. . the strouure is nof imended or oifered for sale(Sec.7044) Heb�thDeperimenf � ' . -. , IiusinessandProfessioxsCode:7GeContractor'sLicense � � . � � . � � �� - - _ .. Law docs aot apply ro an ou�ncr oJproperty wbo buifds Fire Deportmenf , � ; � orimproves tbercoa,a+rd wbo docssacb�uork bimselfar , - - tbroagG Uis orun employees,provided tbat sucb im- Grading �� ' � . provrmcnh arc not intended or ojfered jor sale. If ��. , - - � � - - - � boueucr,tGe buildingorimprovement issold wrtbin ane I Geologital � � . . _ _ _ - —• � .. . . year oj complelion, tGe ow»erbuilder will baoe tbc . � . � burden of provirsg tbat hc did not build or rmprooeJor � Pedestrian Protection � - �. -� - . . . tbe purpose of saleJ. � � � (Fence)(Canopy) � � ' � � ❑ I,asownerofthepropeny,amexclusivelycontrao- I , . � , firg with licensed contractors to constrotl the project(Sec. �� . Special Inspection ` ` � "' ` 7Q4dj��usiness and Profcs'sjojis"Cade;Tbe ConOractor's � (Conc.)(Masonry)(VJelding) � , . I.icense Lau�docs not appl��to an owner ojproperty¢�bo . .. ' - . � ' '�iuildr`or,impmcrs t!>crcon,,'s�d wbv�conrracuJorsucb \.,, �,._ Lof Droinago� . � . � . prblects�icitb a eontractor(sJ licensed�pursuarst to tbe � - . -- _ . . . .. Contractor's Licenac I.auJ. � � Parking_ , „ . - -_ � ' , ,.' . � ❑ �om axempl vndar Sec. �,B.BP,C.for Ihis � . , � . .. � � . rcason : . � , � - . Date � . . Owner � Approvals- Dato .Jm ec�tar'a � �� - � .. � . � p �tjnature , INSPECTOR'S NOTES 'I ' Location—, . 7 . � � (Setback�8 Yards) �j� � � - � � ,. � . � Foundmions° � �� - - - , � Slob -. . . - .... Frame � . � ' � Energy Inwlation' i � . . . ,. � Lath/Drywall— . . . . � . Infcrior - - ' � � Lafh—Exterfor iZ � � - ' House Number— � ' - ' Corrett 8 Posted .. .. . - _. . _ - -. - � . ' � . ' . � Final— . � . . . . Enter on Front ' • ' � � '