Loading...
HomeMy WebLinkAbout1792A 1793A (10) WORKERS'COMPENSATION DECLARATION . . ' . � � . � - . � �� . I hereby_aff�rm thm I have o cerr�f�cafe of consen�.to 5e�f . . APPLICATION �FQR BUILDING PERMIT � insure,or o certifitote of Workers'Compensiion Insurance,or a certifi d topy thereof(Sec. 6 , ab.C.) � � ���0„�j���ry��, �Q��J COUNTY OF LOS ANGELES BUILDING AND SAFETY PolityNo. ampany BUIIDING "� I � Cenified copy�s hereby furnished. ' FOR APPLICANT TO FILL IN 42—C2R ADDRE55 �a'� �'/Q�Q/l/ �� Cenified capy is filed wilh�he counry buildinq inspec- euaowC� � n � tion department.' ADDRESSL322 GdYZOIl LOCALITY ry'� �� � � � �� - NEARESi Date � Applicant Cliv LP CaOSSSL LF � ' CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF etOGS. . n55Es50R '� COMPENSATION INSURANCE � � �- SiZE OF l0T 124'x62' NOW ON LO7 MAF BOOK 7AGE DARCEL (This section need not be compleled if the permit is for one iRnci 33257 etoCK �OT NO. 3� ��'/ � ' h�ndred do�lars�5100)or less.) U Z E � �P l/ '� } . , Tei. Q� seeaa� n, OWNER .�led HCIT125 � 7�4 n,o.598-1841 � CONDITIONS , f tertify ihal in the performonce of the work for wfiich this_ . . _ � ' permif is issued,I 5hoil not employ ony person in pny monner OISTRICT GRQQ UP TYPE FIRE PROCESSED BY sa as-ro become subject to the Workers'Compensation laws. ADDRESS� E7SS BY'2d Cc'lII OT1 F2Ck7C1 /� �� CONSj/ ZQI1�E - O . . . . . . CITY �T �lUt � ZIP a( �� `l Date ' Applicam 9�789 STATISTICAL C1A551FICATION APT. CONDO. V N0710E TO APPLICANT: It, after making this Certifico�e of � -�� ARCHITECi OR � - �TEI. p � Ezemption, you should become subject�lo the Workers' ENGiNeca NO. ��q$$NO.�(LDweIL UNrtS� N Compensation provisions o(ihe Labor Code,you musf forth- ADDRE55 SEWER MAP � Z with comply with such provisions or �his permit sholl be TE� �� - _ — deemed revoked. . � � . - - �ONTRACTOR �NO. � BK, PG, � VA�IDATION IICENSED CONTRACTORS DECLARATION - ❑C, . .. . . I hereby afFirm tha�I om licensed under provisions of Chopter 9. . ADDRE55 .NO.3ZHZ79 VALUA ION , , (commencing with Section 7000)af Division 3 of the Business and ���, / A n O Profassions Code,and my license is in full force and effecL . . CI7V CtASS E Q p�� • � ppp � SO.FT. NO.Of NO.OF CHECK ' ' li[ense Numher�o�7 7 lic,CIPSS._Q� SRE �. 97�. STORIES 1 FAAIILIE$ �. ONE , , ' �j �/�,�� g Canirotfof�/`��R/o pate_�� DESCRIPTION Of WORK NeW F'IOISr: ' NEW � � I om ezempt from Ihe li[en5ing�equiremenls as l am a ADD � _ licensed architect ar o registered professionol engineer , , _ . . . . . , A�TER ❑ F�NA 2. ottinq in my prafessional capacity (Section 7051, RE7AIR � OATE� � Business and Professions Code). USE OF FINAL � - � ' � � E%ISTING BLDG. ' OEMOL sY �-_s 1 7 9,2 A LiC.or Reg.No. Dafe ADPLICANT . TEL -� � �OWNER-BUILDER DECLARATION PRINTI " � NO. ' . � �,H q •�� I hereby pffirm that I am ezempt from the Contracror's license � , . . . . Low for Ihe following reoson(Seclfon 7031.5,Business ond ADORESS .� �2 2 9 T 2 Professions Code):. FkEseti � ' _ ❑ . . . - BUILDING . . , . . . .. +.M L L�.� L U �I, as owner of Ihe property, or my mployees with AODRESS wages as Iheir sale compensation,will do the work and iQ�A�T� � , � 4�.•2,7�8� . the strvcture is not intended or offered for sale(Senion 0 7044,Business ond Professions Code). MOVING TEI. , � � 1,as owner of the property,am exclusively conlracting CONTRACTOR ND. , � � . r�� �9,��„(� with licensed contractors to construct ihe projecl(Seo- qDDRE55 ,�� � . ���.• • •� � . tion 7044,8usiness and Proiessions Code). - � ; , REOUIREO TpTAISETBACKiROM EXIST. _( ,��� � ' � CONSTRVCTION IENDING AGENCY SET 9ACK YARD HWY pROP.LINE WIo7H __ � „ �.,,���� `�l/� , ,� �3���j O � I hereby affirm thot the�e is a construc�ion lending agency for � � � FRONT - � - , � , the perlormance of the work for which this permit is issued c L ' . . �,a 3���,�� � .(Sec.3097,Civ.C.). . - S�oE � - � , . � P.L. r. _ Lender's Name ` e 4''�7�a'� . . - � � , ` �:1� . $ � ' P.0 Fee 5 '� Permi�Fee ��� . • ' � Lende.'s Address _ , �� . � W I certify ihot 1 have read�his applitation and s�aie tha�the iss� ce Fee � = above information is correcl.I agree to comply wiih oll County Invese on fee� �-�n / � -- ! � � ordinonces and Stala laws relating 10 building co�struUion, g��� Totol Fee G� � and here6 outhorize represeniotives of Ihis County to enter : , , ' . mupon Ihe bove-mentioned propeny for inspeclion purposes. ' a �lJ�..-.. � � ��/�.��` ��J-� SEE REVFRSE FOR EXPLANATORY LANGUAGE . S�gnalure af Applicon�or Agenl � Dofe . �'i � � - �PLANS TO APPIICANT , ' ' � INSPECTOR'S NOTES , OR'NER•IIUILDER DSCLARATIOti - I hereby affirm lhot i am exempt from tho Controcfor i To: � � � � Rafurnod � � � ` � � Licenee law for tho following roason. �(See. 703I.5) - ApA�evod , . , IIuainessandProfeSs�jAn�Codry4nyciayor�Eonntywbicb . No. � � - Dato �� -- No. - Data -- - � . -� . _re?juYr'es:d�crn+it to consiruct,alter,rnrprove,demolrsl�, . or re,parr any structare,priorlo rts i.uuance,ako reguires ._. . - .. ' . - � -- � . -.. ... . . ' . . . . .. .. - tG¢aj�[�licant jar aucb perniit to fi'le a r�ned statemeut , , �tbat Ge is licensed parsaane to tGe proruions oj1Ge Con- - �-� -� - � - � � -�� � � � � � �� � � � � �. � tracfor'sLicenseLaw(Cbapter9J(commencingu�it4Seo- � �� ' . �' -; _: � ; tion 7000J of Dioision 3 oj lbe IIusinets and Projessions ... . __ . -. _. .. _ . ._. _. _ "._._._ .. . � CodeJ or t!ae 1 e is esempt lGerefronr and tGe basisfor thc � _ _ _ _ , , . allegcd exemption.Any riolntion ojSectron 7031.5 by � • ;Foqulrod•-_ DateR¢cclved ��' � � anyaQPlicantJoraperniitsubjettstGea/iplitanitoatiuil - -� AFpfOV016-� -- or Approvcd' � pcnally of not more tban fiuc bundred doJJars(8500J.J:- . � Yos No � -. . - � , ?.. :.,. -.-� , , � � I,os owner of�he property,or my employaes wifh Water Certificale , � _ . wages os their sola compenaalion,will do ihe work,and . ... . � � . Ihe struUure is no�In�onded or offered for salo(Sec.7044) Heahh Deportmertt �� � � . . �I3urixess and Projessions Codc:The Contractor'sLitense • �. - - - . ��'���'. . ���-� . � . � � Law does not apply to an oa�ner ojproperty subo builds FireDepartman� , . orimproacstbcrcort,andmhodoe.raucbworkbimaeJjor � , � � � � � tGrougb /is aw� employees,prouided tbat sucb int- Grading provem¢ats are not int¢nJed or�offered jor sale:I� � � � � -��� � -� - - - � bov:ever,tLebvildengorin+provernenttssoldwitbinone Geofogicol�-- � • � ... . . � � . . _ � yeur oj complelion, tbe ownenbuilJer u�il1 bave tbe , . . burden�oJprooing tbat he did not build or rmprove jor Pedestrian Protection � , ' � . . . - t6e purpose of aale). � � (Fence)�Canopy) � � ❑ I,asownerofthepropeny,am,exdusivelyconiroc- tirrg with licensed coMracrors fo construct the projecf(Sec. Spetial Inspection � � � 7Q44�_{3usincrs and Profesa54ryt,�ddr�Tbc Contraclor's - (Canc.)(Masonry)(Welding) �� L�cexseLau�docsnotapp)ytoanomne�.a/pro/�ertywho � . � ., \'ibaiJd�or�im/�ronrstber�on,wnJvuhn�cnntractsjorsucb Loi Drainaga .. . � �y'tojetf.c�uilG a eonlraclor(s}licensed pursunxt to the .. . _ Contractor's Licensc LawJ. ' . Parking � - , � � � � _. . ❑ t am exempi under5ec. ,B.BP.C.for this ' ,� � . . � , . . . . reason . . c . • e ' . . . . . . . .. . _ D6te . . . . . - -Owner . . Approvols �. Octe In:pa o s Signature � � � . fiJSPECTOR'S NOTES Location— ! _ . � .. � , . . � (Setback&Yard �� . � . . -. Foundations � . � � � SIa6 . . . . . .. . Frame y.l " ^ L-� ' , . . Energy Insulofian � � � , � Lat Orywall .P, . . � , . , Jb Laih—Exterior � � -, . �- . _ ' House Number— � . . . , . � Correct&Posted � - - � �- � � Final— � . . � . Enter on Front ' ' ' � � � . , . . . .. - ; . .. ,