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HomeMy WebLinkAbout1774A 1775A �;- -; ; - -- � �' WORKERS'COMPENSATION DECLARA710N � . w R ' � .insure6ar afoemificatelof Warke sefCompenstioo In urances or A��i I V/��I O� �O�\ V�I�D'�V ■ `��I ■ a certified�p�y ere f Sec. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo.ec('/��_�a�o�?��� ���. . . � Certtfied copy is hereby furn�shed. - FOR APPLICANT TO FILL W ;[}Q�B2 _ npo ess ��� �- , � Certified copy is filed with�he county buiiding inspe[- BURDING . tion deportment. ADDRE55 1333 Garzon - �ocouTr � 21/'�L � � � � NEAREST �, /7.�L w�. Date � Appliconl CITV ZIP� CRDSS ST. ' �y i�� CERTIFICATE OF EXEMPTION fROM WORKERS' NO.OF BlDGS. ASSESSOR , , ' 'COMPENSATION INSURANCE ' � 512E OF LOT 65'x152' NOW ON LOT MAG BOOK PAGE 7ARCEL (This seclion need not 6e completed if Ihe permit is for pne USE N MAP hundred dollors(Sloo)or less.) � . TRAC7 2 siocK LOT NO., � NO. � � TEI. SPECIAL a O " CONDITIONS I certiiy Ihat in�he performance oi the work tor which this OWNER nlp _ . . � . - permit is issoed,I shall nof employ any penon in ony monner , .TRiCT G P TYGE FIRE fROCE55ED BY ADDRESS� 655 ��d '�n �n �d CONST ZONE so as to become subjeci to Ihe Workers'Compensation Laws. ,¢ 7 ,/ � O dL 7 {' arr V731nut CA nv � 9 NGN'EER OR. ... . ..... . . N��789 . � CLASSNO. IFIC,ATIODWE ,,(�� APT. CON00. V �ale' = � Appiiconf STATISTICAt CL455` N0710E TO APPLICANT: If, afier makin lhis Cerlificate of - _�V� IlL UNITS_L OW. Exemption, yov shouid become suhject lo the Warkers' y Campensation provisions of Ihe Lo6or Code,you musl foilh- � qDDRESS � SEWER MAP Z ith comply with such provisions or this permil eholl be TE� � �� — deemed revoked. - � . CONTaaciOa � NO. ' � BK. PG. � VALIDATION � - �ICENSED CON7RACTORS DECLARA710N � ���, 1 hereby offirm ihot I am licensed under provivons af Chap�er 9 _.. aoDRe55 . . NO. BZHZ�I9 VAWATION � (mmmencing with Seclion�000)of Division 3 of Ihe Business ond ��� Professio�s Code,ond my license is in full force and effetl. CITY CLA55 — 5 �' � rf B G s°eFT2 457 STORIOES 2 f MILOIES O ' ONEK LicenseNumbepr �/ 0��� Lic.Closs �/ � �� • ./J�.(!fr/tI#1� Dote.. ..Z � .. a Contra[for �ESCRIPTION Of WORK . NG�W I�OI[� '� NEW � � I pm exempt(rom the licensing requirements os I om o I ADD � litensed arcMifect or a regisfered profeszional engineer . _ . , ,. _ ALTER .� FINAL / Cl �1 '�'�[[� ocling in my professional capacify,(Seclian 7051, � RECAIR �ATE/� C?—b ' - Business and Professions Code). u5E OF � FINAL #.� • �+�•2} � E%ISTING BIDG. � � � DEMOI ❑ � , . Lic,or Reg.No. Dafe APPLICANT TEL BY ' -. � '2�7•�2 - OWNER-BUILDER DECLARAiION' �� � - PRiNT1 � �� --� � � No. ' ' . � I hereby affirm fhat I am exempt from Ihe Contractor's License � �" � A e Z 6 7,5 L c=i .Law for the following reason(Sec�ion 7031.5,Business and � A��RESS ' � � �� .,t � Profess�ons Code): . _ � � pkE[N . Q 4'2 7`8� . BUILDING O I, a!owner of the property, or my employees wilh ADDRE55 a •` � ' ' �"" s� ']']�5�'� wages as fheir sole compensaiion,will do the wo�k and - " '."� - '• ' . ' � ' , �he strotture is nol Intended or offered for soie(Secfion ���'4��T�-- � � �� �- " � �#';� �b.ry,� � 7044,Business and Prafessians Code). � MOViNG TEL. �� I,as owner of the ro ert am exclusivei contract�n CONTRA�TOR � NO. P P Y. Y 9 , � � ,�I .3$�LSQ with licensed contractors to mnstrucl the project($eo qODRESS � ! • -- tion 7044,-Business�and Professions Code). �� �, ` + ' + �3 8 2:=�i c=.� � . REOUIRED TOTAL$ETBACK FROM E%IST, � , - � CONSTRUCTION LENDING AGENCY SE7 BACK YARD HWY pROP.LINE WI�TH ' � -I hereby aff�rm ihar there is a construction lending ogency for � ppONi -� � � �" . - � ' ' ' e U,'Z 7—H� the performonce of ihe work(or which�his permi�is issued v l � � - _,(Sec.3097.Civ.C.). . . .SiOE . . . . . _ . • . =' � P.l. j ' . ./.- . Lender's Name L �. ' 8 ' ' P.G.Fee E (� 1 Permii Fee O ' , . � � ' Lender's Address . _ . . ' � W I certify thal I have read this applicotion and srate thar the iss�ooce rRe � _ . aabove information is corrett I ogree ro tomply wi�h oll Counry__ _ .. Inves+�goiion fea � � fJ � - � . � � " , ordinantes and Srate laws reldting to building construction, � To�al Fee ��QC� " m ond hereby outhorize represenlatives of fhis Counly fo enler . , , _ . � . � � �upon 1he ove-meNioned properfy for inspeclion purposes. . . . - � �a'� � 1����ti �f� _ ��y�'f SEE REVERSE FOR EXGLANAipRY LANGUAGE ' , � � S�gna��re of Appl�coni o.Agenr po�e � ' � �� I�� ... . , . . .. .. . , _. . .' '"". .. .. . .... . . . i ' - ,PLANS TO APPUCANT � ' INSPEROR'S NOTES OWNER-DUILDER DECLARATION 1 hereby 6ffirm that I am exempt from the Canimctor's �� To: � �- Faturned �� � ' � ' � Lfcense Law for the foilowing rcason. (Set. 7031.5) ' Approvcd . BusinesbqndPr�fcS�fons;C(odr:zinyafiyor.countywbicb No. - � - Oalo - �� No. -�.Dafe -� - • . _ � �� ���iegnYres�bpernoit eo coustruct,ulter,improve,denioAsl, . _ , . . , orrepairanystracture,priortoitsissuance,alaoreguires ,. _-, . :_ .. . . ....�. ,.-.. .-..'--.- . . ..- . •.. �`''-� .. . .. '� .... . - . . . .. - tGe applicant Jor sucb permit ta file a signed slatemeni , tbat/ic rs licensed pursuant ta!be prouuions of tbe Con- .. . _ .. ' � __.. .__ ..._. . . �..�__.. ._ ... � , trartor's Liccnsc Lav�(CGapter 9J(comm¢rtring a�i1b Sco- - . _ tiox 7000J of Drvision 3 of tLe IIusiness and Pr%ssioxs - � - ' - - � � ' � �� �._ � CodeJ nr tbat Bc ir cxempt tGerefronr and tbe basisfor ebe , . , alinged exemption.Any violatron oj Section 7031.5 by - . Requirod DatdRecmived �,-� . . - . nayapplica�tjorapermiuubjecettGeappl:canttoacivil . A=provals. . � � or Aapro'ved - pcnally of not mare tban jive bundred dollan(5500J.J: Yos No. - - � �• � - ❑ I,as owner of the property,or my employees with . ,.�.., ..� .� ..� -..,� ,, , � -�� ' . ,._ , . _ _ . . . . ... . __:_ .:. . Waier Certifimfe � ' .. _ wages as their sole compensation,will do the work,and � . � �--� �-� � � ��� ' the structure is not iMended or oifered for sale(Sec.7044) Heolth-0epartment , � � . ' - . . _ BarincssarcdPrafessionsCode:TbeCoatrutos'sLrcense � - - •�- - � , � � .. . .. Lau�does not apply to an owner of property inbo builds Firo Depanment ` 5 ` �� �.or improvet tbereon,and wbo doet sacb work bimselJor i � �- � �� �� - � - � �� . 15rougb bit oa�n emQloyees,�Qrovided.tbat sucb�im- Grading � � � � .. � .provementr are not rntended or ofjered for sale. Jf, � - - � . � bo¢�cucr,tbebuildingorimprovcmentisao(duitbinoae Gaologiml� � . _ . . __ _ . . . - ycar of mmylelion. 1Ge osunes-buildcr�will bave tbc � - . .. ,_, brerden ojproving tGa!bc did aot burld or inrprave Jor Pedesirion Protection � ' � �� - . lSeQurfoso oJscleJ. � � � (Fence)(Canopy) �i . - � � � ❑ I,asowneroftheproperry,amexdusivelycontrdo- . �ting ysiih licensed contrattors to construcf 1he project(Sec. � 7044 l3uainess and Pr essroni•.Code:Tbe Contractor'.r Special Inspection � ' � � � °> �. . (Conc.)(Masonry)(Welding) I.itensr Lau•does not ufrply to an owner n�property u�bo �� , , . l''build bt improves tl�reotr,om¢wGo.mntracis for tsstb �i. ; i�.:•.. Lot Drainage � . � - . �prbfects�tuetG a contractor(s�licensed pursuarct to tbe . . .. . . . . Contrador's License LawJ. �� . Parking� � � • , .� � � . � . � . ... . . ❑ I om exempt under Sec. ,B.&P.C.for this �� . . _ . .� . . . ' - . - . . reason . � Dmo � Owner � Approvdls� � Datv �p :toraSir .aturo �- � - � ' . '� � � � � � - , � � � INSPECiOR'SNOTES � " Locafian—� /F+ . . . ..._ . . � . .. (Setbock'&Yards} ► ► � ' � . , � - � Foundatfons" ' ' ' - � � �� � � � � � - , - . Slab � . , . , . _ . . _ . . . . , � . . frame � .� ' - ' . ' , . � .. � . . . Energy Insulation . , , La1h/Drywall— �� - .... � Imerior � � � �� Lafh—Exteriar�• - •�..� � . . C' House Number— '� - � . Carrect 8 Posled � � � � ' � � Final— � - . . Entcr on Fro�f � � � . , . �