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HomeMy WebLinkAbout1786A 1787A .. . _ � . . . . . . ' '. 1 WORKERS'COMPENSATION DECLARATION . .... . .. . _. . .. . . . - .' ;� _ .� � . . . � . . , � . . ��I 6ere6y affirm that I have a certifico�e of�o�se�„a 5e�f .... .- APPLICATION �.FOR�BUILDING PERMIT ��-� � — - insvre,or a certificate of Workeri Compenstian Ins�rance,ar . , a cerY� copy thereof(Sec. b.C.) ' COUNTY OF LOS ANGELES � BUILDING AND SAFETY ' �o-oo-�s�9�t�, , Polity o. � C.ompany ��/�B L. . . � Certified copy is hereby fornished. fOR APPLICANT TO FILL IN 4 _ no�aes5 � �iOL � Certified copy is'filed with the county building Inspec- BUiLDiNG 'rion deparimenr. noortess 1344 Gc7Y'ZOIl �ocnurv �•[�' �i ' � ' ' � - NEARES7 ' / 'Date - �ApplicoN � CITY - - Ziv� � CROSS ST. /—� � CERTIFICATE OF EXEMPTION FROM WORKERS' � � � NO.Of BLDGS. . ASSESSOR � �-COMPENSATION INSURANCE �' � -- SIZE OF LOT �].�}9 XEE) NOW ON LOT MAP BOOK PAGE PARCEL �(This section'need not be completed if the permit is for one U Z E �+P TRACT 3 BLOCK LOT NO. J NO. hundred dollars($100)o��less.) � � . �. - - , > TEL. da SPECIAI p, � OWNER � .�163 H�I�S 714 n,o.. 598-1841 V CONDITIONS � - O �. I certify Ihat in the performance�of�the work for which Ihis . . . iSTFiCT GR P TYPE � FIRE PROCESSED BY V permit is iss�ed,I shall not employ ony person in any manner CON 7 Z � so as to betome subject lo the Workers'Compensotion Laws. AD�RE55 . .F7SS Cl � �� �- - � � , � ��TY wa�ut, CA z�P 91789 O Date - ApplicaM .. . .� . .. . . STATISTICALClA551FIC4T10N � � APT. ONDO. W . NOTICE TO APPLICANT: If, ofler making lhis Certificate of ' ARCHITECT OR � - � - - � TEI. � ,t� Q , y / ENGINEER NO. CLASS NO.��DWELL.UNITS�Z�L 6. Exemption, you should become'su6jec��1a Ihe Workers' v� Corripensotion provisions of ihe Labor Code,you musr foi�h- qooaE55 � � � � SeweR M/+c � �, � Z wi�h.comply wi�h suth provisions or Ihis permit shall be TE� � . �� deemed revoked. . � �� - CONTRnCTOR �SHITIE 3S Q^�R� NO. 6K. PG, � VALIDATION � IICENSED CONTRACTORS DECLARATION pC. . I hereby affirm tha�I am licensed under provisions oF Chapter 9 . ADDRE55 �NO. VAWATION � ! . (commencing with Section 7000)of Division 3 of the Business and � ���, /�n ��4 � _ � Professions Code,and my I�cense is in full force and ef(ect. Uiv ctn55 3 CJ!�j ' � � �"� SIZEFT 1 4OH 5 ORI�ES �. . F MILOIES O CONEK License Number��e?7q �Lic.Class � � n S ConirOClot�Q. ��+� Dare_y/a/�i DESCRIP710N OF WORN HC[j� � NEW � � �, � I am ecempf from the licensing reqoirements as I am o ADD ��� licensed archiiec�ar a registered professional engineer , . . . ntiER ❑ ��FINAL acting in my professional capaciy (Setlion 7051, � . _. -.. . . . ' . REPAiR � DATE /��J ' , . Business ond Professions Code). USE OF� � FINAL - - . � � ���7���7�i � � ��� E%ISTINGBIDG. � � �EMOL B , - .. . . . _. . .. . : Lic.or Reg.No. Dme navucnNi TEi. - Y ��• �.•�2� � � --' � OWNER-BUILDER DECIARATION' � � � -�PRiNT� ��� � � � - � � �� �NO. � � . , � I hereby affirm that I am exempt from the Contractor's License ADoaESS � - - � - � � � � �- - � � :l��11 8 3,�0 4 Law for the following reason(Section 7031.5, Business and . _ . ProfessiOnS Code): . VRE�kNf , � � �,,t " •i° � �a��'�' ❑ . _. . ' _. . BUILDING . . , .. . .. . . . . I,'as owner of the property, or my employees wilh ADDRESS ��"�� ti-. '_8 ��,2•���� �wages as their sole compensation,will do�he work and . � ; . -., . � � the strucWre is not inlended or offered for sole(Section �«A��TY � '_ � �. � !� 70d4,$u5�nes5 an(1 Pro�essiOns Code). MOVING � TEL 'F� 7 Q 7 A ,— � I,as owner of 1he property,am enclusively conhacting CONiRaCiOR NO. � � � � � � �� - wilh li[ensed[onfroctors to[onsfru[f the projecf($ec- qDDRE55 ' - ��� � ��~ ' '- � tion 7044,Business and Frofessions Code): �- �- - � - � � � � �� � - ' �' REOUIRED YARD HWY TOTAL SETBACK FROM,. EXIST. � � �'L7(�(i K O � CONSTRURION LENDING AGENCY � 5Ei BACK FF07.lWE WID7H . � . - I hereby affirm thoi Ihere is o mnstruction lending agency for FeONi � . � � x. ihe performance of Ihe work foi which this permil is issued . v�. � . - � • o�Q�'S�" (Sec.3097,Civ.C.). . ._ . .. .. . �.Sioe . . . . : .'-.�� . ._. � . . P.i. !.- F427�81 Lender's Name �J � � � � � � � ' -- � $ lender's Address v.C.Fce 5 e7 ✓ Per�„�i Fee � �� S� ' � ( . _ . . . � . . . 1 . . . I.certify�hot I have reod this applicolion and slate Ihat ihe Issoa�ce iee � ' ' , � � obove information is corred.I ogree 10 comply with all Counly i„�esrgoi�on Fee � � - � � � � � � - � " � � ordinances and Srate laws reloting to building canstruction, • Total Fee � � � - � _ ond hereby authorize represenlotives of ihis County to eNer . , , . , . � � mupon the a o�•menlioned proPery for inspection pu�pases. . . � . a U��/l�z �i>/�f--�_� . � . ����� SEE REYERSE fOR FXPLANATORY LANGUAGE " � Si9narure of Appl�co��or Agent Da� �. - � � , , �� , �. _ PLANS TO APPLICANT . INSPECTOR'S NOTES ' OS5�IVER-IIUILDER DECLARATION � I hcre6y affirm thm I cm oxempt from the Conlractor's To: � � � � �etuinod � - - � - Lltense Law for the following�reason. (See. 7031.5) .. .. -. . - .. APProvud . . . . ' - - . . Dusiness and�rojr on Cndc:A�ry'Sity or rouaty�wbicL ��l.�_-�. �10. --- --Dete-�-- No. ---.Dete'� -� - - - . . . . . . , " . . .rr�4ires�d�c»nit o constract,allcr,improvc,demolisG, . . . , . . .. . arrepairanystructare,priortoiuivaance,alsoregurres -� -' --- - .-� " " '" � ' � �� . � . - - ' - _ , tGe applicane jor sacG permit eo jife a xigned statemerst _. �. . . . . -.__,„_ tbat be is Jicensed punuant to tbe provisions of tGe Con- , , � � �� � � � � --�� - -- � �- '� ��� "' ' - - �� � tractor'sLitenseLaw(C6apter9J(commencirsgu•iabSeo- . . .. ' .� .., . .�-. � : . .' ' . , . _. _ _ , , „_ . tion 7000J of Division 3 of t6e Butiness and Prvfeuions . . CodrJ or tl�at bc is exempt lGerefrom pnd!Ge basis for tbe � � alle,qed crenr/�tion.Arty vialaliox ojSection 7031.5 by ; � .. Raquired �DetoRrceived � .-.. �� ', .....- . . .� anyapQlicantjoraJ�ermitsubjectstGeapplicanttoadui! _ __ Approvals.._. . .ar A rovod enalt o aot more tGan me bundred dalTars SS00 . Yos t7o aP P 3' J f� l )•�� - � ` '��� � " '� " . . ❑ I,as owner of the ro e . .. . . . p p rty,or my employees wifb Wafer Certiiimte � , � wages as iheir solo compensafion,will do the work,and " '� '`-� ' �'�'"' - '� � � the structure Is not intended or offered for sole(Sec.7044) � He611h Department �- � � . �� Busrnrss and Professiona Codc:The Contractor'sLitensr -� - ��- �1 � � � � '�'^" �-� ' ��'� ' Law docs not apply to an oa�ner oJproperty wbo builds Fire Department '�y � or improves�tbereox,and wbo does tacb work bimseTJor � - - - - - - - - ' Ihrough bis own employees,provided lGat sucb inr- . Grading � � , yrovemexts are not inlended or oJ/ered for safe. !f, - - "' . � - - -- � � �bowever.tbe buildingorinoprovemcn!isrold witbi�one Geological . " __ . _ _ _ , . . _ year oj eompletion, !Ge ownerbuilder wi11 bave tbe burdcn oJ prooing tbat Le did no!build or improve fos Pedestrion Protacfion � � � - �� � - � � -- - - � � !be purpose ojsaleJ. " � � (Fencv}(Canopy) � , � ' ❑ I,as owner of Ihe property,pm exdusively controt- . . , ting wi�h licensed contractors to tonstroct ihe project(Sec. Special Inspection � � ' ' � � 7�44)�usiness and Proje?.cio�sjCoJe;Tbe Conlractor's (Conc.)(Masonry)(Welding) . Literite Laiu docs not apply tn an otcmfr ojpsoperay wGo - � \y�;��uifdibr,:inrproveslbcrcon,yqn8,w{�oeontractsforsucG LotDrainage , '. � ' . , . prjects�iuitG a contractor(sJ7iCensed�punuant to tbe . . . - _ . Contractora License L.auJ. � � � Parkin9 ' '�:. . � � . . .. .. , - `�- �� - � � � � ❑ IamexemplunderSec. ' ��,B.BP.C.forthts � - � �- � . . . . . . . . . - . . reason , ' � � ._ . �Oate. . � - - ' 'Owner , r '� . - . _ . . Approvots T �cte . octor Si�r.etun � - ' . INSPECTOR'S NOTES ' ,. Location— ) . . . _ . . . . (Setback-&Yards)� • • ( � � ' � . , �� ' Foundations, _ - - . . . .-. , , . , Slab� ..• .. � � - - ;. . . " . . .. Frame .� � . i �_��� .�M.rt , . ' , . . � . . SP " Enerpy Insulation , ' , , Lath/Drywall—�� - nf . . . � . - � Interior ' `5 .. . . Lath—Exferior / � -� . . House Number— . �� .. . Carretl&Posted . _ _. . . . . . . . � . . Final— Enter on Fronl � • � � �