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HomeMy WebLinkAbout1784A 1785A (10) WORKERS'COMPENSATION DECIARATION . .. . . . . . .- ' . , . � . � � I hereby affirm thol I have a certificate of consent to=e�f . .. �APPLICATIO�I FOR BUI-LDING PERMIT � � . insare,or a certificate of Workers'Campenstion Insurance,or � . a cer�eli�OPYOO�-of1.5�7c�asp9,Lab.�?� COUNTY OF LO$ANGELES BUILDING AND SAFETY . Policy aJ � �c:ompo4 . . � Cer�ified copy is he�eby furnished. FOR APPLICANT TO FILL IN �}Q '(,ZR ADDRE55 � Lf � �� CerliFied topy is,filed with the�county 6uilding inzpec BU�LDING � " � tion department. ADORE55 1350 Garzon� �oca.uTv L� � � � � � NEAREST . Da�e � Applicant� � -- CITV W ZiP CROSS ST. � � CERTIFICATE OF EXEMPTION FROM WORKERS' � '� � NO.OF BLDGS. ASSESSOR � � � � COMPENSATION INSURANCE �- SIZE OF t07. �JO X14O NOW ON LOT O � MAP BOOK - P/rGE PnRCEt � � (This setHon need not be comple�ed i4 ihe permit is fOr One ,RACT � 33257 � s�ock � �oT No. � 34 USE ZONE NOP� .'� . hundred dollors(E1p0)or less.) . , � 7EL. SPEpAI ��� � � OWNER .�]p� HQfY�S �]14 NO.S9H�ZH41 - �CONDITIONS a I certiiy that in the perfarmance of the work for which this . � � v permit is isiued,1 shall not employ any person in any manner DISTRICT G UP TYPE FIRE CROCESSED BY ADDRE55 655 .Brea Can � �aC� � // CONST. Zpy E �7 so as to 6ecome subject to ihe Workers'Compensofion Laws. � J ? ,../ „( /. O . . . vT `J l� .J lii � GTY {��lU't � ZIP Dote - � Applicont - ' 9�789 STATiSTICALCLA551FICATION � APT. CONDO.- V ARCHITEC70R - � �- � - TEI. �/ y NOTICE TO APPLICANT: If, aNer making this Certiiicate of�-�- ENGWEER NO. CL455 NO. �` � DWELL.UNIT57/ - 6W. Ezemption, you should-become subject�to the Workeri y Compensation provizions af Ihe Labor Code,you must forlh- ' AD�RE55 - � � ' � - SEwER MAP �, Z with�mmply with such provisions or this permit shall be TE� � � � deemed revoked.� - � CONruncroa � $c"� dS�OWR2.'C NO. - � BK. ��� 7G, � VALIDATION � �UCENSED CONTRACTORS DECLARATION UC. .. . . � � I hereby affirm thot I om licensed under provisions af Chopter 9 ADDRE55 � NO. 32$2 VALUATION� ' (commencing wilh Section 7000)of Division 3 of the Business and ���' O x O O� _ Professions Code,ond my license is in full force and effett. CITY C1A55 -]. a 0✓ � saeF' 2 457 70RI�ES 2 MNES 1 CO E� License Number���o27y lic.Closs� � . �'� - - � / .. . � S' , .. . DESCRIPTION OF WORK New Hctre NEW CoMraUor.�e �Date'y/T O � � �'� � - . . ADD . � I am exempt from Ihe licensing requiremeMs as I am a . . � litensed architecl or a registered professional engineer , _ .. „_, _ . AITER � FINAL �acting in .y professional copacity (Secfion 7051, REPAIR � DATE� ���'� , . Business and Proiessions Code). use oF • � E%ISTING BIOG: � �EMOL � FINAL � Li[.Or Reg.No. Dote APPUCANT � TEL. BY . 'F� �Q'U p �� ' � OWNER-BUILDER DECIARATION - - � �'� -- (PRINT� � -� �� � - - NQ � ' � � - • � I hereby offirm iha�I am enempt from Ihe Contractor's License , ' . :� .� � � . . . �����~.��2 1 � Low for the following reason(Setlion 7031.5, Bus�ness and -� /+ooaess � � � . Professions Cade�: , ' . PkE EN � +.... . ' ' ',I •2 6 7,5 P ❑ . . .� . . BUII�ING . - ; . - � -I, os owner of Ihe propeny, or my employees wilh ADDRESS �: F ��! '�'_� woges as fheir sole compensa�ion,will do the wark and � � � ,, •'�2�7,�L� . - ��the srructure is not intended or ofiered for sale�Section�� � �Ocaut�. � - � '� � :� , ��'�� �� ' •-� - _ 7044,Bosiness and Professions Code). MOVWG � 7e�. �, '�. � �� � I,as owne�of the praperty,am exclusively conlracling CONTRAC70R .NO. . � � . � - . �4.2 7'-&� wifh licensed canfra[tors ro conslruct 7he project(Sec- qDDRE55 � ' � - ' .. . �ion 70e4,Business and Professions Code). � � � . � � ' REOUIRED 101AL SETBACK FROM EXIST. ' '� .� • ��rT S S I�. � � CONSTRUCTION LENDING AGENCY ser encK raao Hwr pROP.lWE' � WIDTH� ' ' I hereby affirm thar ihere is a construU�on lending ogency tor � pRON� . � '� . I � . ' -� �#�• •�� - the performonce of fhe work for which this permit is issued F l �� � • - • (Sec.3097.Civ.C.): . . ... .. . . . . . . . SIDE. . . .. . .� _ . . . - .._ . .. . . P.�. ' �:: I •t�2650 . Lender's Name S ' .4�6 rJ Q= ,,- � $ � ' � P.G Fee S � �� Permii Fee / . �I � � - ' ,�� lender's Address � y��. � . ? � W I cer�iiy tha�I hove reod this opplication and sta�e thai fhe � Issuance Fee . �' . � '���7_8, qabove iniormotion is correct.I ogree to comply with all County . In�esnqoion Fee - �- � � �� �/ 0 � � ' � - �� - � $ ' ordinonces and Stale laws relating lo building construclion, Toml Fee � ' �. . � . and hereby authorize representatives of this County to enter � . a -' upon t/hg�'bove-menlfone property for inspection purposes. - � . � , � � � < . ��=�'�����f-�`Z _ �%'I,-��' �SEE REVERSE FOR EXPLANATORY LANGUAGE � . ' . ; � - E ' � Signature of Applicanl or Aqenl Do�e � �s -- ' � PLANS TO APPLICANT ' � - � WSPELTOR'S NOTES � OWNER-BUILDER DECLARATION . 1 heroby affirm tfiat I am exempt from the CoMmdor's To: ' � � Rel�rnod� -� �� � - � ' � - � Uceneo�Law for 7ho following reason: (Sec. 7031.5) � ' � Approved . _ IiusixessnndProJeuioys�'ojl�tYlnycityvr.¢huntywhicb No. �-Dafe---��---�- No. Dafe � - � - . . . �, � -� -,, - �. ,,�._ . requires'Qperrmt to canstrucl,alter,improve.demaJisG, . . . �or repairanystruclurc,prior m iRs irsuanrn,also reguires . -- . .._ . .�� �. :-. � . .. . : � . . . . -,. . . : , --.- . � � tl e a/�plicant fos tv�G pennit!o fi'le a sigrsed statemerst . , that Ge is licensed pursuant to tbe prouurons of tbe Con- . ._ . . ._ . � '.�. . ... �,..., � ..._... .. . . _ _ ... _ . ._ . . .. _. _ . . ._ � . � - � tractoraLicenseLaw(CLa�iter9J(camn+encingu�itGSen � ' '- ' � ' �� '" ' " tion 7000J of Diukion 3 oj tGe IIusiaess axd ProJessions , .�. .�.�, .. .__. _� . . .. . . . . . ��� -� - - � - � , �� � - � - , � CodrJ or tbat Ge is exempt tGerrfrom and fbe basis jor t5e alleged rxenrptian.dny ciolation ajSettion 7031.5 by RaquGed DaieRaeelved - � ' . � . anyappficantforaQesmitavbjectstboaQpficanttoarivi! , . ApArovoi� . .. ._ � � � or Approvad � � � �' :� ��� � � -�pena(ty ojnot more tban Jioe Gundred dollaa(3500J.J: Yas Ne . . � � �� . ❑ I,as owner of tha property,or my employoes with Nlaier Cer�ificate - � , � ,.,.. .. . wages os their dole compensalian,will do the work,and , � � � ' ��� . _-i�. -. �-�...�- ' '� '_��.�. ��. � ihe structure is not intended or offered for sale(Sec.7044) Heohh Deparfrcient� ' � � , 6usiness aad Professions Code:Tbe Corttractor's Licente --� „ � - ' � _ � � . � � - �.' - � I.am docs not apply to an ou.xer of proprrty wbo burlde ._ .�. . ..__ � �.- . . � . . Fire Daportment� � \ '; . , �-or improues tbereox,and wbo docs sucb work�bima¢!f or � - �� � � - �- � lfirougb bu o¢�rr en�ployees,J�rai�ided tbat saoh.im- Grading � � ' � � proeements am not�in0ended or oJJerad/or sale. 1J, - - � - �� � - �� � � boa�evcs,tbebuildingorimprovementisaoldwithinone . Geologictll �'� � � _... . . �- -� � � - . . _ ... year of tompletion, tGc ouinerbuilJer uil!bave tbe � burden ojproving iGat be did no1 build or improve jos . �'� � Pedestrian Protection �� . . - . _ ._ . � !6e j�afYrote o/sa1eJ• . .. . . (Fence)(Canopy) , , � �' � � ❑ I,asowneroflheproperly,amexclusivelycontroc- � , tirtg with licensed wntractors to construct the,project(Sec. Special Inspecrion - � � � � �. ��. ' 7b44)�IIusineas and Projess(otZs=Ebde:Tbe Contrattor's � (Conc.)(Masonry)(Welding) . . . � • _ , Licen.rrlau�doeseotapp�ylaanoumerojpropertywho � � , � � - � ��bkilds�orimJ�rocrstbercon,anil�whocont�act.rforsucG tot Drainago - . - prOjectr'ti�itG a conlraclor(sJ 7itenseJ pursuant to 1bc _ . .. . . . Contractor's Lrcense LawJ. , � . . Parking - �'..�'l' . . . _ . . . . . . . . . . . . ❑ �om exempt under Sec. � ,8.8P.C.for this , .. � \ . � � . .. . .. . . . . . . reason - - - � � Date . _ � � . ... Owne� .Approvals , Dato Inspoctar's Stanctu.� •� - � � � -. � . � � - � -INSPECTOR'S NOTES � . � Locotion—. . . . . . . .. . . . � . � � � (Setbotk R Yords)• � � � � � - � � � � �. Foundations, � . � , - � : � � _ � Slab . . . . _ . _. . . . . . . . . . . Frame ' � ../ !� ' . � . , . . . . . . . . iZh Enerfly Insulation ' . � . . . . . . � . . � . . � Loth/Drywall'-. , � � � ' . � . , � Interior � '� Lath—Extcrior / • ..`\. � _.. � . . � . . � . Houso Number= � -" � � . _ � � � � � � . - � Correcl R Posled � ' - � � � ��� - - -�� � - � � Final— . ,• .. � � . . . En�er on Front ' ' � � �' -