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HomeMy WebLinkAbout1777A 1776A WORKER$'COMPENSATION DECLARATION . . � . � . . . ' � '�, ��'I � ���,�,eeo,a��em;���ofe�ofwo,ke5e�o�mPe�S'a�°��=�°o��eso", - APPLICATION� FOR BUILDING PERMIT J1 a certi£e���h���(Se��qa.�.C.,) �a���, COUNTY,OF LOS"ANGELES BUILDING AND SAFETY r � Poli[yNo. Compony � � � Certffied copy is hereby furnished. FOR APPLICANT TO FILL IN Q3_� ADDRESS .� � y � � � .Certified copy is filed with fhe tounty 6uilding inspeo- BUILDING ' I � - 'fion cleparimenL � ADDRESS - 136�.�GIYZOTI. LOCALITY L . . . . ' NEAREST - � . • � Dale � Applicori� -� �- CiTV �W31TSllt � Lv 9178g caosssT. � CERTIFICATE OF EXEMPTION FROM WORKERS' � � NO.OF BLDGS. P.SSESSOR � � � - COMPENSATION INSURANCE � � � - SIZE OF LOT . 6 X13/} NOW ON LOT .O �P BOOK ' PAGE PARCEL ' (This section need not be compleied if the permit is for one . u z0 e hv+P - h�ndred dolbrs($100)or less.) TRACT BLOCK l0T NO. ' � NO. � � . . TEI. �U SPECIAL , p, . I certify that in the performance of the work�for which this _ OWNER $[1p� $Cil�S � 71� No.. 598-1841 � fONoiTiONs ' � �,permil is issued,I shall nm empiay 6ny persan in any manner DiStaiCi G UP TYPE � F�RE PROCESSED 6Y {„� so os to betome su6ject to 1he Workers'Compensa�ian Laws. ADDRESS �ESS BTP3 Cc1T1 OIl �fJdCl � � CON57 Z'E � � O Y t7 Dote Appiicanl � " ' CITY Z�P ' 1 STATISTICAlCLA551FICATION � APT. CONDO. (~j NOTICE?O APPLICANT: If, afler making Ihis Cerfificofe of ' ARCHITEC70R- � � � .TEL. �/'➢ , FNGINEER NO. C1A55 NO.�DWEII.UNITS� 6. �Exemption,�yoo should�become subjetl to the Worken' � N .Compensation provisions of ihe Lobor Code,you must forth- � qDDRESS � �' SEWER MA7� ? with comply with such p�ovisions or ihis permi� sha�l be � , -deemed revoked. � . . . TE�" � ' eK. � pG, . VALI�ATION . - CONTRACTOR�� NO. . � �. LICENSED CONTRACTORS DECLARATION �i�. . . . � I here6y affirm that I am licensed under provisions of Chopter 9 _ ADDRESS .NO.-32HZ�I9 VALUATION�� �. . (commencing with Section 7000)o(Division 3 of the Business and� IIC. � �nv � � , � Professions Code,ond my license is in foll force and effec�. _ CITY � CLA55 S !" � ' ' ' ' .��/ 50.fT. NO.OF NO.OF CHECK' ' " ' - License Numbenr•�aZ&+27 Lic.Class 5�2E Z 13� STORIES 2 - fAMILIES. �. ONE ' � � - - � ,�f�� ��I1�./� Do�e 7 �7 6� ._ ... . . NE1Y � S . . , . . . . . . COn1ra[tor DESCRIPTION OF WORK . , . . ,. �� I am exempr irom 1he licensing requirements as I om p � - ADD � A; . licensed archiiett or o registered professional engineer . . aLTER Q FINAI � 7 7•7 F+ .. . .:_.__ _.. _ . ._. ... .. DATE . . acting ,in roy professionol copaci�y (Seciion 7051, REPAIR � ' ��� ��. +,� Business ond Professbns Code). USE OF FINAL/ ' ' � � � � � -� - E%ISTING BIDG. � � DEMOL ❑ f . ' � R /� � . Lic.or Reg.No. Date .. � APPUG4NT ' - TEL. ' BY ��•��H��y1= . .. .. �PRINTI . . .... .... ._NO: ' ; . . . . • t5 C U c: - ' � �OWNER-BUILDER DECLARATION -� � , � � � . . 0 4 2 7�-8�� I hereby affirm ihat I am exemp�from the Coniractor's License � � .. . � �- � Law far the following reason(Secl�on 7031.5, Business and� nooaESS � �� � . Professions Code): � - vRE Etii � . � ' � _ ❑ . .. . � . . BUILDING ... . . . . - - .. . I, as owner of Ihe property, or my employees wilh A�DFE55 wages as their sole compensation,wiU do the work and � . I . � � � � Ihe struaure is not iroended or oifered(or sale(Section �OCauiv - ;� �� , � . � 7044,Bus��ess ond Professions Code). ' MOVING � TEL � � . ' � � � ,� 7�,b A � I,os owner of ihe property,om e.dosively contracting' cOnlieaC70R. � NO. ' � �� - �� � � � •2� with licensed contraciors to construU ihe projaU(Sec- qooRE55 � � - �.';��� • -- �ion 7044,Business and Professions Code).� � � ��. - - � . . , . ' REOUIRE� TOTAL SEiOACK FROM E%IST. CONSTRUCTION LENDING AGENCY SEi BACK YARD HWV pRO�.UNE — -wioiH'� ---� ' � � � � .2 3 9.3 6 ' I hereby affirm lhaf there is a conslruttian lending agency for FaOnIT . � �� � ' � � � ' � the performance oi the woik for which Ihis permit is issued ' v.�. - � . _ ' . '��E�9 3[.� (Sec.3097.Civ.C.). . � . . SioE . . . . .. . � j� ( � . . v` - 04.27-81 tender's Nome J x . - . , . . . . � $ � .. . a.CfeeE - q� �+ PermitFee �aU � �,,���:.� ` � �i . . � _ Lender's Address � . � . . ., _ . , . W �I certify thar I bave reod thrs opplicouon and state that the i:soo ce Fee ' . �. - . a above informauon is correcf.I agree ro comply wilh all County_ �o�esngmian Fee � � � � � � � � - � , - - . � ordinancez and State laws relating to building wnsrrucGon, Toal Fee �'� , � . " and hereby authorize represema�ives of this Counfy to enter , , _ ,. . .. . - . l Q ' upon Ih bove-meroioned property For inspection purposes. � � . �. . �� . . _ � a` ������:�_ 7��7�p/ � �� SEE RfVERSE FOR EXPIANATORV IANGUAGE� ' ' � � - �/ w�� '� � $Ignal�re ol ApfJl�conl or AgeN pole � - �� � ���, .. .. .. . . . . . ' . . _� .. .. .. . ._ . . . .. .. . .. .. . .. .. , i . . . . .. . . � . . ... .. . ./ . 1 'PLANS TO APPLICANT ' � ' INSPECTOR'S NOTES OWNER-BUILDER DECLAAATION "�I hereby affirm that�am exempt from ihc Coniraclor's To: ReWmed � � � " ' � . License�Law for the followfng�reason. (Sec. 7031.5) , - - - Approved . - _ BurinessandProf�35ip+�s�dde:Any.eitydttnvntyicGrcG no. -� --Date ----� No. .� Date . - -� ��- .� , �.�� � �,. � -���qr?ir+es a perniit ro constract,alter,irxprare,demolisG, , or reparr any rtructare,pnor to itr issuance,'aGo regurres �� � - -'' - � ' ' � " � � - � � � - - - - tGc applitanl jor sueb permit to Jile a si�cd statcrnent _ - tbat be is licensed parsuant to tGe provuions of tGe Con- - , --- � ' � �-- � - � � ���� � � ' ", tractor'sLicenxeLaw(CSapter9f(commencingwitbSeo- . . . tion 7000J of Drvirion j of tbe Butinets and Profesiiont - � � � � . . CodrfortGatbcisexenrftfbciefromandtb¢batisfarlGe _ aAeged rxernption.Arzy vrolalion ojSettion 7031.5 by P.equired _ DetvRecolved • ��� . anyapplicantfarapermitsubjeUstheapplicanttoaciviJ ._.- _Approvals. .. -or Approved penalty oJnot more t1�an jive bundred doUart(SS00J.j: �Yos No . � . - - ' . ❑ I,as owner of ihe property,or my amployeas with Vla�er Certific6le ' . , wages as their sole wmpensation,will do the work,and .� . "- .. .. . . the structure is nm(nlended or o{fered for sale(Set.7044) HealthDoparfmcnt� �- • - �. . ' , � IIusenessoxdProfessionsCode:TbeContraclor'sLitense . ,- . . . -. ,":7� [�.. . _ Law docs not apply to an ouroer ojQroQerty wbo builds - Fira Depariment � . . or rmnroves tbereon,and wbo doessacb¢wrk bimselJor �� - - . tbrougG bis own empJoyees,�provided tGat tutb inr- ' Groding , , provemenls are nol inlended or o/fereJ for sale. !f, - - �- � bowevcr,tlie barldrng orinrfrooement isaold wrtbiro one Geological ', _ _. . .... .. _ .._ _. . . year oj completion, !Gd owner-builder suil!�baue"tbe � ., burdex ojproviag tdat hc did not build or improue jor � Pedesirian Protecfion ' , � . � ibe fssrf�ose ofsaleJ. � � � ' (FenceJ(Canopy) � , - � - � ❑ I,as owner of�he property,om exdusively contrao- � " � � , tirg wi�h licensed coniractors to construcfthe project(Sec. � Specfal Inspection � -� ' ' -_� ' � 7q44Jyfusiness arrd ProjesiiDn6.:Coder Tbe Coneractor'a , (Conc.)(Masonry)(Welding) , � ��� I,icensc I.aa�does nnt apply tn an oxcrirr ofproperty u+bo - - �ti����bnifdsbr i»rproves tG�reo�r��ru!��L+o�cbntracls for sucb Lat�rajnage - pro�eck�u�itb a contractar{sf licensed�pursuant to tbe � � � . . . - Conlractor's License LauJ. ' , . Parking - � . . . ❑ I am exempt under Sec. ,B.6P.G.for this � � - �•\ . � . . .. . - � reason .. • ' � Da�e Owner Approvals Oato ns,p clar's Sip turo � . . . . . . . . INSPECTDR'S NOTES � Location— _ ._ ' . ._ .. .. . . (Setbatk 8 Yards) y�f� � � � ' Foundafions � / /� 'r . . . . . . . . Slab . , . . . . . . - . . . . � .. - Frame �, - O �7 ' . . � . , Energy Insulalion ' . � � � . � � Lath/Drywoll—.,* ' , 'Inlerfor � , Lath—Extcrior J � - � . __ � � , . \ . . Houso Num6er— � . ' � � . , � � � � � � Correct&Posted �- - -� Final— , � . , � Enter on Fronl � ' � ' � 1 . _