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HomeMy WebLinkAbout1778A 1779A (10) � WORKERS'COMPENSATION DECLARATION . . . ... . .�. � . � . � . ; . .� I.hereby affirm thai 1 have a cer�ificme of�o�=e��,o se�f. . . . . ��qpp��CATION ��FOh BUILDING PERMIT - insure,or a certificate of Workers'Compens�ion Insurance,or � � o certifie copy thereof(S gqQ b.C. ' � D/O-dD-��/%�� COUN7Y OF LOS ANGELES BUILDING AND SAFETY PolidyNo. Company ❑ Certified eopy is hereby furnished. FOR APPLICANT TO FILL IN gU��DwG G,� � 44—BL- �+DDRESS .s � �: Certitied topy is filed wi�h the county boildinq inspec- BuaDING � I,, L fi0n department. A��RESS �136 LOCALITY �[�✓� ��ote� � -Applicont � � � [ITV Wa1nUt zia� 91789 CROSS ST. ' � �r�N � CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BiDGS. ASSESSOR - •' ' ' COMPENSATION INSURANCE . SIZE OF LOT � � � _ NOW ON LOT h1AP BOOK �i PAGE 7ARCEL (lhis settion need not be completed if the permit is for one � . U O/ni nnnv � // �� � hundred dollars(5100)or less.) - � . , . TRA�T 33257 BLOCK LOT NO. � NO. } TEL d O SPECIAL I ., a OWNER 5hea Ha�s � 714 No.598-1841 a CONDITIONS I certify thot in the performance of the work for which Ihis - � p p y y per5on in pny manner DISTRICT GR UP TYPE '�� FIRE PROCESSED BY ermit is issued,1 shall not em lo an - � �1 ADDRESS ' CONST. ZOy� so as to become subject to the Workers'Compenso�ion lows. � �/ �g � � ✓ � � CC aTv Walnut CA zia 91789 � c� O Date �� � � AFSpIiCOnt ' ' . STATISTICAL QASSIFICATION ', APT. 'ONDO. V ARCHITECTOR � - - -�TFL. � NOTICE TO�APPLICANT: If, afler moking this Cenificole of- �, oU ' �� � w 'Ezemp�ion,�yoo shoold become subjec� �o ihe Workers' ENGweErt NO. C1A55 NO. DWELL UNIT y �Compensotion provisions of the lobor Code,you must fOtlh- ADDRE55 SEWER MAP Z �with comply wiih such provisions or this-permit shall be� — deemed revoked.' . . . TE�� . . gK, � p�, �. � � VALIDATION � CONTRACTOR .Satf�.' dS�QN7IIPY ' NO.' � - �UCENSED CONTRACiORS DECIARATION � �i�, , ,. � , I hereby affirm tha�I am licensed under provisians ot Chopter 9. . AD�RESS . ' _ . . NO.32HZ�J9 VALUpTION - - � � (commencing with Section 7000)of Division 3 of the Business and .���' f(,p�A J ' Professions Code,�and my license is in full force and effen. ,. GTV Cta55 $-1 = (/J [ ' , n SO.FT. NO.OF NO.OF ' CMECN - �'A� 7 7�S F L'ItenSe Numbef ���7 LIC.C�O55� $RE 2 45 $TORIES FAMIlIES 1 ONE � DESCRIPTION OF WOGK E �� �• • •'o'�� o/ `' NEW Confmctor�(4 IVdNxld Date N/.Z7/�/ . .. . .. - � ADD � . . - �. ':I +L 6T,S2 � �� I om ezempt from the licensing requiremems as I am o � � � licensed architect or o registered professionol eng�neer . , _ , , ,. . . . . ALTER � -FINAL �,�� � � _� . oUing in,my professionpl capocity (Seaion 7051, � DATE�j . - b:�2 6 Z 5 2� ��Business and Professions Code). REPAiR � USE OF - DEMOL� B N'�'� O�G I L H� � EXISTiNG BLDG. � - ❑ y � Lic.or Reg.No. Date APPLICANT TEI. � �` ' �� OWNER-BUIIDER DECLARATION� �� � - �" � vRiM� � � �� � � NO. � �� _ . �� � -�� 7 Z Q Ft I hereby affirm tha�I am exempt from the Controctor's License '� , . . . , . . . �� � �� � Low for.the following reoson(Section 7031,5,Business ond Aoorte55 � � - �` �, _ . .�.', , Professions Code): _ . . FRt ENt -" .� �q 2��/� .❑ . . . ... . BUILDING. - - . 7' . V I, as owner-of the properly, or my employees with nDDeE55 i � "�:i . wages as�heir sole compensarion,will do the work and , � , �.C,.��S S{1� � the structure is not Intended or of(ered for sale(Seciion �aA��7Y� �� •. ' , ' -�. . � - . 70a4,Business and Professions Code). nnOwNG 7E�. . � � �/ p � I,as owner of the property,am exclusi�ely coNrocting CONTRACTOR NO. � • � � i. � 'Q 4-2 I ��%� with licensed contraciors to construct fhe project(Sea i� . fion 704d,Business ond Professions Code). - . . ADDRE55 ,. ... . . �REOUIRED TO7AL$ETBACK FROM E%IST. ' ' ' CONSiRUCTION IENDING AGENCY SET BACK YARO HWY pROP.tINE WiDTH � I hereby alfirm Ihm�here is a consvucr,on lending ogenty for pRON� . - '� - �� '� � the performance of the work for which ihis permit is issued � c,i. . . , , , � (Sec.3097,Civ.C.). . ,.... .SIDE . .. . . . , �' - . . _ ' v.�. 1 lender's Name � � L .� . � e4 ' � �.C.Fee E �Q � Permi�Fee OG � � `-��'�� . . .. . Lender's Address ' � W I ceriify ihat I have read this opplicaiion and state thm ihe issuonce Fee � � .� �� - ' = • o6ove informotion is mrrecl.I agree ro wmply with alf County in�esrgaron Fee -. . . � _ ^/ � � - . �� � � � - � ordinances and Siaie laws relating to building constructian, ioiol Fee p�/� ' �, ' � . - and hereby authorize representotives of this County to enfer . _ �• � up/on Ih �bove-meMioned properry ior�inspeclion purposes. . . ; . . a l�����rt�� L�-��_� � - SEE REYERSE FOR EXPIANATORY LANGUAGE - ' �' . Signo�ura ol Appi�cani ar Ageni Doie , � � � �� �s �� � � �PLANS TO APP,tICANi � INSPECTOR'S NOTES ' OWhBR-BUILDER DECLARATION . i heroby affirm thot I am exempt from�tha ContracloPs To: �� ke}urn�d � , � � 4icense Law for tha following reoson. (Sec. 7031.5) - � Approvod ,_ 13usrncssanrl,Profe�r,2{6�s�Cnde:An�ci[yo�t�pntyu�GicG No. �- -�� -�-�-Dato�--- -- No. � Date � � � � � . � requYirf�Actririt to constract,aller,improve,deraolub, , _ _ . orrepairanyslruclure�priortoitsistusnce,Rlsoreguires � -�-� � -- � - � ' ' � '�� - � � -- - � � � � �� � tGe applicant jor sucb permit to jile a sign¢d sta0c�eent _ . tbat be is fkensed punuant to tGe proui.rions ojthc Con• - �- - - � " �� -� .. "- � � ' �� �� ' ' - � tractar's Litenm Law(Cbaptcr 9J(ronimenting uitG Sco . . _. . , � .._ . . . ',�, . � .. _ � . . . � � � tion 7000J of Divisran 3 of tbe Butinest and Professions � � CodeJ or tGat Gr is exempt tGerrfrom and t6e basis for tGc � . . alleged exemption.Any violotion of Seclion 7031.5 by .,Ceqvired DateRecnlved •� � anY°pPJicantJorapermitsubjectslbeapplicanttoativr! � , _._ Approvols _. � or Approved Penalty oJnat nrore tGan jivc Gandreddollarr fSS001.J: Yas No _ .. ... . • , .� ❑ I,as owner of tho property,or my employees with Nlaler Certi(icale � � ' � wages as their sole tompensaiion,will do Ihe work,and , ' - - ��.�.� � the suucture is not intended or offeiod for aalo(Seo 7044} .. . . � . . . � "; . ._ � " . � �, Health Dapartment " '� ' .� Buriness and Projersions Cod¢:Tbe Contrac0or'sL7cense , - - � ��� - . _ _ � � -- �� Law does nat apply to an oumcr ojproperty wbo bullds Fire Department �-- . qrimprove:ebeseon,and a�bo doea ssscb u:ork birxs¢Ijor - � � � . tbrougb Gis oam rmployecs,pronided t!at sacb�im- � Grdding ��� � � pruvcments arc not intended or offrred for sale. lf, � - � -� � � � �Gomevcr,lGebuildingorimprovenecntissoldwilbixone , Geologitol � � � . , . . . . _ yenr of complctian. tLe ownervbeildcr will bave'!be � � - burden ojpraving tba!bc did not burld or improve jor Pedestrion Protacfion � � - . . the purpas¢of saTeJ. ' �� ' ' , (FenCe)(Canopy) , , � � ❑ �,as owner of 1he property,am exdusively conlrao- � � - , ling with licensed tontractors to construct the project(Sec. , Special Inspection � � � ` �' " 7044).$usiness and PrdJessida;}�ode:TGe Contractori � (Conc.)jMasonry)(Welding) ,I.icense Lam dors nol a/�/+ly!n¢n oeoncr o//�ro(,erty who - - � - ��„builds�or�an�proocslGe��n, a�3wLoeollructsforssscb Lol Droinogo ° ' _ �- . pro`ject3 u:itG a eontrac�ar�sJ licena'c'd pursuant to tbc _ Corrtractor's Lrcensc LauJ. � Parking . e . . . _ , • - . . ❑ I am exempt under Sec. ,B.BP.C.for Ihis _ __ . .. . . fOOS0l1 .. . 1 � ,. . . . . Dale --- - � � - Owner- . Approvol: i Dcf• I oue r's S( iafura � � . , � " � INSPECiOR'S NOTES' Lomtion— v � � - � � - (Setback 8 Yards) . � �►Q �' . . _. - . . - � � � - Foundalions � � � - - ��-- ' � _ � Slab - . . - . . . � . . . �.. - Frome /0-G .. . . . . . � . . ' _ " � Encrc�y Insulotion � � _ . � � . . Lath/Drywoll— ' - - . . � Interior ' ' '� � � . lath—Exterior � � ' - ' � � � ' �\ . House Number— . - . , Correcf 8 Posted � . ' . . . . -. � ' . Final— . . � . , . . . , � ' Enter on front � � - � � �