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HomeMy WebLinkAbout1780A 1781A (10) � WORKERS'COMPENSATION DECLARATION . . .. . . . , . �� I herebyaffirm that I have a cerlificate of tonsent to=e�f. . . . : APPLICATION 'FOR BUILDING PERMlT � � insure,or a ceriifimte of Workers'Compenstion Insurance,or �� . a cerY c d copy�hereof($� lab.C.) COUNTY OF LOS ANGELES BUIIDING AND SAFETY �b/a-mo-p$/'�°�G ,P❑olicyNo. Company �dLt�aK. .. . " . Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUIIDING 43 A2R ADDRESS � Z �❑�-Certified�topy is filed with}he couMy boilding inspec- 6UitDiNG - , � A_ .., . fion depanment nooaess 137$ Gc1Y'ZOri tocaurr /T L— ' ' ' NEAREST � Dare nppnca�� � arv Walnut ziP 1789 caoss sT. E /P�d CERTIFICATE OF ExEMPTION FROM WORKERS' - - � � NO.OF BLOGS. ASSESSOR - COMPENSATION INSURANCE � SIZE OF LOT. ].6Z X7O � NOW ON LOT O . MAP BOOK G�1GE DARCEL � (This setrion need not ba completed if�he permit is for one � � iN �P 3 3 ' �hundred dollars(S1D0)or less.) __. tRnCr 33257 BIOCK ior n,o. 36 NO. } e�. V sv�ani a I certif that in the erformance of fhe work for which this OWNER ��3 $�S 714 0. 598-1841 �� CON�iTiONS-� fl Y P � DISTRICT� GROUP TYPE ' FIRE PROCESSED BY („) peimif is i55ued,I sholl nol employ nny person in any manner qDDRE55 . �ESS BTed �.'c"iTl ri �OdC� � � CONSL _/, ZONE � so os to become subject�o the Workers'Compensdlion Lows . , v - '7 � O aTr Wa t CA z�P 91789 `� �- Dale �� Appli[anl' .- ARCHITECf OR -. . . . 7EL,_ ,._, SIATISTICAI CLASSIFICATION �, APi. CONDp. V �'NOT�CE-TO APPLICANT: If, after making Ihis Certificote of� ENGwEER NQ ��J W �QA55 NO.�'LILDWELL.UNITS� d -Exemption, you shoold become-subjett to 1he Workers' . �n Compensatian provisions of the labor Code,you mosl forlh-- qDDRE55 - � � � ' SEWER MA7 z with comply with such provisions or ihis permit shall be . TE� , � deemed revoked. � � - . coNtknCTOR � dS�OWC1eT NO. �' BK. PG. VALIDATION . � LICENSED CONTRACTORS DECLARAT�ON � LiC.. ' � �� � . . I here6y affirm that i am licensed under provisions of Chapter 9 . ADDRE55 n,o. 328279 VALU/1T ON � (commencing wirh Seclion 7000)of Division 3 oi Ihe Business and LIC. /, ' ProFessions Code,and my license is in full force and effect. _ OTV C1A55 —1 5 Y�DOv � � � ��' ' �f�S $Q,-FT. NO.OF' NO.OF CHEIX - ' ��� � ��licenseNumber �&.�/7 � lic.Class d"/ SRE STORiES PAMilIES' ONE �� , ' �-L /(� � S �MK l�L�LO Date� DESCRIPTION OF WORK NEySnT HQ[L� NEW O . � C0�lrocfor _ . � . � I am exempt from�he licensing requiremenis os I om a � ADD licensed archi�ect or a registered professional engineer . . _ _ ._ _ _ . .. _ . ALTER _� -FINAL o -�+,/ ' acting in my profeesional mpacify (Section 7051, REvniR �ATE _Z . jf _ ; Business ond Protessions Code). USE OF ' � FINAL - L�7�•O A � - EXISTING BLDG. _ DEMOL r� . LiC.or Reg.NO. Dote AFPLICANT . . TEL. . . . BY � .��:'��~G t .... . ....� �OWNER-BUILDER DECLARATION - � .. .. �PRiNiI -- - . . . . NO. - . � �I +2�4.� � � I hereby affirm thaf I am exempt from Ihe Contractor's license - � . ' . �� � � ' - Law for the following�easan(Settion 7031.5, Business and - ADDRF55 , . �1�' "�_ �2P9.1 �� Professions Code): � � vkE ENl � � _ � ' ' ' . � �I, as owner_of the property, or my employaes with DDRESS , , ' . �., 0����8� ages as fheir sole compenzation,will do fha work ond � .. � � �- the srroaore is nat inrended or offered(or saie(Section� - �«AUtY _ , . F� ']$.� �'_. 7044,Bosiness and Pro(essions Code). � noOViNG- TE�. " . � � � I,as owner af Ihe propeny,am ezclusively mNracting � CONtRAC7oR NO. . . � �+�•...•y• � ./ wilh licensed wNraclors to consirutt ihe project(Sec- ADDRESS � . � � � - � - .tion 7044,8osiness and Professions Code). � - � � �'� a�3 6�.��� . � REOUIRED TOTAL SETBACK FROM E%IST. � CONSTRUCTION LENDING AGENCY SET BACK YARO HWY vROv.LINE W�DiH � - - �, . . � ����`�O�.� / -� I here6y affirm Ihor there is a mnsiruction lending ogency(or - fRONi • ' , f Ihe performance of the work for which this permit.is issued C.�. � - � II . (Sec.9097,Civ.C.l. � . . . sioE . ; . .. � . . . . . . .- Q.`Z 7 a�� ' v.t. / J' : Q Lender's Nome � " ' � - � /� .��`J i g � 7.0 Fee S d. Permi�Fee u70 �U •- .�� .. � � tender's Address . ' � . -- � 1 certify thai I have read this applimtian and stote ihar the i:.�a�ce Fee ��f . � � aobove iniormolion is carrect.I ogree lo comply with ell County _ . I�vestiga�ion fee - . � � � ���{ � �' - � � . . ." � �ordinances ond Srote lows relaring�0 6uilding mnstroction, To�al Fee f� � , . f �and here6y uihorize representatives of ihis Counry to enter .. . , . .. . � � � upon Ihe ove-men�ioned roperty for inspeUion puiposes. . � � � a � � ��J-� SEE REVERSE FOR E7(PLANATORY LANCUAGE � - � � o s �^ / " Signol�re o�App n1 or Agen� Daro � � ._. . _. . _ ... . . . . . . . . . .. . . .... ... .. ... .. .... . . . . . . .. _. . . . . \ � -" � PIANS TO APPLICANT ' - INSPECTDR'S NOTES � OS9NER-IIUILDER DGCLARA7'ION , I hare6y affirm ihat I am exempt from the Contractor's � To: � Fe}urnod � " Ucense Law for the �following reason. �Sec. 7031.5) . .. APPraved .. . IlusinessanYP[oJest7ons.Q��lq�Anycitxorrorintyw6icG No. � -Datc �� No. - �afe - � � . . . re��irc.?3 per'ryirt to cons�ract,aller,improrc,demoTirb, ,� � .�� .. . . . . . .. orrrpairanyrtructurc,priorloitsiuuancc,afsoreguirc.c �� - � - �� ��- - � - � - �� - � tbe applrraat for sucG pernrit fo Jile a sigacd statnnent � ' - ��- -- ---� -- . � ��. �. . .� . . . : .. � ... . - tractor'sLrcenseLaw(Chapter9f(omrren ngu�'tb5en. �- -. -. _ -. , .. • . ._ , .. ,. . tion 7000f of Dioision 3 oJ tbc Uusiness and ProJessions . , - .... -. CodeJ or tbaL Gc is exemQt tGereJrore and ibe basirfor LGe . a!leged exemplron.Any violation of Section 7031.5 by Faqutred. po}$RateHod � ' � � "- ' a��yaPP���Q��Iorapermitsubjectrtbeapplicanttoativi! .A�provols ... � or A roved exalt o not more tban ive Gundred dollcn SS00J. Yo� No PP . �' P Y f .�� l l� - � � ❑ 1,as owner of fhe properfy,or my omployees wNh VJater Certifiwte � ' wages as their sole compensalion,will do ihe work,and � � � .1ha structure is not iniended or bfiered for sale(Sec.7044) � Health Department� . � • .t _ . , _ � Businessand Profcssians Code:Tbe Contrattor's Licensc � - • � � - � - � - - Law docs xot appJy to an ou�cr ojproperty wbn builds . � Firo Daparlment " �� ' or improv¢s lbereon,and u�bodoes sacb work bimtelJor ' , - � � � -- -� llrougG Gis oa�n enrployees,pronided tlat suth im- Grading . � prosremrntr arc no! inteaded or ofjered for sale, If, ' - - - Gamever,tLebuildingorirnprovementissoJdmitbinone ' Geological- � _ .. _ . . ycar oJ compleaion, tGe oaxerbuilder will bave tLa � . barden ojproving ebar be did not build ar improre jor Pedestrian Protection � _ .. the}+urpose of taleJ. � � � � (Fence)(Canapy) � - . ❑ I,as owner of the properly,om exclusively coNroo- _ firg wi�h licensed con�rac�ors to construct the project(Sec. Speciai Inspaction • � � � 7044);�usrness arsd Pro'_(clsioni,,�de:The Conlractor's � (Conc.)(Mosonry)(WeldingJ "�icense Law dnes not appl��eo aa oee�ncr ojproperty svbo � � �� -� - � � i�vilds`or,timproees!!ereor�,�'r,rnd wGo mntracts for aucL � LotDrainage . � � . ��projecfi�u�itb a eonfraclor(iJ%icen'icd pa'rsaant to tbe � ' - -- .. .. � Contractor's License LaaJ. � � Parking. . , � .. ; . . . � . , , , . . - ' �� � ' � - - - � ❑ Iamexampfonder5ec. ,B.&P.C.forihis ' � . . . . � roason , ^n�: , ' ' - . . . . . . �Dete � � Owner � Approvcls + pate Ins oefor's S naturo . � � INSPECiOR'S NOTES ' Location-- . (Se�batk 8 Yards) � ._ . . . Foundafions' ' /� � " " - - � - � � � � Slab" �. .. • ,. . _ / ' Frame ��O- . . , , , , , � Energy Insulation • � � , . ' laih/Diywall=, .. . � . � _ � � � Interior . . , La�h—Exterior �- -� . _ � � House Number— ' . � Correct 8 Pos�ed � � , ' � " � � ' -, Final— En1er on FroM ` ��•� � � ' �