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HomeMy WebLinkAbout1782A 1783A (10) --- - ----- ,_ . _. ._ __� _ _ r. ._ ._ —.i . __ _ � � WORKERS'COMPENSATION DECLARATION .... ._. . _.. . - � , , �� � � . 'I hereby affirm thm I hdve a ceriificaie of consent to 5e�f .. . � . qpp�ICATIQN FOR �BUILDING PERMIT �� insure,or a ceriificaie of Workeri Compenstion Insurance,or � � a cer�t�{i�J opy h reof�(5�c �}(��"Lob.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy F7a.� ��_O�o�7�riy �G�L[/Q�LG � ' - "T � �, 'CertHied topy�s here6y fumished. FOR APPLICANT TO FILL IN nooa ss .77� (.�'/�' Ti O/?� �� Cenified copy is filedwith the couroy bWlding inspec- � BuuDiNG ' . lion deparlmeM. ADDRE55 1381 �ouuTr /,{` �Dme. Applicant � Ciiv - Wcl�S]Ut zia�� 91789 ceoss sr. � �i-L s/?/,� � ly' ' _� CERTIFICATE OF EXEMPTION FROM WORKER$' S¢E OF lOT Z�O�X9O�� NOW ON 075. . O � MAV BSOOK ' ' PAGE vARCEL COMPENSATION iNSURANCE � - /� � ' (This sec�ion'need no�be completed if the permit is(or one ` U5 Z� rNP�P /,/333 . TRACi BLOCK lOT NO. / 'NO hundred dallars(5100)or Iess.J � • .� >. Tei. p SPECIA� a OWNER �Q� H Q NO.� � A a CONDITIONS '�I cer�ify that in the performonce of the work for.which this..,._ �.- u �perm��is issued,1 shall nof empioy any person In ony monner T__, , DISTRICT G UP 7YPE FIRE PROCESSED BY ADDRE$$ 655 Brea C�1 n SWGIl � so as to become subjecl l0 1he Workers'Compensation laws. � . ', � COn1571� ZO�IE O � .Date � ApplimN� ' ��Ty . Z�P StAT15TICAL CLASSIFICATION� - J APT CONDO. V ARCHITECT OR TEL. nq NOTICE TO APPIICANT: If;afier making this CertiiiEote of - ENGwEER NO. CLA55 NO.�DWELL UNI?5� 6W. Eaemption, you should.become subject lo the Workeri , y .Compensafion provisions of.the Lpbor Code,'you mvst forth- qpDRE55 SEWER MAP � .Z wi�h comply with soch provisions.or �his permii shali be TE� � ^ .deemed revoked. . - � CONTRACTOR $�C1C' 1S Q�JI'12.L 'NO. � BK. ���PG. YALIDATION LICENSED CONTRACTORS DECLARATION ���, _ _ I hereby�affirm ihat I am Gcenzed under provisionsof Chapter9 ADDRE55 ..NO.32HZ 9 VAWy TION ' I � , . (commencing wi�h Sectio�70p0)of Division 3 of the Business and ���. [7,2r�O n ! Professions Code,and m license is in full force ond effeci. CitY CLA55 B-1 5 (%�J �/ ' y,�G,�'Q �. � �—/ SQ.Fi. NO.OF NO.OF CHECK ' ' LicenseNumber �7������� � LiaClass SRE STORIES FAMIUES � ONE , ! �� ��� ' lt�a7/�i DESCRIPiION OF WOkK NEW � s � Contractor �Date T . ❑ . � ' � I om exempt�from Ihe licensing requirements as I vm o ADD � licensed orchilect or a registered professionpl engineer . ALTER � FINAL q � . atling in my professianal copacily (Seciion 7051, REVAIR � DATE — /— �, Businesz ond Professions Code). USE OF E%ISTING BLDG. DEMOL ❑ 8 NAL � -,z� 'T S Z{� lit.Or Reg.No. Date AP7LICAM . TEI. Y #..•r�.Q� �� - � OWNER-BUIIDER DECLARATION � �"" (PRWTI � � � - � �- NO. � ' I ' � � � I hereby offirm that 1 am exempt from the Contracror's license . _ . .. . ; �� '<2 6 7.5 2 Law for the iollowing reoson(Sec�ion 7031.5,Business ond P�D�RE55 ' ' ' - Pwfessions Code): �- pkeSEM �� � 2 •+�L��.�'^L'c=.�. � ' � BUIL�ING ;.�'.i � �❑� I, as ownei of the properry, or my employees wilh ADDRESS � �� ' _ -• - wages as their sole compensation,will do the work ond `�AL TY — . � - • r '�O,(j'2 7_�� � �the structure is not intended or offered for sole(Seciion . . - 7044,8usiness and Professions Code). . MO�ING 1E1. i �� ���A � ❑ �I,os owner o4 ihe praperty,am extlusively tonlraUing' CONTRACTOR NO. . • il � with licensed conlroctors lo tonslruc!the project(Sec- qDDRE55' ' � ' �*� •���1 . ..� lion 70d4,Business and Professions Code). • � � � � -� � � � � - � REQl11RED TOTAL SETBACK FROM EXIST. - CONSTRUCTION LENDING AGENCY SET BnCK YaRD HWY peoa.uNe WiDiH � . � , I hereby off�rm thor there is a constr�crion lending agency for - - pRpNi � ' i� ' ' �� � the performance of ihe work for which th�s permit is issued v i , �� ' �� •t;2'��'. � _ .(Sec,3097,Civ.C.�. _ � SiDE � � �i. � .- ' , v.L , ' 1 I. e+eLl26��� lender's Nome A - � � � 04 P.G Fee S � Permii fee V O - .� ���� ` • O�.Z�J�'�� _ Lender's Address �5,�.a , , _ � � , . W I certify Ihal I have reod this applicofion and stote that Ihe Issu e Fee � above informalion is rorrecl.I agree to comply with oll Counry Invesi� Fee . a�� � I - � � ordinances and Stare laws reloling to bvilding construcrion, ga��o� ,/� ' ' " ', . � and hereby uthorize representatives of this County fo eNer imal Fee j � � a upon the ove-menlioned properfy for inspection purposes. �� - . ,�3� _�l��� /�'�'-�� SEE REVERSE FOR E%PLANATORY LANGUAGE " I � � S�gnarure of Appl�cont or Agenr po�a . ' �, ' �� � �� �PLANS TO APPLICANT. � � INSPECTOR'S NOTES � OWNER•BUILDER DECLARATION 1 heroby affirm�hat I am exemp�from�the Coniracror's To: � '� �� � Relvmcd � ' " �� ' ' ' �� � Lftanse�Lcw for the following reason. (Sec. 7031.5) � •� � Approvod BusinessandP,rojessiqn,�CQkmAa��tity,orFbuely.�ebicG , tJo. �-���Dute-� � --� No. pate � � . � � . regriFMsen'j)e�nrJtto conslract,alter,improve,demoJisl�, . . or repuir any structure,'prior to its iuuance,ako reguires - �- — � � " �" - - - � �� � � � � - , ' tGe ap/�licant for sucG pernrit to Jile a rigned statcinent , tbat Lc is Grenscd purtuant to tb¢prae•isions ojtfie Con- --� �� � - � � - - ���- �- �� � lraclor's Licenre Law(Cbopter 9J(commencing utitG Sec- - , . tion 7000J of Division 3 of tGa Business and Projessions � �� �. - - � � �-� , � _- � - - �� . . �CodrJortlatGrisexempltGerejro»sandtGebati.rfortbe � _ . allrged esenrptrors,Any violatian af Section 7031.5 by �,R¢qu(rod � DateRecolved � � .,-. , _ _ anyapf,licantforepermitsubjecktbeapplicantioacivil _.____Approvols . ." - ' � or Approvod . � . � penally oJnot more tban jiuc Gundred do!lars(SSOOJ.J: Yos Nc � . �., -. . _ �� � ❑ I,as owner of the property,or my employees wifh � 1"later Certiticate , . wages as their sole compensafion,will do the work,ond ' . . � - __ . . � the strucWre is not Imended or offered for sale(Sec.7044) NeohhDeparfinem. - '� _ . DusinessendProjessiansCode:TbeContractor'sLicenre ,.- - _ . .._.. � - . . Law does not upply eo an owner ojproperly rubo builds ... .. . _ __ ... . . . , � FireDepartment � _ , ���arimprovertbereox,andwGodocsaacba�orkbimseljor - � - � � - - � lhrougb bis oum catployees, prourded lGat such im- Gmding � � �Qronenrents are no! intended or oJjered jor sale.lj, � - � � � - � � bomever,tGebuildrngorimprouenrentissoldeuitbirsone ' Goologic6l�- - � . . - . . . .. � - � ,. . year oJ completion, tLe ownerbuilder�will�Lave tbe , burdeh oJprocing tbut Gc did not build or impros�e for Pedesfrian Protoction .' . . tbe parpose of ralef. . .. . (Fence)(Canopy) '. � �� � � ❑ I,asowneroflhepropeny,amexdusivelyconirao ` - - tirtg�'+uh licensed contractors ta construct the praject(Sec. Spetiol InspecHon ' ' � " ' 7q44)Basiness and Pro,�eidiops%Codc:Tbc Contrador's (Conc.)(Masonry)(Welding) � -License Law does riot apply tQan ownrr,of pr'operay wbo � � - �bnJlds nr•imfroces tGerewrt+Ytad wl�o�ton(raclsJorsuth �.. _ lot Drainage ' - � . p�ojects�yailG a tontractor(iJ/ic'cnsed pursuant to tGc � . .. . Contrattor's Liccnsc LauJ. ' � ' . , Parking . `•l' . �'� . . . . _ . .. ❑ I om oxempt underSec. ,6.8P.C.for�his � � , . � � . . .. . . ' reason � �� Date � � Ownar ' r • i . . .. . . _. Approvals w Dafo Incpoct s 515naturo ' , �� � � , . , _ . INSPECiOR'S NOTES Lamtion— S — .. . . . . � � , � _.� (Set6ock 8 Yards 0 � ' � � Foundotions,, . . � � , . � . . � Siab� .... . � � . . . . - . ' � -- Frame /0 �Y ' . � � . . . � Ener�y Imulation , � � � � � Lmh/Drywall— „ ,1 . . interior � � � � � • Lath—Exferior � � .. �� .. . . "-t House Nvmber— � � . . . � � . Correct 8 Posted ' � - � � � ' Final— • . . . � . Enter on Front � � � - �