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HomeMy WebLinkAbout1690A _ . —'" _'_.T,-,..__""_.....---.��-_.._.. . . � . . . .. _ . . , WORKERS�COMPENSATION DECLARATION .. .. _. _! . . . _ , ^ _ . .�. . . . . . _. . .. ' .. 4—��—'�� - .• I-hereby afhrm�thot I have"a certificate of consent l0 5e�f . _ . �. .. A P�`''��I�AT I O N' F O�R B U I L D I N G P E RMI T � insure,or a certifimte of Workeri Compenslion Insurance,ar � a certified capy thereof(Sec.3800,lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Polity No. � Campany � Ce���fied copy is hereby furnished. . FOR APPLICANT TO FILL IN . ! Aooaess r� .� i,,.�.r[� � �Ceniiied�copy is filed with the county build�ng inspec- eunoiNG � � � tion�deparfinenl.� - � ADORE55 �� .� LOCALITY � ��-�i ,.{/,� / Dme � � � AppllcaN � �-� �- U7V ��ly.a/� Zlv •���6' fR055 57. �-.c/ G/La-.�.�--[/ � � �CERTIF�CATE OF EXEMPTION FROM WORKERS' ' � � NO.-OF BL�(35. �, ASSESSOR . - , � � � �COMPENSATION INSURANCE� . - 512E OF LOT . NOW ON tOi � MAP BOOK � PAGE PARCEL (Thls seUion need not be completed if the permit is for one� �,`.�f u5E 20NE �P '/ � hundred dollars(E100)or less.) � - , TRnCi �/�3 BIOCK LOt NO. � �,� NO. � l� �.�TS } TEL. p SPECIAL a � OWNER G' • � .c�C/�f/ NO. - d �`�� CONDITIONS I cerlifyihot in the performance of the work for_whith this . � u � permif I5�ssued,1 shall no1 employ any person in ony manner / OISTRtCT GROUP TYPE . . FIRE PROCESSED BY ADDRE55 � U (��'�-!fY �� CONST. ZONE so as to become svbject to��he Workers'Cam ensotion Lows. . . O `p �j � . � � C .�—�-.G= �..�•- t�� i/7l.� ` 1G a,u-e'" ° �ate Appli[ant � ��TY ZiP STATISTICAI C1A551FICATION � APT. CONDO. �J ARCHITECTOR - .� � . � TEL. - �NOTICE TO AGPLICANT: If, ofter making this ertificate of ' . --, � � � w Enemplion, you Should betome Subje[f fo ihe Worke�s' FNG�NEER. NO. CL455 NO. 2- DWELL.UNITS � G. Compensa�ion provisions o(�he Laboi Code,yoo musi forth- �� qpppE55 � � � � sewea n�nr - Z wilh comply wilh such provisions or ihis permit shall be ' . , � '�� � ,- . deemed revoked. . . . . Na s"lI.�C s' , gK, p�, � � VAUDATION� � CONTRACTOR ' L� �• . �� LICENSED CONTRACTORS DECIARATION - ���'3��JI�I� � � � I hereby afflrm thor I am Iltensed onder provisions of Chopfer 9 . .. _ qDDRE55 ,r.� /�.,IS NO. VALUATION � . - � (commencing with Sec�ion 70D0)of Division 3 oi ihe Business ond ��� ��.�1 � - �Protess�ons Code,and my license is in full 4orce and eNec1. air � CLA55 ���� E �9 s��� " , � � � � � ��p�( I�I . �.� SCJ.EFT.//7 J�5 ORI�E$ F MILOIES CONEK . . ..� . � . Uce�nse Nvmber �l�C.Class �`� . . ��' /J� . . . � � 5 . . - . ConlroClorT�.+ G L�/ pa�e -7����Z � DESCRIPTION OF WORK y NEW .❑ - � � . � ADD � . I am exempt from the licensing requirements os I am a � licensed archifeU or a regislered professionol engineer _ . � ALTER � F�NAL L/ . - � � � - ..oCting in my professional [apacily (Secfion 7051, REFAIR � DATE T� y� � � Business ond Pwiessions Code). , USE OF FINAL� /` �� � � � - � ExI57ING BIDG � � - DEN�OL ❑ gr `(_, . / . � � Lic.or Reg.No. �ate APPUCANT TEL. � �CLLf.�-e^-� . . . . , � ��-� ' � � OWNER-BUILDER DECLARATION � '" ' PRiNT1 � - � � - ' � �NO. � ' � - , I hereby offirm ihot I am exampl from ihe Contratlor's license . . � . . � �. � Law.for the following reoson(Section 7031.5, Business and ADDRE55 � - ' Professions Code): �. , GRE EN � 2� 6 9,Q A ' ..❑ - . . . . . � BUILDING _.. .. . _ . . _ . � .. , � , I, as owner of�Ihe property, or my employees with � qoDRE55 '�.� � � � �..� woges os fheir sole compensalion,will do 1he work ond � . � �� Ihe structure is not intended or oifered for sale(Secfion � LOCAIiTY � � � " „-�1_j� � � � ,, 7044,Business and Professions Code). MOViNG TEt. � ' � '��1`` �' ���.�� 2 7,Jr' Q � �. .�� I,a5 owner o4 the property,am extlusively contratling '- CONiRACiOR - .NO. - . � - � - - �_ ��. wirh licensed controctors to mnslruct the project(Sec• �, - _(-- •�.�� 2 7.`5�� , . � tion 7044,Business and Professions CodeJ. . . ADDRE55 � , , , _ � CONSTRUCTION LENOING AGENCY REOUIRED YARD HWV T�TAL SETBACK FROM�, EXIST. -' � . O�O� "H 2 : SET BACK PROP.LINE WIDTH . � - � I hereby offirm tha�there is o consrruction lending agency for- FROtvi � . . �- �'y � � - � � � '� .� � rhe performance of the work for which this permii is issved P.t _ � � � � � . (Sec.3097.Civ.C.1. . . . . . _ . _ SiDE . _. . .._. . � . . . �-._� . . ,"�...,'._ . . � , . .P.L. _. . . . . . � , Lender's Name � � �I � ' �'�'� ' ' � � � tender's Address P.C.Fee 5 . .... . . .. . Pe�m�r Fee � . F�� - . � . � � � .I certify�ha�I have read this application and slole thpr the Isw re Fee 0�.•.SU � . � e abova informafion is correct.I agree to comply with oll Counry . � imesrga+on fee_ . . / . -. ... , . . . . . - _ ; ��ordlnonces and Sfa�e laws relaiing�o building mnslruction, - Toial Fee Z7•`�� ' � � .� . and hereby authorize representafives of�his Counry to enter , . ,. . �. '� upon�Ihe obov nti ned p per y r mspection purposes. �� . � . � . `y' ' � � i�,� � _ � i'. J . r �.�r�- �hg� � � � SEE REYERSE FOR EXiIqNATORY LANGUAGE�� ' - ' " ' Signoture of Appl� �or Agen� �oie � . . ��� . .... . . . . • � i PlANS TO APPLICANT . ^ ' � � INSPEC.OR'S�NQTES O�YNER-BUILDLR DECLARATION . �heroby aifirm thot i am exempt from the Contracfor's To: '� �� Returned ' � ' � � Lttense Law for tho following reason. (See. 7031.5) � APP�evQ� . HusinessandProJcssionsCodc:Anyrityorcountya•hicb � No. - - Dato - �--- � No. �� ��� Date �- -- - � . - , � - • �- . � -regreires a pern�it to eonstrucf,ulter,improoe,deniofisG, . . . , , orrepairanystracearc,priortoitsrueanro,afsorequims . � � . -' ..- � . .� - . ..... . - - .- .. '- .-- .. - -. . - tGe applicant Jor sucG pernrit to Jile a aigned staten�ent � , . tGat Le is licensed purossant to tbe proroisioru of the Con- -' ��'� �-�; � � - "' � '� - �� - traclnraLicensel.aw(CLapter9J(conrm¢ncrngwitbSec- ' ' � � � ',. � -' � tion 7000J of Division 3 of tbe IIusinesr and ProJessions �-� ' � � - �� - � . CodeJorflatGeisexemyttGerrjromandfbebasisJartbe _ alle,qed exemption.Any vrolaLran of Section 7031.5 by � �.aqutrod pateRecatvad � . � � � � � anyuppficantforapermitsubjeclstGeapplicanttoacicri! � - AAFrovala - . - er Approvod � . pcnalty ojnoi morc tban jive bundreddolJars�(SSOOJ.J: Yes No � � . _ � . � ❑ I,as owner of fhc proparfy,or my employees with \'laler Certific6le '�, wages�as their sole compensotion,will do the work,and . � ' � ' - �. � the structure is not in�anded or offered for salo(Set.7044) •�Busixess and Pro essions Code:T'be Conlractor's License . '. �� � . . _ � - ' Health'DepoNmant, '�' , ` . .. � � ._t.., _ . . .. . f .. - -.. . - -.- ... . - . `�•'.- .. _ � ' . ' .' 'L¢ru docs not apply to an oayrer ojQroperty wbo builds FireDepartmont , . orimproocstbercon,andwGodocstsscbworkbimseljor - � � • � - - - � througb bis omn emQloyees,J�rovided tlot aucb im- Grading � � � , � J�rovements are not intended or offered for sale. I/, . - - . � - � bou�eoer,tGe buildrng orimprot�emcnt issold witbin one Goological� � . _ � , . . . . � _ . . year oj eompletion, tGe owner-6uilder wilJ bave tbe - . � burden of proving tbat be did not baild or improceJor Pedeshfan Prolection . � . .. - �tbe parfiasc of aalef. � ' . (Fence)(Canopy) � � � _ . . ' . ❑ I,as owner oi the properiy,am exdusively mMrac- , � tirg with licensed coniracfors fo construu the project(Sec. Spedol Inspection � ' ' � ' ' � 704d)IIutiness and Projessions Code:Tbe Contractor's (Conc.)�Masonry)(Welding) , . . , . Zicensr Luw dors not apply fo-an ou�rrer of�r�erey wl o - 'buiJds or inrproves tGereon,ond fubo contratts for sucG Lo1 Droinaga , , . , -frrojeCls Wilb a eontractor{sf liccnsrd purirsant to ibc . . . - ._ . � . . . Contraclor's Liccnse LaaJ. . Porkin9 ' . . . . .� . . . . . . . . _ . .. .. .. . �❑ I am exempt under Sec. ,B.BF.C.for this ' . . . . . _ . . _. reason . � �ate Owner ri t t P�i�YP�s Dato Inspector's Slgnaturc � � � � � �� - � INSPECTOR'S NOTES ' Location— _ . . . _..- _ .. � . . . �se�ba�k��ra�a�i+ Fodnd'otlons� ; 1 �- �� - � - �� � . . • 87a6 i)'i'.� � • � � . - . . . . . Frame'- ��J :U a � .. . � . . , , Enerqy Insulation ``' (�� fl . . .. . . . ' � . . . . . . w��Jci Lath/Drywoll— , . In}erior � ��- � Lmh—Exferior �� � __ _ . • . . ._ ._ . . . House Number— � , � ' . , . . . . Correct 8 Posted -� - - � � � � � Final— � �� � �� Enter on Front � � fa—��