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HomeMy WebLinkAbout1271A 1272A � .��r. r MPENSATION DECLARA710N ,r , �� .. . :.... .... �. . . .. . , . , ,.., .., _-.. ..... � ORK�RS'C6_ .f,� . . . . . . . I have a certifimfe of consent.to self �.� pp��CATIO�N����-FO�I� BUTL�IN�G��-P�ERMIT�- � � � ,�^fiereb nf m that I i. sure r a c tifimier'of Workers'Compensation Insuronc . o rtitied o thereot(Sec.3800,Lab.C.) COUNTY OF LOS ANGELE$ BUILDINCr AND SAFETY .r � � Na . Company�. � _ . __- � � ' cerafi d mp is here6y furn�shed. FOR APPLICANT TO FILL IN Buu°iNG ' ' p ADDRESS �/ i� Certif d co y is filed with ihe tdunry building inspec- � gUIIDING � �� � � � � �-- - � � ion epar enf. ADDRE55 ,j/Y;:�� � ��` Yy", ' � ' ... _.. ... . � p � . . . . .. . ... . . . .. . . .. � �ai � Appliconi � CITv � s ' , ZIP LOCALITY ..� , 'i �,,. CERTIF ATE OF EXEMPTION FROM WORKERS' SIZE OF LOT �NOW ON LOTS �� � C OSSSST. � � � � + - COMPENSATION WSURANCE . - ; {This secti need not 6e completed if ihe permit is for one �� � " ' - --�-� � � .� . � - AS$�SSOR � � �� - - �R hundred ollars($100)or less.) TRACT BtOCK LOt NO. MAP BOOK �PAGE �PARCEL /���_ TEL . - � � . . ' - . . . .OMNER ..�. (,..d"JIr'L�y I7��t . .NO:� ` 'r USE20NE � �MAP ..." . 1 ce thai in the performonce of ihe work�for which ihis NO. , - �it is issued,I shall not employ any person in any manner 7��,�, � �j��y - � � SPECIAL - �� - �d so as lo become subjecf fo the Workers'Gampensation Laws. - ADDRESSc:.K-�� � -� . - � '/(i�V - CONDITIONS Q . . .. . � . .C4TY.�P�'. ��._._. ZIP. �.��V� � V �Dais - � APPlicani � i _ . _. _. .. . . . . ...._ ... . . � ARCHITECT O[2''� " - aJOTICE TO APPLICANT: If, after making this Ce?tificate of `r � TE�' � ' " ) .DISTftICT G UP TYPE FIRE PROCESSEp BY. �em tion, � ... . ENGINEER_ �a�1�9 � , � NO.Z��`lZ€3�� y CONST.e t � � p you should become sub�eci to ihe Workers' , �. y , ,ompensation provisrons of ihe Labor Coda,yoo musl tarth- qDDRE55c�.��G, � �� � " ��/ � �j � wiih comply with such provisions or ihis permit shall be � -- - -- TE�--- � qpT, CONDO � deemed revoked. � . . CONTRACTOR � N� ._ STATISTICAL CLA�,54F �.1 � _ LICENSED CONTRACTORS�ECLARATION -- -- � � � - '��' '" -� � � LIC: �� CLASS NO. �flOJELL�.UNITS I hereby affirm ihat I am licensed under provisioos oF Chapter 9 ' ApDRESS NO. (commencing wifh Secfion 7000)of Division 3 of ihe Business and , . . SEWER MAP � � � � Professions Code,and my license is in full force and effect. CITY �' � � -�� � � - -LIC.-� � - . . . C�aSS.... . ..� � VAUDATION . ..� . 5(a:FT.... .... _.NO.OF NO.OF CHECK BK. pC. ' LicenseNumber LiaClass � - �� SIZE STORI€5 � PAMIUES � � ONE��� �� . � � � � � -- VALUATION � � � - �ESCRIPTION OF WORK " - �"- ' ' ' NE�' � _�I�z (:1 A .� Contmcror � Date ❑ a. � , 'T�� �^�' ADD �I om exempt under5ea -������'"�"`L�E;Z,y. � ��-Ut� - �-- ❑ - � t e z - . - ALTER h' °r�' . 8.&P.C.for fhis reason . . . REPAIR ...S - . . .` . .. � ' � ? �1 �L� � Date: USE OF � - `� � � EXISTING BLDG. DEMOI ' gY � � P f - ''���yJ� � APPLICANT �t�,,,.., �,J.� _. _. .TEL ��. ..FINAL�� . .. . . Z� .~7.O S= 9 � RATION_"_`.�"'�.�� PRINTI C,3M'I�t� 17Z�i' �IVO���t'+'��..... .�AT � J 2�G"�l�) Si nature "2 NER BUI�DER DE � I here6 affvm-thot I am exem t fr� the Contractor's License y �� � � � �- � - Low for the fallowin �reason Secfion 70.31.5,Business and ADDRESSL Z � �, %�l' ��� F��A� � � . - . � -_'.'�fessions Cdde)� � � PReset�i..... . _ . .. .. .. By, ._,.. . . . . . . . . .. . . � 1 BUILDING I, ps owner of ihe property, or my employees wiih ADDRE55 . : , ;� wages as their sole campensation,will do ihe work and . ..... .-. ... -.. . -. .. . .. . ,= . - .� ,•;;.� -. -.. ihe structure is nol intended or offered for sale(Se<tion tOCALITY , �. . - . 7044,Business and Professions Code). � -�- MOvwG � -� - - - -- ieL -- - ��-� ' -- � �-- �� 2�.�F �� � I,as owner of fhe proparly,pm exdusively contractinq CONTRACTOR NO. , �with licensed-contrauors to construct tke project(Seo- . . . . . - - .-... .--.. ..----.. . - . . .-.. .. . �� s r. m a.�. . tion 7044,Business and Professions Code). ADDRE55 . ' � REQUIRED .TOTAL SETBACK FROM . i:. � . � I � H E?`f. ��j � -CONS7RUCTION LENDING AGENCY � � SET BACK YARD �'HWY PROP.LINE WI�TH� i; � i�� � � -. � I fiereby affirm thai ihere is a construction lending agency for PRONT � �°"'i.^"�� � ! pv h C ^,,C Z ... tbe formance of the work for which�this � � " � �-, per permit's issued P.L -. .. . -, .. _ _ _... .. .... i.� -., (Sec.3097,Civ.C.). SIDE � G��_�� . � P.L. . . _ . ._.. _.. ... . .... .... . > Lander's Name - � � � � - '�- � � - � " a.""� L�MA Ref.N .: - . ' � Lender's Address � ��-' - � P-C.Fee$ ,. -,�',�' -- Perm t Fee � �a ,� � �+ � � . _ I certify that.l.have read ihis application and state that.the . . h' {� - - � -hs�ance Fee � -IDMA-P/C#/ . ' M a6ove information is correct.I agree to comply with all Counfy � � ` � � ' - � _ "�� � ordinances and State Iaws relafing�o building conslrucJion, . . ' ��Cf 4?v... 7omlfee-�- � �- �- ond hereby outhorize representatives of ihis County to enter - LDMA��Perm.# � � - � � . .. ...., . . . . � upon t above-menfioned property for inspeclion purposes. .h� q - • �p /// y��,'� /(' �SGz.�st.. ./ .._ ... � a j��� ��� �-' l.� � I�'(P���i �� SEE REVERSE FOR E%PLANA70RY LANGUAG� o� . . . . . .. � ... . ^ �Signature ot licant or Agent Date . - -� �--��""� � � . . . . .. . ._. - _ . _ . ( YLANS TO APPLICANT INSPECTOR'S NOTES � ..OWNER-SUILUEA,D�GLARATION , . . I hereby affirm that I am exempt from Ihe�Coniracior's - To: Ret�rned �� � - ��License Law for ihe following reason. (Sec. 7031.5) . . . . . .. .... APProded . .�Bu,siness andPrqfessio2e.a Code:Axycity or�cvuntp"u�hich No. Da}o No. -�����DoYe' �-� � . � -. � �- . . requires a permit to rnnstruct,¢lter,im¢mne,demo[uh, - .,.., � �_:� .;�,;, �. „ ��, .� �.�', or repair any structure,prEnr w iEs issuance;miso requires - '� . . - . � � _ � , � . � tl�e appldcant fnr surb permit to file�a.signed statement � � "'"`��- "� "��� � "� . tbmY b,e u liccnsed[arsuant to the pravisdons of tbe Coii. � � � � � tractor's License Law(Chapter 9J lcommencin,�.mith Secr :,� �� � -� �' � . � ��� � � � tion 7000J�f Divisiox 3 of Lhe Businesr and Professions � ' � �. � � CodeJ or that he is aroempt therefrovi axd the busrs for the � . � - . ''� alleged exemQtiom.Any vEolulfort of SecEion 70315 by . Reguired �DateReceiveSl� -- �- � - -- - � - anyupplicantforapermitaubjects�Yhe�upplicanttoncivil Approvols or Approvefl Qenulty of not more tban ffve bundred dollars(S'S00J.J: � � cYos No ,.., " � . ... ' _. � . - . . �--�- "'�� - �� �� .. ��� � �- � ' ���-" � - � ❑ I,as owner ofAhe property,or my employees wiYh Water Certificate � - � � . wages as iheir sole compensation;wi�l do the work,and - ` � . � . the siructure is not intended or offered for sale(Sec 7044) Heaith Department . _ � .. . � ... ... � ��. �� �- '�.� -- �:-� -�-.." � . � .BusinessandProjes;ions.Code:Tfie Coniractor'sLicense � . � . � � Law does mot apply�ta an owner of property who builds Fire.Qepartmem .. _ . . . . ,� �-� �-�- ���-- � �� - -�-� �� - -�- �� -���:. or improves t5ereon,and tvfio does sucb euork bimaelf or � � � � � �tfirougb,h(s own employees, provfded that sucb inpF, �'� � � Grading " -- - �: pr U menn�are xot intended or ffered for s le. ' bouen�er,tbe buiLding�improve»eent is�odd wdPhen o�� � Geologi�al . � - .-.:: . . �- ._�� �.�. '� ..- ' � .:-: year of completion, tbe nurreer-builder well bave tbe - - - berdett of proving tbat he did not bufld or impmne jor � � _ � _. . . . . . .._ . ._ .��_ .t� tbeprj. _ f.s¢leJ. � . . , � �-' '�� ss ose o � �� P.ederif+anProtecPion . • - �= L] I,asowheroffhe (Fence)(Canopy} � �� �� , � -� -- - ---���� �� -�-� � pcoperty,qm excl�sively mntrar � . - `�1ing with IiGensed contractors to construct ihe project(Sec. . Spe<ial inspection " 7044)Bussness and Professeonr C dc 7he Coretractor's �3 (Conc.){Masonry){Welding) ��� _ - , � . . _ Li Pn I w�oec not pfly L wne Jproperey u�ho t ;.. , � &u ldc nr:'m�prnve.v thereon,arid-who rnntracts jor ruch ` ro cts with n contracto s licensed ursuanl to tAe Lor Droinage� . . _ . . . . P l ... �l P . � � � , �� -Contrac[nr's License Law�.� � � Parking . , ���. . ; .:.. . . .. _. . ._. . .._. .. .._. . ;. .... . . .. � ❑ I am-ezempt under Sec. .,B.BP.C.for iFis � G/ �! . "�"'� `. ;, .. . . . . _._ . . . . � ��� reason . .. .. ... .. . . . .. � �+f �/Stll,!^� � e�'�,/7� !/�"C./ „' "a)�'�i'Y 1.. �r�–UP�,T.,.–/��,.. ., � Date . . _ � . . Owner � .. 4 APProvals Date Inspector's Signdture ` - �INSPECTOR'S NOTES�� , ..� , .-.,.,, , _ ,,, .. r : C�a locaYion— . . . ... , . ..� • �. . . v.l +":_: �.. FSetback&Yards) . .. . . . . .. . .. . .. oundations � �� ' � � �` Slab _ _. _ _ . .. . . . .-.. . y . , -.. . . .. . . . � . , . . . . _ . �,c� Frame �..: . ... � . . �. _ . . . . 3,. Ener9Y..lnsulation �- .-. . .. . .. .. . . . Lath/Drywdl— - , _.. . . _ ._. . . .,��: . . . ., �, . '� . .. � . .. . Interior .. . ... . . .. . ... . . .. . �.Lath—Ezterior � . :: t.i . '. .: _ �".._ ; --G ' ' .� ' ... _. ... . . . . . . . . � House Number.. :.. . . . ., _ � . _ . ,. ,. .. - ... . . . .. . . - . Correct&Posted � - " � � � � Final— . ......-. � .. . _... .-. ����. :-,.,� _ ..-...,,.... �. . . . . . . - Enter on Front � � ' � - � � � � �