HomeMy WebLinkAbout1287A 1288A_.. _ ..
WO 'COMPENSATION bECLA,R'ATION
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�by ff fh have a certficateof_cosenitt?s■ ��CT�®� FC+ BCJfLC�rIVG�-PERMITin urr ertifica of Workers' Campensat onInsua e, _o a copy th reo4 (Sec. 3800, Lab. C.) COUNTY OP LOS ANGELES BUILDING /PND SAFETY
ohc Company -
C _opy is hereby furnished.
Certified co is filed with, the county buildinginspec-
lion dep meet. '
Data --Applicants -
CERTIFICATE TSF EXEMPTION FROM WORKERS
"COMPENSATION -INSURANCE
(This sect ion 'need not be completed if the permit is for ,one
hundred dollars ($100) or less.)
I certify that in the performance- of the work for which this
Permit is issued, I shall not employ any person n any manner
sous, to become subject to the Workers' Confpensalion Laws.
Dote - APPlicanf - .... _
OTICIE TO APPLICANT: If, after making this•Certificafe of
I"' �^mption, you should become subject to the Workers'
; npensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be -
deemed.,revgked -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 ofihe Bus ness and
Rofessions Code, and my license is in full force and effect. _
License. Number Lic. Class
Contractor Date ,
I am exempt under Sec.
B.&P.C. for thi reason
- _. ., ate:.., -
Sigedture -- ;=—
OWNER -BUILDER DE RATION
I hereby affirm that I.am exempt fro the Contractor's License
Low for the following .reason (Section 7031.5, Business and
'Professions Code):
I, as owner of the property, or my employees with
wages ds-iher sole compensation, wil I do the work and
the structure is not intended or offered for sale (Section
`7044 Business and Professions Code'): _
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code).
- -
CONSTRUCTIONLENDINGAGENCY_ -
I hereby affirm that there is a construction lending agency for
- the performance of the work for which this permit is issue
(Sec. 3097, Civ. C.).
m
Lender's Nome
m Lender's Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
m ordinances and State laws relating to building construction, ...
and hereby authorize representatives of this County to enter
FOWAPPLICANT TO-FILL1�('
ADDRESS
OUILDING
ADDRESS'
f 2e^
CITY wy Lf
ZIP
LOCALITY
NO OF BLDOS. -. ..... ..._.,
NEAREST
SIZE OF LOT
NOW ONLOT-'
CROSS ST
- _
TRACT � BLOCK
LOT NO. f�f__
ASSESSOR
MAP BOOK
PAGE
PARCEL
OWNE
U E _.Eo MAP
NO
C
PIC L
ADDRES �' �'
- 4�
t CONDITION
CITYZIP..
72:74.5)5
2 74. !• _
Ji
ENG ERT L' trim
-NOT�.�S �^ ,',�' ^,
. DISTRICT, GROUP_ TYPE
n CONST
FIRE_,..
ZONE
PRO SSED, BY
7
"- - " -- ---
CONTRACTOR
- - -TEL `'
NO.}-,
STATISTICAL C IFIFI TION
A CONDO.
-
- -LfC: `
CLASS NDWELL
UNITS
ADDRESS
NO.
_
SEWER MAP'
-
CITY -
.
LIC
- CLASS
BK.�.
VALIDATION --
SQ. FT. OF -
NO OF ,. CHECK
- -
� % p -'
SNT
SIZE -- STORIES
FAMILIES ONE
- -...
.•"' %,+
- -.-
-- - -'
. VALUATION
- -
-`�` ..... 2 S
DESCRIPTION OF WORK" -
-`" "' - - - NEW
--'
s
ADD
4✓4.d-�
,
I I, O 1 8 7 3
- - ALTER
- -
.
REPAIR
USE OF
DEMOL ❑
> .. -.. .,
-,
2 2 2T cg.
EXISTING BLDG
_
APPLICANT -� 'c'
TEL+
�� NO t Z "+.s-iG.
FINAL
-P
-'.
DATE .� � ,.
..
,.
-
.j . a m. P•,®-'.1
ADDRESS —? ezl
FINAL ..-
LOCALITY
'TEL
MOVING
CONTRACTOR
NO
..I 222-8
ADDRESS
..REQUIRED ,TOTAL SETBACK ___- -
SETBACK YARD' HWY---, - 'PROP. LINE - WIDTH
- -
- -
- -
FFRONT
LDMA Ref.
yqssuance
Fee 4°' e -
ion Fee
70
_... ... "' .
... Total Fee
P.—
upon t a above -me tf. roperty for inspection purposes. _•'} G
a / r?`—/.6 SEE REVERSE FOR EXPLANATORY LAN UAGE
Signature of Ap i - t or Agent Dote
CL
..
INSPECTOR'S NOTES OWNER-IWILDER DECLARATION
PLANS TO APPLICANT
-,.. I hereby affirm that I am exempt from the Contractor's
To:
+-
R'etumed,7A0prdWed
- License law for the;follow ng reason (Sec. 70315)
..
,.
;
„ • �f tinycityorcountywbicb
- Busrnessand Pro esionsCoder
No. Daee
`• Na. " "OaYo'requires
a permit to construct, altar, improve, demolish
orrepair any structure, prior to its issuance. also require s
can
the applit for such permit to file a signed statement
that he is licensed pursuant to, the provisions of the Con-
- - tractor's License Lain (Chapter 9) (commencing uith Seg-
-:
- tion 7000) of L)ivision 3 of the Business irnd Professions
-
_
Code) or that he is exempt therefrom and the basisfor.-the
alleged exemption.. Any violation of Section 70315 by
_
Required.
Re uir_d._
r; g p licand o a ermrtsu ec
Approvals
orfAppoved
y of not more than five hundred dollars ($c500).):
"� penaltyo(
Yes No
otnerofbanfiehiadreapplicanttoacivil
_
- - - - ❑ y, or my employeei with
�^
Water Cerhficale..
". wa es as their sole. compensation, will do the work, and
- 9. P
--"-
the structures not intended or offered for sale (Sec 7044)
Heglth Department
-
_ ....,._.... .„. ::... < .._ ,:.. Business and lsrfes,i.ns Code: The -Contractor's L cc se
Law does not apply to an owner of property who builds
Fjre. Department
--
--- '- • -- - -- - - - or improves thereon, and who does such work hintselfo r
'
through .his own employees, provided that such sm-
Grading - .,
- -
provements,: are not intended or offered for salg)''�' ;.gp
-.
-
- however,. the building or improvement is sold within _
-
Geologroal
year of completion, the -ownenbuilder will have �he _
.... burden o/proving that he did not builder improve for
Pedestrian Protection
;,-. �:
the purpose of vale).
(Fence) (Canopy)
- - - ❑I, as o ner of the property, am exd6sWely contrac-
_
pt uct the project (Sec
Spatial I ct on -
7044) B sin Code. The Contractor's
d Pofes on,
�!1
,'
(Cont.) (Masonry) {Welding) -
-. does apply owner ofproperty who
-
-
-
_ -
- - builds or improves thereon, and who contracts for such
-
”
Lot Drainage
-
projects with u cnntractorls) licensed pursuant to the
- - - - -
t_
j
- Contractors License Law).-
- ing
_34r"
- ❑ - I am exempt under Sec. , B.&P.0 for this.
,ir/'6/�%f J 7".- •�.--s'
__ __. ___.. _ reason .. ..
Date Owner
�� �
.'9'v /—..�s''� �' •�
__ _ .... ..
APPr6vals
Date Inspector's Signature.'
-
INSPECTOR'S NOTES -
Location
.
-.- :.: •. .•. ..
-
;Setback & Yards)
_ _
- --
-.-
Foundations
- c- - --
Frame
o✓
Energy Insulation
Loth/Drywall--
Interior
Lath—Exterior
House Number
Correct & Posted
-
Final