The URL can be used to link to this page

Home My WebLink About1287A 1288A (6)_ WO 'COMPENSATION �3ECLA,R'ATION _ h �by ff fh have a certficateof_coseni�,tq s p yy�� ®� ��( R�� PER in urr ert,fica of Workers' Campensat on Insua e, /"1r `` Y LVV/ �VV7 rr0 o copy ih reo4 (Sec. 3800, Lab. C.) COUNTY OP LOS ANGELES BUILDING /PND SAFETY ohc Company - C _opy is hereby furbished.: Certified co is filed with, the county building' inspec- tion dep meet. - - Data --Applicant CERTIFICATE OF EXEMPTION FROM WORKERS -' COMPENSATION INSURANCE �'''"- (This section need not be completed if the permit is for ,one hundred dollars ($100) or less.) I certify that in the performance. of the work'for which this Permit is issued, I shall not employ any person in any manner sous, to become subject to the Workers' Conspensaflon Laws. Dote - Applicant OTICE TO APPLICANT: If, after making this Certificate of f"' 1^mpton you should become subject to the Workers' npensatton provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed.,revaked - - LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisio, s of Chapter 9 (commencing with Seci ori 7000) of Division 3 ofihe Bus ness and Professions Code, and my license is in full force and effect. _ License. Number Lic. Class Contractor Date , I am exempt under Sec. B.&P.C. for this reason Sigeature : : - =— OWNER -BUILDER DERATION - I hereby affirm that I.am exempt fro the Contractor's License Low for the following reason (Section 7031.5, Business and Professions Code): I, as owner of the property, or my employees with wages as their sole compensation, will do the work and _ the structure is not intended or offered for sole (Section `7044 Business and Professtons Code'): _ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). - - CONSTRUCTIONLENDINGAGENCY_ - I hereby affirm that there is a construction lending agency for - the performance of the workfor which this permit is issue (Sec. 3097, Civ. C.). Lender's Nome Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, ... and hereby authorize representatives of this County to enter FOWAPKICANT TO FILL BUILDING ADDRESS BUILDING ADDRESS 21 CITY wy Lf ZIP LOCALITY .- NO OF B{DG$ - ..... . -_., NEAREST - - ._._ - ".'.... .., ........ - -.- SIZE OF LOT NOWON -LOT -' CROSS ST e TRACT - BLOCK __,._ .. _ LOT NO. �J,° ASSESSOR MAP BOOK PAGE . PARCEL OWNE l N t' U E EIJ MAP - ... C �� _ FECAL ADDRES -44 IV CONDITION p` CITY ZIP. ARCHITECT �- NEER tri ENG L - TEI `++ NO� .�S DISTRICT, GROUP_ TYPE - n' CONST FIRE ,.. PRO SSED.BY �C. j�y.. _5 ADDRES�?g f: � -- " "- -"-- CONTRACTOR -TEL `' NO STATISTICAL CjQ.S IFI TION A CONDO. - - - - -LIC: CLASS NC6,eSDWEIL UNITS ADDRESS NO.- ... _., SEWER MAP CITY - LIC �. - .: CLASS BKS. �.- VALIDATION -- 54. FT. NO. OF NO OF ,. CHECK -� % A- 5 IZE -- STORIES FAMILIES ONE - -... . '," .. _ _. VALUATION _ .� ..... 2 S DESCRIPTION OF WORK" - -`" "' - - - NEW s � ADD 4✓4.d-� , I I, 0 1 8 7 3 ALTER.... REPAIR ❑ _ $ USE OF _. DEMOL ❑ >-, 1 2 2 2T 8_6 EXISTING BLDG _ APPLICANT -� 'c' TEL+FINAL �� ZNO t -+.s-iG. -P ':. .. ,. ADDRESS .-% FINAL .... PRESENT .! -... _. By _.... -_ _ ._:.. _`._ 1 t2 0 4.0 01 LOCALITY _ .TEL ,.` 2 — 8 MOVING CONTRACTOR NO ..) 2 G ADDRESS ..REQUIRED TOTAL SETBACK ___- - SETBACK YARD' HWY---, - 'PROP. LINE - WIDTH - - - - - FRONT. P.L. SIDE P. L. J`p _. ... LDMA Ref. P.C. $(�Fee1C 7-3 s PermtFee,,aaqq 4/ Issuance Fee e - Investigation Fee 'LDMA It' - Notal Fee .. s Perm. CL upon't a above -me tf: roperty for inspection purposes. � �+- /-- 7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ap i - t or Agent Dote .. INSPECTOR'S NOTES OWNER-UUILDER DECLARATION-,.. PLANS TO APPLICANT I hereby affirm that L am exempt from the Contractor's To: R'etumed, - - - .. - 'License Law for the ;follow ng reason (Sec. 70315) .. _. ,. - ,. A roved PP - „ ,.. - Bussness'and Pro essioves Coder ... • � f �Tny city or county tubicb No. Date `"• Na. " "Data' ":<'- _- - -. - - - requires a permit to construct, altar, improve, demolish, or. repair any structure, prior to its Issuance. also requires the applicant J r such permit to file dsdgned statement that he is licensed pursuant to,tbe provisions of the Con- - - tractor's License Lain (Chapter 9) (commencing with Seg- - - tion 7000) of L)ivision 3 of the Business itnd Professians �uf ine alleged exen:ptso Any violation of Section 7031.5r.-fbe _ _ Requited. Date Reaehiiod .. .._; any aPplicand for a permit subject'•, tfie. applicant to a civil A roJals PP - or Approved '- penalty of not mare. tban five hundred dollars ($500).), ' -' -Yes No ,, .: .. - ❑ I, as owner of the property, or my employeez with y^ Water Certificate.. wages as their solecom ensation, will do the work, and 9. , P --"- the structures not intended or offered for sale (Sec 7044) BusinessanJ Pr fessioni Code: The-Contractor's L cc se Law does not apply to an owner of property who builds Fjre. Deparim ent - -- '- ` -- - - -- - - - or improves thereon, and who does such work hintselfo r ' through his own employees, provided that such ;m- Grading - ., - - provements,: are not intended or offered for salgo''�' ;.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 build ar improve for Pedestrian Protection ;,-. '` the purpose of vale). (Fence) (Canopy) - - - ❑I, as o ner of the property, am exd6sWely contrac- _ construct the project (Sec - i Ipcon 704)BsinsdPofesnCde The C6nractor's5petiaf 4anowner �!1 (Conc ) (Masonry) tWelding) doeapply ofproperty who - - - - builds or improves thereon, and who contracts for such Lot Dra nage - projects with a contractor(s) licensed pursuant to the - - - - - t- j - Contractors license Law).- ❑ I am exempt under Sec. , B.&P.0 for fhI's . �/, 6/�%f J 7"- •�.--s' __ __. ___... reason .. .. Date Owner : _. Appr6vals Date Inspector's Signature.' - INSPECTOR'S NOTES - Lomfion . - ;Setback & Yards) -- -- -.- Foundations . • ... ? Frame o✓ Energy Insulation .. . ,.. ..,. ., ,:,. ... .,,.. Lath/Drywall— Interior Loth—Exterior House Number Correct & Posted - Final— Enter on Front--