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Home My Public Portal About9327 BLACKLEY ST_Building__ WORKERS' COMPENSATION DECLARATION V`I hers'v affirm that I have a certificate of consent to self insure,or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or g certified copy thereof (Sec. 3800, Lab. C.) _ COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N'o., t Company `LI� JG' ' BUILDING ❑ CC eified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS E----Certified copy is filed with the county building inspec- BUILDING� tion department. ADDRESS ;5,z,7 _.t!�0Y Date Applicant CITY' lim— Cj ZIP l 7 LOCALITY G NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. J S COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT' BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) ` ` TEL. OWNER J 'V � NO. ' Q�j- USE ZONE MAP I certify that in the performance of the work for which This NO. J permit is issued, I shall.not employ any person in any manner ADDRESSIIAI�LRV SPECIAL a so as to become subject to the Workers'Compensation Laws. / CONDITIONS O CITY { ZIPWA? U Date Applicant ARCHITECT OR TEL., � NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. _e� DISTRICT G OUP TYPE FIRE PROCESSED BY CONST. ZONE O Exemption, you should become subject to the Workers' o +� w Compensation provisions of the Labor Code, you must forth- ADDRESS J a with comply with such provisions or this permit shall be r TEL. �,.p STATISTICAL CLASSIFI ATION APT. CONDO. N deemed revoked. CONTRACTOR' O NO.&7 /Z7 Z LICENSED CONTRACTORS DECLARATION LIC. CLASS N DWELL. UNITS — LIC. hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the BusinessLIC. SEWER MAP and Professions Code,and my lic nse is in full force and effect. CITY - CLASS BK PG 07 VALIDATION SQ. FT-. NO. OF % NO. OF CHECK ry-, License Numbe Li c. Class �✓ SIZE STORIES Cs FAMILIES ONE 2-6 /� VALUATI N f�••� Contractor Date V DESCRIPTI N OF WORK ' NEW ❑ At•CT.T 01 ADD ❑ $— , 3 ❑1 am exempt under Sec. �y�7 650.^45 ALTER ❑ ITEMS B.&P.C. for this reason $ vO REPAIR +v0 Date: USE OF ❑ TOTAL £ 25 50 oEXISTING BLDG. DEMOI Signature OWNER-BUILDER DECLARATION APPLICANT TEL: 7FINAL CHECK 65 0°^' (PRINT) NO DATE 0__);rqq0_ CHANGE o00 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section.7031.5, Business and ADDRESS FINAL _ Professions Code): PRESENT. By ��-_ hi f i,r V BUILDING I Ij tJ3 '7i~%8q ❑ I, as owner of the property, or my employees with ADDRESS t wages as Their sole compensation,will do the work andC,r�i': the structure is not intended or offered for sale(Section LOCALITY 1 AM, � 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of The property, am exclusively contracting CONTRACTOR NO. 330 ?19.95 with licensed contractors to construct theroject (Sec- 7- Sec- tion 7044, Business and Professions Code.) ADDRESS ITEMS 1 Et ki to REQUIRED YARD HWY TOTAL SETBACK FROM EXIST: qtc CONSTRUCTION LENDING AGENCY SETBACK PROP. LINE WIDTH itITAE. e.. r I hereby affirm that There is a construction lending agency for FRONT t the performance of the work for which this permit is issued P.L. i•HE!:Ni ?19.'1_t (Sec. 3097, Civ. C.). SIDE {.�i r. r"y Epj 3> P.L. CQ z s r:! c.J ^ C:HANGE Lender's Name -� m C+`1 / LDMA Ref. # P.C. Fee$ rmit A � i � Lender's Address .r ) 13000-0001 9/271_11/13i 0 1 certify that I have read this application and state that the a -1 ssuance Fee / LDMA P/C# ► 5852 ) AM .too , 8 above information is correct. I agree to comply with all County Investigation'Fee ") ` R ordinances and State laws relating to building construction, Total Fee t LDMA Perm. # a and hereby authorize representatives of this County to enter upon th ove-men ' property for inspection purposes. a 7 =!E t'i -CC,,. C 1 SEE REVERSE FOR XNATQRY 6CW AGE T Si nature of licant or A Date r rn LAI hJ !a) `. WORKERS' COMPENSATION DECLARATION `I he � re y affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT . or a "certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy 10..Company BUILDING � ertified copy is hereby'furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS `� �� CITY C ( ZIP D v LOCALITY Dat Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKER ' SIZE OF LOT Q NOW ON LOT Z CROSSSST. L COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. OWNER — NO. USE ZONE MAP I certify that in the performance of the work for which this NO. permit is issued, I.shall not employ any person in any manner ADDRESS .. SPECIAL O} CONDITIONS so as to become subject to the Workers' Compensation Laws. � O CITY G ZIP !', L 7 Date Applicant ARCHITECT OR f TEL. ENGINEER NO. DISTRICT GROUP TYPE FIRE OCESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of CONS .. ZO � Exemption, you should become subject to the Workers' w Compensation provisions of the Labor Code, you must forth- ADDRESS ! �� a with comply with such provisions or this permit shall be TEL. STATISTICAL CLASJI TION APT. CONDO. N O•� Z deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK L PG / VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic, ClassR � SIZE STORIES FAMILIES ONE c�� ,, `+ �n,. VALUATION Contractor�VTf''� l.�I°'� Date DESCRIPTION OF WORK NEW ❑ s ❑1 am exempt under Sec. Ga L ADD ❑ ► ALTER 0] B.&P.C. for this reasonREPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL 99 Signature APPLICANT TEL. FINAL 1 OWNER-BUILDER DECLARATION (PRINT) NO. a I hereby affirm that I am exempt from tDATE he Contractor's License ACCTAT Law for the following reason (Section 7031.5, Business and ADDRESS FINAL 3307 60.510 ,Professions Code): PRESENT By ❑ I, as owner of theproperty, or m em to employees with BUILDING I ITEMS Y P Y ADDRESS wages as their sole compensation,will do the work and tc- the structure is not intended or offered for sale(Section LOCALITY , TOTAL 6 0 ® 0 7044, Business and Professions Code. MOVING TEL. CHECK c ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. rF7ECK 60..:0 with licensed contractors to construct the project (Sec- ADDRESS CHANGE .00 tion 7044, Business and Professions Code..) CONSTRUCTION LENDING AGENCY SETT BACKK YARD HWY TOTAPROBACNEFROM WIDTH I hereby affirm that there is a construction lending agency for FRONT I �31L- 9/22/89 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE 5854 2 AM, 9:44 P.L. Lender's Name ®Q LDMA Ref. # P.C. Fee$ Permit Fee Lender's Address ' �+ 0 I certify that I have read this application and state that the Issuance Fee 6 � LDMA P/C# Boo 8 above information is correct. I agree to comply with all County Investigation Fee d ordinances and State laws relating to building construction, Total Fee LDMA Perm. # a and hereby authorize representatives of this County to enter upon -above-m ed property for inspection pgposes. a N ( SEE REVERSE FOR EXPLANATORY LANGUAGE- Signa ure of App scant or Date