HomeMy Public PortalAbout9158 BROADWAY_Building__ WORKERS' COMPENSATION PECLARATIQN
I hereby affirm that I have a cerlifi2gie.of consent la self. APPLICATION . FOR' BUILDING,PERMIT . �.
insure ora,certificate.of Workers Compensation'Insurance :. .-
__
.:. certified 'copy thereof (Sec 3800, Lab.C.) .COUNTY OF LOS ANGELES -'- - BUILDING AND SAFETY-
Policy No: f i , Company `. .-• - , _
Certified copy.is hereby fu_roished' -FOR-APPLICANT TO FILL 1N noloeess !✓
-.0 Certified copy is filed with the county building inspec- - . BuITIN
,tion department: - 4;.., .- ADDRESS
Date CITY .� C.. I ZIP: LOCALITY .. • _ _� ..0
Applicant ,
- - ' NO. OF BL S. NEAREST_ 1 _
�• %' CERTIFICATE OF,EXEMPTION FROM'WORKERS' .X SIZE OF'LO - "NOW ON LOT - 's CRO555T. --' J'h;f• /V
'COMPENSATION INSURANCE - - ASSESSOR
" `(This section need not be completed if the permit is'for one TRACT BLOCK- - _ LOT`Nd MAP.BOOK
'- 4 PAGE' - PARCEL
:hundred dollars ($100)or.less ) : • T TEL +~
s . , OWNER NO. USE'ZONE MAP - t
I certify that in.the performance of the work for which this _ NO
SPECIAL'-' - }
3 /�'7.L..v•. - - - i
permn`is issued, shall not employ any person in any manner ADDRESS (/ [CONDITIONS aO
so as to become subject tache Workers.Compensation Laws:4. -
♦.. . . i:; CITY " O f _ZIP .0 ce
,.Date - - - Applicant ARCHITECT OR - TEL .DISTRICT GR P. TYPE- - FIRE'S ROCESSED BY 1 O
`NOTICE'TO APPLICANT: If, after making-'this Certificate of ENGINEER NO.,.. U
` CONS ZONE
=Exemption,,,.you should-. become subject to.-the_Workers' J w
Compensation provisions of•the Labor Code, you-must forth ADDRESS ,w �-:�. _ I
with comply with such provisions or, this permit shall be TEL.• STATISTICAL CLASSIFICATION - - APT CONDO Z
deemed.revoked. .- CONTRACT NO. - - —
•r LICENSED CONTRACTORS DECLARATION.'--s+ -. - ^- - LIC. CLASS NO. )WFLL. UNI '
_ Z
Ihereby offirrrithat fiam licensed under provisions of Chapter 9 ADDRESS _
NC_ _ , 1
. {(commencing with Section 7000)of Division 3 of the Business SEWER MAP
-
and Professions Code,and my Lcense,_is in full force and effect. CITY {LASS BK. PG •� -VALIDATION '
50. NO. OF NO. OF CHECK (J ,
License Number LIc. _Class - SIZE _ STORIES FAMILIES ONE * .•f t�
` DESCRIPTION OF WORK.. ♦ NEW
VALUATION
Contractor Date qq
- ` ,. - ADD 27
❑'I am exempt under Saca , • - • : (M _ tt :,
ACCT. ,GF tJ
1 ILC�{�-JI 33W
— 1I
-, B BP.C. for this reason � .
USE OF REPAIR '�` � 's -" -� " -'TOTAL -34064
• +��
_ _ _ ❑
Date: _ _ EXISTING BLDG. DEMOL
Signature APPLICANT
OWNERPRIM FINAL —
-BUILDER DECLARATION DATE O-�RC/T ,
7 1 L, -
.I hereby affirm that I am exempt from the:Comractor s License _
ADDRESS
law for the folloviing reosoh (Sectlori' 7031 5, Business and rZA' FINAU d.r.
:y Professions Code) -` s: .. _ :,,. ' PRESENT
ESEENT. ... _ By -. .: . .a. .
❑ DING
I, as owner of the,property, or my employees with ADDRESS -
wages as their sole compensation,:will do the work and
the structure is not intended or offered for sole(Section LOCALITY
<
7044; Business and Professions-Code.) MOVING. .,TEL_. _ r _ a}.�� { 1'+ + J9/7. 1 { 1O L�O
❑ I, as owner of the properly, am,exclusively contracting CONTRACTOR NO. t L +.5 < t rt! .. .�Ir7
with licensed contractors to construct the project-(Sec-
ADDRESS
tion 7044, Business.and Professions Code.) j \ i J 15 L-
- REQUIRED - - TOTAL SETBACK-FROM- -EXIST.. -
CONSTRUCTION LENDING AGENCY SET BACK 'YARD' HWY PROP. LINE WIDTH y a - -
hereby affirm that thereis a construction lending agency for FRONT
•'the performance of the work for which this permit is issued ;) - ' P'L , _ - _ l }. ♦ / t
(Sec. 3097, Civ: C ) SIDE.. _ 1 1l.•. .,") 1.` .
Lender's Name
P L. 1 t (!+,v -
♦ - LDMA Ref n i Al ACLT.i
PC Fees Permit Fee- - - ' - i. IJ' 91] - il�t•'1ril-
Lender's Address - 7 .n^ { 1
9 I certify t have read-this application and state that the Issuance Fee I v7 �o LDMA P/C q ► ;' i ITEMS -
a above i r o - _ __ � '
8 - is owed. agree to comply with all County Investigation Fee --:' - r: _ -
¢: ordin- c d St a laws relating to building construction,r Total Fee .+ 'LDMA Perm. q TOTAL ilei.11
a and er outh Ke re resentatives of.this County tc enter _
up e' ove' enti ed propeity for ins Edi n urpos ' -- ' —, - :.HEtX 10161 11
SE REVE FFOR E PLANATORY IANGUAG _ - CHANGE •013
^�fRS _ _.
S gn re of Applicant or Agent , � 0 e - 30°10 '. _to
,- ,