HomeMy Public PortalAbout9158,9152 BROADWAY_Building__ WORKEPS' COMPENSATION DECLARATION - - -
I hereby affirm that I have", certificate of conienf to self ///]�� O �(/,a �Ip�Ip� I�}� n n �n 2
insure, or acertificate-of-Workers' Compensation Insurance, APPUy!!' IRO V—II•®R B�J��®�u� IG FERN '
.or a certified copy thereof,(Sec'3800,lqb C.), 1,. - - IT I-I. I I I I.. I a
- COUNTY OF:LOS ANGELES-, BUILDING AND SAFETY
Policy No.' - 'Company
❑ Certified co 'is hereb furmsshed.. FOR APPLICANT TO FILL IN euILDING
. PY_ Y , ADDRESS +
❑ Certified copy is filed with the countybuilding inspec- - BUILDING n -- 13 n n - - - - - -- -
tion department. - ADDRESS -C� 7Z'✓ rrte�,
- -
6y (f.,. . - � .:i,F LocAuPy
Date - Applicant NO. OF BLD _
1.
CERTIFICATE OF EXEMPTION,FROM WORKERS' SRE of 1.0114bNOW ON LOT ; - - ''i NEAREST - - - -
CROSS SL.' lA/
COMPENSATION INSURANCE C- _- - '- ASSESSOR _ '
(This section need noPbe competed'if the permit is for one TRACT • -' BLOCK LOT NO. MAP:BOOK. _ PAGE PARCEL
hundred dollars ($100) or less ) • • TEL/J s
' OWNER NO, 7 USE ZONE MOAP ' `
I certify that;in the performance of the work for which this' .�-i,A _ 'y^/ SPECIAL' - - Y
permit.is issued', I shall not employ any person in any manner LARCHITECT
CSC/-) L ,\�' CONDITIONS i. d
-,so as to become subject.to the Workers Compensation Laws. Q
ZIPDate Applicant - R TELNOTICE TO.APPLICANT: If, after making'this Certificate ofR NO--
ZONE"GROUP TYPE" FIRE ROCESSED BY Q
CON ZONE �•'
Exemption, .you should become subject to the 'Workers n 3 ., 2 U
Compensation provisions of the Labor Code, you must forth- . ADDRESS- _ _ V K ✓ 'a
with comply with such provisions or. this permit shall be - TEL. -
STATISTICAL C S .KATION APT. .CONDO, to
deemed revoked.. % CONTRACTO NO. - Z
LICENSED CONTRACTORS DECLARATION _ -. • _ - ' _r.. uC g CiA55�NO: - DWELL UNI75 "
' -
hereby affirm that ADDRESSNO.
am licensed under provisions of Chapter 9 -«,
LIC. +
n�
.,
(commencing with Section 7000)of Division 3 of the Business .'.J
and Professions.Code,and my license is in full force and effect. CITY 'CLASS BK.; PG _„i V LIDATION
Si) FT. ' O. OF NO. OF' CHECK-
License Number - _Lic. Class - SZE STORIES FAMILIES ONE- ' o ��
v 7..I_
Contractor Date DESCRIPTION OF WORK NEW .
$ �TI j �_la0i �J07i •fCNC 7
❑ am exempt under Sec _ ADD ❑ 1 +'L„J C
u/ �"'- ALTER .O - D TOTAL 797 e6_•2
8.8P:C. for this reason - _ - 'REPAIR ❑ JS - �F1G�`Yi - 777.J2
Date: ` USE OF _ ,._ ff
, ,. _ EXISTING BLDG'. O[a DEMOL.❑ ruw`�r - '��
Signature - - ' APPLICANT /I TEL FINAL,
OWNER-BUILDER DECLARATION . (PRINT) F-P NO. _
hereby affirm that I am exempt from the Contractor's License - DATE (� -
Law for the following reason.(Section 7031 5, Business and ADDRESS - /�- FINAL + VVUV—�_13001 ' 9I79/99
Professions Code):. - «. PRESENT- - - _ ", 3gY .<" ! "- 59¢[,7E p AMyIO:,T e'}
El . - .• - `t ' ,:'1 : _
I, as"owner of the property,.or my employees wBUILDING
ith ADDRESS
wages as their sole compensation,will do the work and - -' -- - 1
the structure is not intended or offeredforsole_(Section LOCALITY —g
❑ 7044, Business and Professions Code. MOVING- -TEL.
I, osowner of the property, am exclusively contracting CONTRACTOR NO. k :CI
,a i tt
'with licensed contractors to construct-the'project-(Sec- ADDRESS Y. S ] 'y t.I e I1`(C)1 1tk01.11
Tion 7044, Business and Professions Code.) - , jr ITEMS
-TOTAL SETBACK FROM EXIST, ' \] - 1 L I E1;:�
'CONSTRUCTION LENDING AGENCY ," - SET BACK. YARD Hwy PROP. LINE wl iH. 3
hereby affirm that there is a construction lending agency for FRONT TOTAL 06is
the performance of the work for which this permit is issued - P L' • -
(Sec. 3097, Civ. C.): . SIDE - • a
P L CHECK,-, -. 11161.11
y} til
lender's Name f y II(;{{�'INGE III!'
• LDMA Ref. H c
�m r - P C fee$ /'v/ Permit Fee -� - U ' +
Lender's Address �T
I,certify` that haver d this plimtion and state that the Issuance Fee 3- &0- LDMA PTC N D 1?Il�llJ-i}IJU1 •' f."?11
Sabove information i rrect a ee to comply with all County estigatlon Fee- - _ _ _ CIr5f7 . 5' i
R ordinances and St IQ re ting.to building construction, Total Fee 'i~ 1 LDMA Perm. R i•' MtF !-'
a and hereby,ouch e r pres ntat es of1this.County to enter _
upon the abo enti a ro ty for inspectio purpose
a
SEE REVERSE FOR EXPLANATORY LANGUAGE .. 't
Signatu of Appll t or Agent l' Date 4