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Home My Public Portal About9435, 9437, 9441 BROADWAY_Building__ s�(r WQRKERS' COMPENSATION DECLARATION /� I� LL /� p �rl��{p� 'F�p �r��( �FP�p�� E�}�,r�{�/�LT� l heiew,ryPfirri that hove a certificate of consent to self //T� PP Q([ /p� M V FOR BUMO�U G PLSUOL1G T lJ insure, 6 d�ertificafe of Workers' Compensation Insurdnce, 1f�10 Illl lS V(/11 Il or o.."ified copy thereof ($ec. 3800, Lab. C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. -Company El Certified copy-is hereby furnished.. FOR APPLICANT TO FILL IN BUuowG G 35 • - n ADORESS _ Certified rime is filed with the county building inspe<- BUILDING �✓ AC (NU RL tion department. ADDRESS ✓ /J Dote- Applicant - CITY 1 G..( ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO, OF SIZE OF LOT S 3 S' NOW ONUDGS NEARESST. COMPENSATION INSURANCE ,/ LOTCROSS (This section need not be completed if the permit is for one TRACT 7� �0 BLOCK LOT NO. ASSESSOR hundred dollars(EI00)or less.) MAP BOOK PAGE PARCEL /� TEL. ,r�JJ OWNER C.OK S'-'K• �O, NO. USE ZONE - MAP / 5/ I certify that in the performance of the work for which this (` /AL� ' -7 NO. --L(r/ J permit is issued, 1 shall not employ any person in any manner ADDRESS- S!� �' SANTA ,T A i1-v� (O, I SPECIAL jy so as to become subject to the Workers'Compensation Laws. CONDITIONS p arw �GkF-&A zip pp� V Date Applicant - B ARCHITECT OR TEL. I NOTICE TO APPLICANT: If, offer makinthis Certificate of L��((tt '1_` DISTRICT GROUP TYPE FIRE P SSED BY 0 g ENGINEER O kK I�ILC(.{T./(,1.. NO. -OS60 H Exemption, you should become subject to The Workers' � 'p n Q �_I CONST.�/ .ZONE T U Compensation provisions of the Labor Code, you must forth- ADDRESS I"1 JO E Q� FsO+ Q LAve �p ,v - W with comply with such provisions or this permit shall be - - A /� d deemed revoked. CONTRACTOR p.A TEL' rL. STATISTICAL CLASSIFICATION APT. CONDO. Eq rr) NO.qt 7—a I 20Z 7 ✓ Z LICENSED CONTRACTORS DECLARATION - -. p LIC CLASS NO.�' DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ) 1N• 'SAS '11, NO. 6 7 (commencing with Section 7000)of Division 3 of the Business and 117p LIC SEWER MAP Professions Code, and my license is in full force and affect. CITY L-+ CLASSBK. �. 3'y VALIDATION- SQ. FT. INC.OF I NO.OF CHECK License Number N6 Q Lic.Class SIZE STORIES / FAMILIES a ONEVALU . Contractor 9 A A 6,o-Srtjl„ 6-Date � DESCRIPTION OF WORK "' NEW . $ ' � �r �p� D 04a6A i uN ❑. ADD OOU pq 1 am exempt under Sec - ,,nn__ ALTER ❑ pyo 'I e p8 6 2 B.BP.C. for this reason e.✓amu REPAIR ❑ T f / (^ /L/t/t e e 6 2 CJ.S.c�J . te: USE OF J VVV .- (.I(�(�(io.t) I(f t:tOsw EXISTING BLDG. DEMOL ❑ - Q 'I`9'.8`8 Sianoture zw�— L ✓ APPLICANT TEL. t/ A7 i:_J: (1 OWNER-BUILDER DECLARATION PRINT CJ IOC(QN•( - DcECG NO. 7y'�^.JZ�`FI FINAL ) p $I �.=: d HPI_ '+- DATE - 1 hereby offirmRhat I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and ADDRESS FINAL P� Professions Code): 71RESE BT. ❑ BUILDING 9Jf 7' Yl A,45TZ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sole(Section 'T LOCALITY - 1 7044, Business and Professions Code). - MOVING - TEL 1, as owner of the property, am exclusively contracting CONTRACTOR `NO. POE ,a with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS - ?(7 114•x.+ ! CONSTRUCTION LENDING AGENCY REQUIRED. YARD HWY TOTAL SETBACK s —;rfy SET BACK PROP. LINE WIDTH 1 I I Ct t-, I hereby affirm that there is a construction lending agency for FRONT .e the performance of the work for which this permit is issued P,I. TOTAL (Sec. 3097, Ci, C.).. SIDE C'mE I' 1If P,.,-JC Lender's Name --� LDMA Ref. k L TF •(_I_t c:t�arc- m Lender'sAddress P.C. Fee$ Permit Fee •Q( 3 —�s certify that I have.readthis application and state that the ..- Issuance Fea - /D P/CN _ above information is correct. I agree to comply with all County Inveftlgotlon Fee I�1_I;�-t ll tl_1 21 •/i:`i ordinances and State laws relating to building construction, TDMA Perm. It and hereby authorize representatives of this County to enter Total Fee ,.,�. L' upon the �' abo ve-mentioned ro/ppp�arty for inspection purposes. , . i } i Ahili SEE REVERSE FOR EXPLANATORY LANGUAGE SignoNre of Applicant or gent- Date e.i _ s _ 7 M- ,WORKERS' COMPENSATION DECLARATION W e 4— - inswe, affirm that hover certificate of consent to self APP1) C /A1 � ON FOR B1) AILMIG PERK lT insure, oro certificate of Workers' Compensation Insurance, LL (/'l� uCI v uCI LLSS IIINNN u ' or a certified copy thereof (Sec. 3800, Lab. �C..) - - r1 G,tvg2,.SpTlou COUNTY OF LOS ANGELES - BUIL G ND SAFETY - - Policy No, O 7L tr Company r BUILDING Certified copy is hereby furnished: frJS �- 6+� FOR APPLICANT'TO,FILL-IN - - B• " ADDRESS Certified copy is filed with the county building inspec- BU LDING ,`/ D�- n bond 1paUmem ./'`e/ ADDRESS T1 D jA Date 1 0 Applicant u&K.1 Ali CITY Cl- q ZIP LOCALITY A ERTI FICATE OF EXEMPTION'F,ROM WORKE14y NO.OF BLDGS. NEAREST If COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. - (This section need not be completed if the permit is for one - br• LQT- ASSESSOR hundred dollars ($100)or less.) TRACT O BLOCK lTE O. MAP BOOK PAGE PARCEL.: TEL. USE jQNE MAP OWNER A• C,•-�V-C 1'lL'c eUU C.a, NO. K/ V I certify that in the performance of the work for which this LnY••JJ11 �/ �- permit'is issued, shall noDemploy any person in any manner ADDRESS ISb N- ('� (� !d"'� 11V SPECIAL so as to become subject to the Workers Compensation Laws. CONDITIONS CITY ',ec.d�.A ZIP 910 to " Date - Applicant ARCHITECT OR s TEL/p p Q NOTICE TO APPLICANT: If, alter cooking this Certificate of ENGINEER �kN �h INC NO:a�o� I lS-7(.lI DISTRICT GR UP TYPE FIRE PROCESSED BY Exemption, you should become subject to the Workers' rr/l fy/ /�5{J� CONN. ZONE Compensation provisions of the Labor Code, you must forth- .ADDRESS k T V LN O/a r �� U uJA rr •1 1/ `]J^ with comply with such provisions or this permit shall be deemed revoked. C Y TEL p STATISTICAL C SIFICATION APT. CO CONTRACTOR Exc.A I��Ln NO�oLf -5�a3 LICENSED CONTRACTORS DECLARATION' _ p - 'LIC, CLASS .0 DWELL UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS -0,60K �� NO. - SEWER 0 MAP (commencing with Section 7030)of Division 3 of the Business and /� �q LIC /� �a Professions Code, and my license is in full force and effect. CITY ll Tj > ,!Q CL.455 l/ L%Z� BK PG. I VALIDATION y �S�C/l?, /J SO. FT. NO.OF NO. OF CHECKd O0F�sl21' l.:1Z ZI SIZE STORIES FAMILIES ONE 'License Number Lia Class 0 /� /� 11 VALUATION Contractor ✓�-u-RWLl9r.te DESCRIPTION OF WORK Y'14 hA p AIA-11t, NEW �. am ex pt under Sea CS S QV _ cl� D [ ADD 0 f D 0 MT--1- ALTER LU B.BP.C. for this reason 6 GYC P.L k2C,I REPAIR $ d! USE OF Date. EXISTING BLDG. - DEMOL Z Signature APPLICANT `{��. TEL/p h FINAL — OWNER-BUILDER DECLARATION PRINT) .17 A Carr 'iwN G,. N(Y�OIJ DATE I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and ADDRESSI,V N' S 1 I4Ji l� �'^� r'�"?U FINA 1r Professions Code): PRESENT By OBUILDING 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. ' I, as owner of the property, am exclusively contracting CONTRACTOR - NO. j• , with licensed contractors to construct the project (Sec- A tion 7044, Business and Professions Code). ADDRESS AC•r.T.a REQUIRED TOTAL SETBACK C CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH - �;(�7' 613 ;I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. L ITEM_ (Sec. 3097, Civ. C.). SIDE -' CAtiLra t� a S'il�re t� P.L. TOTAL 60 a 5-O Lender's Name - - Lender's Address Co�1tNA CQ r LDMA Ref. R GHECY. b0•�CI $ P.C. Fee$ Permit Fee .,l'•L cHAN' VIJ I certify that I have read this application and state that the Issuance Fee / LDMA P/C A D above information is correct. I agree to comply with all County Investigation Fee ordinances and State'laws relating to building construction, tocol Fee LDMA Perm. R rl� i - rj��y' and hereby authorize representatives of this County to enter 0O�C.I-t_oo1 upon the ab entio perry for ins pectio�n/p rposes. Se , n lr /`.�/) `r 110 1 AM E;19 SEE REVERSE FOR EXPLANATORY*LANGUAGE \�l•S)a'rk�"' Signature of Applicant or Agent Date - /�•S• o% 5 q+ID Ir /Yflk