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Home My Public Portal About9437, 9441 , 9445 BROADWAY_Building__ WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self /pY IJI'ylf ON TI011Vll FOR YS r8l✓uOLD VO. PISIIUL1V 7 insure, or a certificate of Workers' Compensation Insurance, !/'1111 II LS `V- /!V tl V U or a certified copy thereof (Sec. 3800, Lob. C.) Policy No.J7d cop is Company S+ (p�p¢a iN7LCN1 K COUNTY OF LOS ANGELES BUILD NG AND SAFETY �' Certified copy is hereby furnished. LNS F.{uD BUILDING �r FOR APPLICANT TO FILL IN ADDRESS - p�0c,9ptQiuij Certified copy is filed with the.county building inspec- BUILDING - • tion department. ADDRESS q 3 .� F7ES AV, c / Date `' / y I � Applicant CITY ZIP LOG4LITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF'lOi NNO 6F OW ON LOTS NEAREST COMPENSATION INSURANCE CROSS ST. L.Lu�!Rli. - (This section need not be completed if the permit is for one TRACT ��+�-�a0 BLOCK LOT NO. �r ASSESSOR hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL OWNER ,j/ 1-\ �F,r yl/L. W. TEL USE NE MAP I certify that in the performance ofithe work for which this (� .-ANO' NO. permit is issued, I shall not employ any person in any manner ADDRESS 1� /J` ,SAa�� AT_, fA YT/E--11 �U SPECIAL so as to become subject to the Workers'Compensation Laws. /) CONDITIONS CITY G(ScC.I ZIP Dale Applicant ' ARCNITEC70R �A) r np TEL. /J NOTICE n, APPLICANT: If, after.making this Certificate of OZX.I '�L I,T- 1l DISTRICT _GROUP TYPE FIRE PROCESSED BY, ENGINEER NO. Exemption, you should become subject to the Workers' /Y)Y CONST. i 3QNE , Compensation provisions of the Labor Code, you must forth- ADDRESS /� �S/. O1- [ CDsr I NJA LV L/ with .comply with such'provisions ar this permit shall be deemed revoked. - c TEL ( p STATISTICAL CLASSIFICATION APT. DO, CONTRACTOR L?Q �vplLN N 011 LICENSED CONTRACTORS DECLARATION g LIC CLASS NO. a DWELL, UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �i7 �J4' 416 NO. 632-- . (commencing with Section 7000)of Division 3 of the Business and (('' //^^"' LIC SEWER MAP , Professions Code, and my license is in full force and effect. CITY ,int 6c 61Z, . C. CLASS (217_1e_7_) _ - VALIDATION HECK QQ /y L SQ. FT. NO.OF NO.OF BK. PG. rS License Number ^U �'" 37 Lic.ClassC�)�8-�I SIZE STORIES FAMILIES ONE �VYs i NEW ❑ : VALUATION Contractor DESCRIPTION OF WORK ' n ( ADD O D I am exe t under Sec. /GyNRV-`flA Fd Of SI�L [:] - U ALTER B.BP.C. for this reason i-Luz, tiOlYa.�- E] S d* REPAIR Date: USE OF EXISTING BLDG. C, DEMOL Z Signature APPLICANT �Q� T1l('AI (PRINT) (�"�� Nd.O( IF��JZ'`/ LZ �- OWNER-BUILDER DECLARATION DA E (`/�� y e ' I hereby.affirm that I am exempt from the Contractor's License gppRE55 .� N- Jnn 1 FdM /./Vy'- �ZC) "FINA t Law for the following reason (Section 703L5, Business and Professions Code): PRESENT By I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,willdo the work and - D the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO, with licensed contractors tb construct the project (Sec- ADDRESS lion 7044, Business and Profession s Code). REQUIRED TOTAL SETBACK - e CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. UNE WIDTH ;I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.I. - (Sec. 3097, Civ. C.). A., L� SIDE 1 CTlvtr` Owi P* S LF +i IJL�NIIC 'lender's Name UDMA Ref. III /�� F, $ IJDI/LN^ CA P.C. Fee$ Permit Fee - 7 50.`10 Lender's Address h41 - _ .05-7 o certifylhoCl have read this application and state that the - PP Issuance Fee LDMA P/C k D' 1ITEI IS above information is correct. 1 agree to comply with all County Investi otion Fee c0 ordinances and State laws relating to building construction, g "\ jll(AL. . 60 e ' Tool Fee LDMA Perm. RGu and hereby authorize representatives of this County to enter "C:HEC•K- d 1 up/o/n,thrf/'obove-mantio properly for inspediop rposes. `�^^�''��) n„ - - (/�/L `� jr SEE REVERSE FOR EXPLANATORY LANGUAGE e v2 l-Lc� ,}/- t_HANGS •�a L Signature of.Applicont or Agent Date _ tJ. I),r_7 ]� /J(f•O `r LM/'®�r /�/ •• - `7 LJ I OLIOO-0061 1/ `/? '.r/{ Y ,4VgP,KERS �MP.ErJSATION DECLARATION /�L fL--�� - ! ,vy,PTseitb, dfhmt that I•hove o certificate of consent to self W0 ��//""L1��4 V� ®�I ��Q�D�E�p� �FP�FT/1 �� - uSG.re ar a certificate of Workers' Compensation Insurance, LL N I D uvV IE II1111�Y1U1 010 f�iligd•copy the 3800, ) �-•� (�< C0UNTY.10F�LOS ANGELES,. UIL ING AND FETY . Polir:yl a y LL:, -edified co is hereby furnished. BUILDING Py y FOR APPLICANT{TO'FILLrIN^, gDORE ❑ J;Certifietcopy is filed with she county building inspec- BUILDING �/ /IJ d _ nt. ADDRESS 3 - '/ , ILJ (A'/J r � Dat Applicant CITY Te G ZIP tOCALITY CERYIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 1 9 sa 3 NO, OF BLDGS. NEAREST COMPENSATION INSURANCE NOW ON LOT CROSS ST. (Thissection,need not be completed if the permit is for one •�ll _ ASSESSOR hundred dollars,($100)or less.) - TRACT s2fp U BLOCK LOT NO. 1 MAP BOOB I PAGE PARCEL �o k 3 No. 7-JrG ( usE ZONE hwP S I certify that in the performance of the work for which this OWNER NO. r2 permit is issued,.I shall not employ any person in any manner FT S' A l77vAa-,410tj SPECIAL so as to become subject to the Workers'Compensation Laws, ADDRESS ISD N•^�L `1 NQ ) k/ I CONDITIONS 0 CITY xc-Ap//.t ZIP ( (006 V{. Date - Applicant .'a.. ARCHITECT OR TEL. lr' NOTICE TO APPLICANT: If, after making this Certificate of -1 DISTRICT SOUP TYPE FIRE SSED BY ENGINEER (C NO. rOS6 (q( Exemption, you should become subject to the Workers' �j /� n ,^ � I CONST�j1 ZONE Compensation provisions of the Labor Code, you must forth. ADDRESS l-i 3p _ SADP& F0cU' e 41Ne. 5, U c.7 - y W' with comply with such provisions or this permit shall be d` deemed revoked. - A /• ILL. STATISTICAL CLASSIFICATION y APT. CONDO. (q CONTRACTOR t.p. NO. `f �I LICENSED CONTRACTORS DECLARATION CLASS NO.dZCi DWELZ L. UNITS s•-� LIC+ g 7�ri q�d 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,V N•�{�r jQ � NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP V ^7 ' Professions Code, and mylicenselicense is in full force and effect. CITY 7z*,, (� CLASS . VALIDAT J !J �!p I ��O SO' FT. NO.OF NO.OF CHECK _ BK. PG. A ' / License Numbbe^er `1 Lic.Class _ SIZE STORIES FAMILIES . ONE # e • e e f1 Jlh'F lwH 37L.CO. Date / DESCRIPTION OF WORK NEW, VALUATh,OZ1 N ^,L 1. 15835 ' :Conti am ADD JEEI o rv' e 1. 15a35mI am exempt under Sec. /Z fL✓`B:BP.C. for this reason �ArrtQo �; ALrER /� 08. 1 9;-88 USE OF REPAIR . a e. - EXISTING BLDG. DEMOL ❑ �\ S'anature I ' APPLICANT (JL( TEL. jD `/q�(j OWNER-BUILDER DECLARATION PRINT �//LC.I/a r/^ NOFINAL . J-YbY DATE l / 1 hereby affirm that I am exempt from the Contractor's License - j Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): P Q e By �•(/ /�F'""' ACS•-tT=F ❑ BUILDING -/ 3 B/CO �/•'D `' ! 11-11 TI 1.1-{ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and D the structure is not intended or offered for sale(Section LOCALITY i T•� 7044, Business and Professions Code). MOVING TEL. El 7,-iraL 7t., i I, as owner of the property, am exclusively contracting CONTRACTOR NO. I I 1 �. 011 with licensed contractors to construct the project (Sec- t fi.t; rp 1-1 rffl tion 7044, Business and Professions Code). ADDRESS i, ( •CEory. .(.t/'-'r-- CONSTRUCTION LENDING AGENCY REQUIRED yARD HWY TOTAL SETBACK SET BACK PROP. LINE WIDTH 1 hereby affirm that there is a construction lending agency for FRONT 1•t c'-.N the performance of the work for which this permit is issued P.L. (Sec. 3097,Civ. C.). SIDE - P.L. I}i i[lil—U_iLli i;�/v7 Lender's Nome - is8; ?! LDMA Ref. M m Lender's Address � P.C. Fee E `�Ll Permit Fee D I certify that I have read this application and state.that the Issuance Fee LDMA P/C If _ above information is correct. I agree to comply with all County Inrestigtn n Fee ordinances and State-laws relating to building construction, Toto) a LDMA Perm. R and hereby authorize representatives of this County to enter upon the above-mention roperty for inspection purposes, I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Ag nt Date -