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HomeMy Public PortalAbout9439, 9441 BROADWAY_Building__ _WORKERS'COMPENSATION DECLARATION � II--���� /� i hereby affirm that have a certificate of consent to self A P H IC '"UM N FOR O BIL n�n M N IG PERMIT ERM T insure, or a cert ifiw to of Workers' Compensation Insurance, L,L u� (I� V L+L uV u�u u ar a certified copy thereof (Sec. 3800, Ly b. C.) Policy No.07S�faSd Com an S-Y• COUNTY OF LOS ANGELES BUILD N AND SAFETY Certified copy is herebypfurnished. tNSU - F:U-CVZFOR APPLICANT TO FILL IN BUILDING ADDRESS Ll - ❑ Certified copy is filed with the county building inspec- BUILDING nj,�j tion a ortment. ADDRESS _IY7 Date llq 1,0 Applicant 1JId CITY=IQ -. .ZIPCt LOCALITY CERTIFICATE OF EXEMPTION FROM WORKER ' U NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one I/ I,� ASSESSOR hundred dollars ($100)or,less.) TRACT 4:26pcD BLOCK LOT NO. �D(lorb MAP BOOK PAGE PARCEL OWNER ,yyS liJFr.Y(✓..(AC U1J(wI. NO. USE ZONE MAP I certify that in the performance of the work for which this t-�� NO. permit is issued, I shall.not employ any person in any manner ADDRESS 'A V s A E, s,U' Q �O .y SPECIAL , so.as to become subject to the Workers'Compensation Laws. CONDITIONS Date Applicant CITY Alf L^^'^" ZIP -91o© _ ARCHITECT OR ,/�J TEL/p pip DISTRICT G UP TYPE FIRE PR SSED BY NOTICE TO APPLICANT: If, after making this.Certificate of L`7rj 1U� 76�) CONST. ZONE Exemption, you should become subject to the Workers' ENGINEER f' NC . NO. `'L) ///� p/�/Q 2 Compensation provisions of'the.Labor Code, you must forth- ADDRESS IL`F,0 W- Dl�'K •S'TL �Jlt.f{a �/r " /T 3 with comply with such provisions or this permit shall be j TEL/�, ,r�' ' STATISTICAL CL4551FICATION APT. ONDO. deemed revoked. - (' CONTRACTOR J� ( iKCAYA—LN NOerf•w't-`(a3 _ LICENSED CONTRACTORS DECLARATION - tic. �T (�p L CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 'O ,�J,lc �((� °NO. ISO O v� (commencing with Section 7000)of Division 3 of the Business and (� zs LIC SEWER MAP Professions Code,.and my license Is in full force and eff ct. CITY Q 1/.4 c. CLASSIC 17.-&?,] BK PG. _ VALIDATION a. �f 50. FT. NO. OF NO. OF CHECKO License Number 2�Lic.Class v h -`I SIZE STORIES IFAMILIES ONE.. V NEW VALUATION- Contractor r Date DESCRIPTION OF WORK $ Q C ADD ❑ ry Jin ❑ (� I am a mpt under Sec. ALTER ILILI B.BP.C. for this reason VVT REPAIR s N - Dale: USEEXIOF BLDG. DEMOIL z Signature - APPLICANT I(n //'' `` TEL s- FINAL 7 PRINT " WK /s,uITWIJIi.TEL. VY'7�iZ OWNER-BUILDER DECLARATION DATE — I hereby affirm that I am exempt from the Contractor's License W' r�•c- f7� Low for the following.reason (Section 7031.5, Business ADDRESS JF7n/ltd A,,-,A andFIN Professions Code): PRESENT - By 1, os owner of the property, or my employees with BADDRE UILDISS . . wages as their sole..compensation,will do the work and _ the structure is not intended or offered for sale(Section LOCALITY - 7044, Business and Professions Code). MOVING - TEL. , 1, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). ACCT.r CONSTRUCTION LENDING AGENCY YARD HWY L REQUIRED TOTAL SETBA K .56107 SET BACK PROP. LINE WIDTH C - .^ 4D•"� hereby affirm that there is a construction lending agency for FRONT �•.i , the performance of the work for which this permit Is issued P.I. - 1 ITEMS (Sec. 3097, Civ. C.))., (J SIDE P.L. - _ 60 -580 Lender's Name LDMA Ref. p CHECK 40.513 Lender's Address 6t,l `A P.C. Fee$ Permit Fee D CHANGE _I a I certify that 1 have read this application and state that the Inuonca Fee LOMA P/C p 4 above information is correct. I agree to comply with all County Investigation Fee - , �.�] o ordinances and State laws relating to building construction, - n 't (' 1. 1/ :✓L.'J Tocol Fee LDMA Perm. 8 OLPJD—SOD. , and hereby authorize representatives of this County to anter 3'- . �� upon the�a�b�oJve-mentione roperty for inspec io 7purposes. �`�WLr /1.. 75 Dili 1 AM ,�.}J [�(,( L Y'(/�/"^ SEE REVERSE FOR EXPLANATORY N jI�GE•••J 136 0 iGu/IF/6 Signature at Applicant ar A ent Date )4—, .�� WORKERS' COMPENSATIONDECLARATION - -� �•- _ -- -- - 4 �T,-. - - v a _ ,T - - i;heTeby affvm.that I have a certificate of consent to self //(]�� O O //(�� I�I��Ip� gyp} �r�y D insure of a certibtote of Workers Compensation Insurance, LA PP L O C� MON Ou O LLQ �V��•D H U V�J'+ U LS UOD O 7 or'acertified copy thereof•(Sec. 3800, Lob. C ) - '+^ - '" - 7 ' - - _. .. -77� t`t • •* � [ COUNTY OF LOS•ANGELES I A S ET „r Policy Na���S_4_s V Company - ® .Certified copy is'hereby.furnished.. (ta 4A- L`c FOR APPLICANT TO.FILLJN -} BUILDIADDRENG i �. oni copy is filed with the county bwlding inspec ' - BUILDING ;[r � Aj/J- - - - - tondepartment' ADDRESS T�7 :..:. ,h i � ,.. /1 p Date p rz: r- Aplicant -Lj(�-k-I bilk CITY .Com. - _ ZIP I LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS` ' -' '-"' 'NO. OF BUDGS.- - --- - - -; NEAREST "+ COMPENSATION'INSURANCE' SIZE OF LOT NOW ON LOT CROSS ST. Ct IJ (This section'iieed,-not be completed if the permit is-for one --- - - - - - ASSESSOR - `� hundredidollcrs ($100)or less.),.,, „ TRA-CT O'. BLOCK LOT NO. MAP BOOK �'` PAGE PARCEL n :n- - L,s TEL USE ZONE MAP I.certify thdt•id the performance of the work for which this OWNER" jy ' LILY. ' NO.- - NO. t 1 y permit is issued, -shall not employ any person m any manner � ,�-..A� �A �( - SPECIAL - - -�•• - - - = LL r - ADDRESS N' FiT•rlH H' Q-- �O CONDITIONS - O so as to become�sublect to the Workers'Compensation Laws sly t ,. /7 o. •,<t CITY. AKCIa(X�A'- - ZIP. _ �,I m Date Applicant - - o ARCHITECT OR TEL. V NOTICE TO APPLICANT If; after mokmg'this Certificate of 4& kALCi4N Q.L.. ' NO. _DISTRICT GfjQUP TYPE , FIRE P OCESSED.BY_ ENGINEER - 'L ) ' CON ZONE Enemption,' you should become subject to' they Workers' "-- GE Compensation provisions of the Labor Code you must forth- with comply with such provisions or;this permit.shall be - _ ADDRESS - - - 5F pg. _ _1 N TC.q_.� 4 TEL. ,r ,.-1 STATISTICAL CIA IFI T N .APT. CONDO/ "j deemed revoked„ y ., ,.•• , ,}.. \•,. i+. CONTRACTOR S.f�F1 t+5 QU-C n C-0_ NO. T��-J b _ /y��� �/Jq� ' ��/�/ _ 4Y/ f LICENSED CONTRACTORS DECLARATION _ -_ __ . _ CiA55 No._SL_$tisWEiL UNITS C- T (�, � A�L ((��•f� LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1(�� N• SFU`rl A k�T"-W '/�oNO. T f7 70 ' i (commencing with Section 7000)of Di3isiori 3 of the Business and LIC SEWER.MAP + _- . -_ _. Professions Code, and my license is in fall force andeffect. CITY AR.c11eQa.A CLASS��� -- BK-• "'�' VALIDATION •�; a +. te.- /' SO. FTLl . /�� NO.OF __ •'1� NO OF _ _CHECK - .• Li cense Number -T `� 7 /U Lic Class Ge V&Q� - SIZE - �C/ STORIES .OL FAMILIES - ONE Cot ntroctor.l%aA'C_uDW3•(14 Cllzfti(.a Dote �a DESCRIPTION OF WORK " -'" - NEW - p ADD O I am exempt under Sec. - - -02 �/- " .ALTER - D B.BP.C. for this reason _ G' -�^"v CST REPAIR ---- - - -- - USE OF t - `Date:' EXISTING BLDG. DEMOL ❑ L -, 2121 Signature ` _. -._. APPLICANT) GI�TLL(' YUrr NEO.- f -0'� FINAL 9 OWNER-BUILDER DECLARATION _ I u ` 2121 2121_ _ . ..DATE/D.--17�! -- •-- -1 hereby off irm that I am exempt.4,ni the Contractods License , Law for the following reason.(Sectido 7031.5, Business and ADDRESS- l Ssa/ AT. �� you rvccD FINAL - "'Profassions'Code). PRESENT ' - - - - - '" BY.. ` - BUILDING :�, I, as owner of the property, or my employees with ADDRESS _ r�ii•i u ._ ._ . . _• wages 6s Weir sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY .3 D ' . 07- r '11121_.7J 7044, Business and Professions Code):- - MOVING " _ - TEL. r + , I, as owner of the property, am exclusively contracting. CONTRACTOR NO. �" with l icensed•contractors to'construo the project'(Sec- - "-' ' -' - '-` .- •�; '("xx - -or tion.7044, Business and Professions Code). ADDRESS I t1C ]. I ��•{•! ,. .. _ REQUIRED. TOTAL SETBACK.FR CONSTRUCTION LENDING AGENCY'- - SETBACK YARD ' HWY _ PROP. LINE _J WIDTH [f-r'fT 1 hereby affirm that there is a construction lending agency for FRONT _ T • �I"ifjUtll' ••C1(1 U the performance of the work for which This permit is issued --- D.L.--.- - - - � - - -- - -� - - - -.- (Sec. 3097, Civ. C.). p' � SIDE m CALff-tbL r A ,5�. e P.L. _ _ _ _ _- _ - .. .. Lender's Name � i < /n/ FA,� I� i S p 17i+T'/� 3 ` LDMA Ref q i I�lltl�-I I(JI � 1�iE Vii .-. - _. _ /7WdUX�a YJ't/e. �nV WA " - P.0-Fee$ _. •� Permit Fee '� •o1J'-' 2121 - ],r�T' �l{1 Lender's Address i I_certif that I have.read.this application and.state Acathe .._ _ '7 Y PP 2121 -. _.. Issuance Fee D • - -CDMA P/C fl- - - D - - Q above information to laws agree to comply with all County' In,.tigation Fee �� g _ordinances and State laws relating to building construction, �t (;!#. z -2121•" U and hereby authorize representatives of this County to enter - - Fatal Fee -.LDMA'Perm. N' g upon the above-mentionIt operty for inspection urip ses. - - i 7 i 7� a SEE REVERSE FOR EXPLANATORY LANGUAGE -Signature of Applicont orA6ent --21.21,.-.- Wbw 21 21 f•.y BOO 12 - 21 :1:1. .-.-