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Home My Public Portal About9509 BROADWAY_Building__ WORKERS'COMPENSATION DECLARATION - + firTm that I have o certificateof.consent to self I AI\PLI`/� e ��yATl�'I�~fF.OR BUILDING.° PERNIIT � sure or o certificate of Workers' Com ensation Insurance, -� R or a certified copy thereof (Sec. 3800,.iab ...000NTY,OF LOS-ANGELES. BUILDING.AND SAFETY i Policy No. Company • �n I- iified copy-is hereby furnished. FOR APPLICANT TO FILL IN - BUILDING LTJ/ ADDRESS oi Certified copy is filed with the county building inspec- BUILDING SO r -tion epariment: - ADDRESS •L,, CCL kc, . Date Applicont ` . CITY ZIP I�_Ll V LOCALITY ERTIF .ATE OF EXEMPTION FROM'WORKERS' - NO OF BLDGS NEAREST '`• ' %'COMPENSATION INSURANCE. • SIZE.OF LOT 6-7 it OO NOW ON LOT CROSS ST. ' t (This section need not be completed if the permit is for,one ASSESSOR _ 'hundred dollars (5100)or less.) _ TRACT BLOCK LOT'NO. MAP BOOK PAGE PARCEL - ' TEL. USE ONE -P \Q q_ 0.a.E5123 - I certify that in the performance of the work for which this ` NO. }} permit is issued I shall not employ any person.in any manner �f I SPECIAL, sous to become subjecVto the Workers'Compensation Laws. '- ADDRESS "\S v.- F o0.<S�W CONDITIONS - Q, sU; Date + .- .Applicant , CITY \ SG •G.t.�.. ZIP OI I ARCHITECT O TEL. NOTICE TO APPLICANT: If, offer making this Certificate of R., t l DISTRICT G OUP TYPE FIRE7APTCONDO BY Exemption, you should become subject.-to the Workers' ENGINEER LS Cb f Yp NO. -\�S� y/ -V CONST. 20NV Compensation provisions of the Labor Code, you must forth- ADDRESS - O r ✓ .5with. comply with such provisions or this permit shall'be TEL STATISTICAL CLA55 ATON . - Ndeemed revoked: CONTRACTOR CC NOL J� - Z LICENSED CONTRACTORS DECLARATION LIC.. . CLASS NO: DWELL. UNITS_ ' I hereby affirm that I am licensed under provisions of.Chopter 9 ADDRESS ' NO. (commencing with Section 7000)of Division 3 of the Business and / LIC - - SEWER•MAP Professions Code, and my license is to full force and effect.. CITY ' CLASS _ BK yqU SO. F NO.OF - NO. OF CHECK e•e•e License Number Lic.Class - SIZE , STORIES FAMILIES 'ONE - VALUA 1 N DESCRIPTION OF WORKQ,_ NEW Contractor- G GDate AE3f ❑J am exempt under Sec. v \0 _ DD ❑ _ o 9.2?'r 8$' - /,' ALTER a - B.BP.C. for this rection t {�-Q Wf r REPAIR ❑ f 1/� ry0o OG - DEXISTUSE ING BLDG. 6""' G _ OO DEMOL ❑ ( b �r - -Signature ... APPLICANT -- _ r..__- . - FINAL - - OWNER-BUILDER DECLARATION' PRINT C,L'• 1 �P+rsvL �.I._T a-�r?:s - I hereby off irm that 1 art'eDATE iempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS. FII�•y�' / s Professions Code): ' •-• - p B y h _q ❑ I, as owner of the,property, or my employees with BUILDING - --� ADDRESS ` :�ti� - •wages as their sole,compensation,will do the work and I7 the structure is not intended or offered for sale(Section LOCALITY ® 1 I I H`✓ 7044, Business and.Professlons.Coda).. .• MOVING , TEL. - ' ❑ I, as owner of the properly, amiexclusively contracting ' CONTRACTOR NO. . • LLIt� ', F with licensed contractors to construct the project (Sec. j ,�l lion 7044, Business and Professions Code). ADDRESS REQUIRED ` CONSTRUCTION LENDING AGENCY YARD HWY .TOTAL SETBACK-FROM— F� 1 ' �' 1 c r Tr j j0 SET BACK PROP. LINE WIDTH - v\ � �{-G I hereby affirm that there is'a construction lending agency for FRONT v�,-n1 � the performance of the work for which this permit is,issued• . P. `�i, `s,.� �-�: =1. \ �1 Jc (Sec.3097,Civ. C.). SIDE - - _ ,_ •<. t �bIaii;L tif;f6j 4i G�.�Cq; P.L. Lender's Name `.- J �. . 3 .� 4 v ai,) ,_ , P.C. Fee E rb Permit Fee LDMA•Ref4E\ • t\r O��5. \ x i ' c m Lender's Address "`-`- •` i'f;13 I certify that'I have read this application and state that the _ once Fee LDMA P/C It y;1/ u•�J=��I 9 above information is correct. I agree to comply with all County Investig Fee- �`-` q ordinances and State laws relating to building construction, - r} r•j'f:= -' and hereby authorize to resent-t' es of this County to enter ' - Tot Fee /, LDMA Perm. p Y. j up o boye-menti ed pr ty for.inspaction 1 m SEE REVERSE FOR EXPLANATORY LANGUAGE f'UCsrLr ��i,(S Signature of Applicant or Agent -Iht w - I' ��f' Mt�T �9i)r/r. WORKERS' COMPENSATION DECLARATION 'I hereby affirm that I ' f W rkers' Come of consent la self L -APPLICATION FOR. BUILDING .PERMIT - insure, ora certificate.of Workers' Compensation Insurance, - - tor a'certified copy thereof (Sec. 3800,'Lab. C.)r_ .. - •'� - ' - o . COUNTY OF LOS ANGELES- � =. BUILDING AND SAFETY' Policy No. < Company .11•C• ' ❑ ertified copy is hereby furnished. - FOR APPLICANT.TO,FILL IN ADDRESS�f- �SV`7 `p,�2o*'t,, ertified copy is filed with the county building�inspec- - BUDDING'. p f� - ttiioon.clepaar�rlment • . .. ADDRESS 13TZ0/J�(.0� = Date. y,r q 0."A(iplicant 'AZAL, LL7lrltil� CITY'. F N�-� Cf I IF LOCAUTY -TC�I'I►x-f' ��1 I NO. OP LOT 17 NEAREST_,. ✓p r e CERTIFICATE OF EXEMPTION FROM WORKERS.. I C SIZE OF LOT ' 'NOW ON LOT CROSS.ST. C.COMPENSATION INSURANCE INSURANCE - ASSESSOR' + (This section need not`be completed if-the permit is'for one TRACT BLOCK - l0T NO '- MAP BOOK" - PAGE ' ' PARCEL' hundred dollars ($100)or less ) - - TEL. MAP OWNER 0--QC) 'SS. NO. Yy3 5�7� USE ZONE rP I certify-that ,n the performance of,the work for,which this 'pp _ / - SPECIAL - > permit is issued, I shall not employ any pe In any manner ADDRESS O J�O L-A$' R-oS�� CONDITIONS' � : 0 so as 4o become subject•to the Workers' Compensation Laws. - - ,. .._ _ . , :. CITY- .`(-Fz- ZIP . ' - -.. :.•, a.. _ - u Dote Applicant i - - Of ARCHITECT OR - - TEL P..TYPE ... FIRE- PROCESSED BY NOTICE TO APPLICANT:.If,. after makingthis Certificate of ENGINEER NO.. `(_-\l/h✓�O .DISTRICT ..GROU - - CONST. ZONE Exemption,- you should become subject to the Workers - - w ;Compensation provisions of the Labor'Code you must forth ADDRESS 's' with comply-with such provisions or,this permit shall be - TEL. ,�L`/ p STATISTICAL CLASSIFICATION p APT CONDO ' '-.deemed,revoked. . _ CONTRACTOR 'Z„(� A)r=.k.l LLOP F^NO. / Y•;--'Sd z - - - 7 � z , LICENSED.CONTRACTORS DECLARATION, - LIC. CLASS NO-sf . DwEtt. Ow75 I hereby affirm that I am licensed under.provisions of Chapter 9 ADDRESS 113 So -E ��u-f' f3Ls` NO (commencing with`Section 7000)of.Division 3 of the Business L c UZ� q LIC. 'SEWER MAP _ CITY I`f I /73 ) CLASs -and Professions,Code,and my license Is in full force and effect - _ _ gK_ =pG—3 - ' . VALIDATION . . ` SQ.-FT. QA V NO. OF FA,INO OF ',CHECK License Number Os 122 Lia.Class'- SIZE STORIES FAMILIES ' ONE E7r� /,r>% !w VALUATION -�a, J' .Contractor AZA, �'�`t'O` pate � J�; �I DESCRIPTION OF WORK , 1 bL I� s " NEW - �) / �T CD. rT ADD....❑ Pilo. '•,.K S 4D.1 1 ❑.I am exempt under Sec. ALTER ❑ --- -- -- - - L U P'J " B.BP.C. for,this reason - - - S . REPAIR ❑ r Date' _ USE OF1 .. . EXISTINGBLDG.' DEMOL .•1 Signature - APPLICANT' c�et - - TEL - g - ' (PRINT) )�1L U(,I�r'7'l'- "I P» Y3 Jd''�r FIN�A�L/, J�7 OWNER-BUILDER DECLARATION pNkC I hereby affirm that I am exempt from the Contractor's License ADDRESS 'L.3�0 'V AL'}� ��t`uYj `ZC f- - •' ' Law for the fo lloV✓ing.season ($ectiiin 7031.5, Business and FIN .. 1 Professions Code): PRESENT-. ._ _. _ - ' _By- i _ - _ .r• ❑ UILDING 1, as owner'of the property, or my employees with ADDRESS I_ a 3` wages as their sole compensation,will do the work and - - - - - - the structure is not intended or offered for sale(Section LOCALITY - �' - r_ , : t I ut. .7044, Business and Professions Code.) - - MOVING - - TEL 1 ` ❑ 1, as ow net of the property,�am exclusively contracting CONTRACTOR. - - NO - I 1 E S with licensed contractors 4o construct the project (Sec- ADDRESS /_ - - - _ -' 1j+1}f •,G' ;r tion 7044,.Business and Professions Code.) ..-:REQUIRED - TOTAL SETBACK FROM : EXIST.•. CONSTRUCTION LENDING AGENCY- SET BACK YARD HWY PROP. LINE WIDTH a_ I hereby affirm that there is a construction lending agency for FRONT - I dp (jl j the performance of'the work for which this permit is issued -P.L: (Sec. 3097, Civ. C.). .SIDE Lenders Nome /C ' �t._ _ LDMA Ref. N _ r `` L J P C. Fee 5 PermityeeF {I Q" j Y Lender's Address - : / Y , . Ail v •C�7 a I certify.that I have read this application and state that'the _ •- - Issuance Fee o � LDMA PiC Rpool - c 8 above information Is correct. I agree to comply with all County In mtigation-Fee: s-� ordinances and Stat e la s.re tat ing to building construction, Total Fee J � LDMA Perm. k a and h reby authorize re esentatives of this'tounty to.enter upon a ave- -ntion d'property'for inspectwn purposes / rorfie p ��'1 .« ' p.. .. - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appli nl or Agent, Date.