HomeMy Public PortalAbout9560 BROADWAY_Building__ . r WORKERS' COMPENSATION DECLARATION -
Y .:. , ' .. PPLOCQ��O[� FOR [��Od[ �,[�� pC L�G�I��
I Aereb affirm that I have o certificate of consent to self O D
insure, or a.certificote oPWorkers' Compensation Insurance, . - .
or a certified copy-{hereof (Sec. 3800, Lob. C.). '
'COUNTY OF LbS ANGELES - - - - BUILDING AND SAFETY
Policy No. Company -
'❑ Certified copy is hereby furnished. FOR APPLICANT TO-FILL IN ADDRESS '
�v0 rTe G/i'r-C.
❑ Certified copy is filed with the county building inspec- BUILDING - -
tiondepartment. - .t - ADDRESS Q
:Date Applicant CITY � �57 ( ZIP O !�- LOCALITY
O. OF BL GS. NEAREST
• CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT - ' NOW ON LOT - - CROSS ST. . -
COMPENSATION INSURANCE '
(This:section need not be'completed if the permit is for one TRACT - - BLOCK LOT NO. - ASSESSOR n
MAP BOOK p'�O 7 -OPAGE a ` PARCEL`dpa
hundred dollars ($100) or less.) OWNER 5 /NO. - USE ZONE MAP / -7
I certifythat in the performance of the work for which thisn NO.
sem( .y— I- SPECIAL }
permit is issued, I 'shall not employ any person in any manner '` ADDRESS - /� CONDITIONS
so as tobecome subject to the Workers'Compen tion Laws. O
//))`�';��� �. ��qpp�) CITY - ZIP U
Daae acct r-Z-«RPPlicant ARCHITECT ^ EL. -Z-15 � - Oc
NOTICE TO APPLICANT: If, r ma this Ce ate of ENGINEER - O 7. DISTRICT GROUP TYPE' - _. FIRE PROCESSED BY
g CONST. ZONE
Exemption, you should b ome ject to t orkers' / �., Q U
Compensation provisions of the Labor Code, you must forth- ADDRESS !/r// - A�0 x--� V' � .dG(Lyt� a'I
U
CIL
with complywith .such royisions or',this \\\ STATISTICAL CLASSIFICATION 'APT. CONDO. N
p permit-shall be - I TEL.
deemed revoked. CONTRACTOR , LA�f rn NO �7 , _ Z
LICENSED CONTRACTORS DECLARATION L` ,/ LIC. CLASS NO.�DWEUL UNITS_
I hereby affirm that I am licensed under provisions of Chapter 9 V ADDRESS O/v ANO.
n LIC. /n� SEWER MAP
(commencing with Section 7000)04 Division 3 of the Business CITY Raferrtoa / (�CLA$$
and Professions Code,and myljcense is in full force and effect. BK.lb PG. /�7' VALIDATION
O(j , SQ. FT. NO. OF NO. OF CHECK
License Number m 4..tic. Class LOj(P SIZE STORIES FAMILIES ONE -
/L •� �itA Cb'�LS� (P_ / Y• VAL TION -
Contractor bate L DESCRIPTION OF WORK /' NEW
❑ am exempt under 1 .ec 4J �W ADD
BAP.C. for this reason _ ALTER ❑ - • - -
' p r •� L REPAIR ❑ $
ate:. /.Y USE OF _ .. �.
EXISTING BLDG. - DEMOL' ❑
APPLICANT TEL,
S'gnotur���� � 4g �A'
(PRINT) �L✓Q' NO. 'j?: ' "FINAL �'J
OWNER- ILDER DECEARA PRIN7 v
I hereby affirm that I exempt from the ntractor's License l� //� DATE ''Z ,
Law for the following reason (Section 7031.5, Business and ADDRESS /.-lgrav A77 • FIli'�•
Professions Code): PRESENT _ B
BU WING
I, as owner of the property, or my employees with - ADDRESS \ C
wages as their sole compensation;will do the work and - - - - - -
the structure is not intended'or offered for sale(Section LOCALITY - "j�_
El I,
-7044, Business and Professions Code.) ' MOVING . .. TEL. D . -;Ft
as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct theroject (Sec-
tion 7044, Business and Professions Code.) ADDRESS T•--.� ` - :,_A� �'�'
REQUIRED . TOTAL SETBACK FROM EXIST. "--t.- ;`�^l `y s• •"T VL ��•i=
c CONSTRUCTION LENDING AGENCY - SET BACK YARD HWY PROP. LINE WIDTH - i'�, i C
I hereby affirm that there is a construction lending agency for FRONT _i S(�...U,•)•L� 7 !TEN": -
the performance of the work for which this permit is issued - P.L. -- - - - - -
(Sec. 3097, Civ. C.). - SIDE - rff(��1- 4F -43 —9
, P L. . .. .... _Y •: - ••per•'- 1 1. P 1 -
Lender's Name \iF"' "• \r �y iiF i- +117
LDMA Ref. W
Prit Fee' &1349
P.C. Fee$ D -
CHANGE . I !
- Lender's Address - -
c I certify that I hove.read this application and state that the 'Issuance Fae a`` 7 S LDMA P%C N
ordinances and State laws relating to building construction, Total Fee LDMA Perm.
0
above information is correct I agree to comply with all County Investigation Fee
cJ .J J. -o� TI
.q ti
a and hereby authorize representatives of this County toenter �. Art {oec
�R upon the above- or property for inspects n'///p���urpopppses. - - ^ - x%74'= Art
X �` naNre of Y _ $EE REVERSE FOR EXPLANATORY LANGUAGE
^ 5 Appli5a9 or ant - Dat