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HomeMy Public PortalAbout9902 BROADWAY_Building__ WORKERS' COMPENSATION DECLARATIOIQ Si nt to sf insure,or afcertifcatte of Workers' CompenatoI have a certificate of neInsurane, APPLICATION FOR BUILDING PERMIT 7ISI or a certified copy thereof (Sec. 3800, Lab. C.). COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS G Certified copy is filed with the county building inspec- BUILDING `,F rl AY tion deportment. ADDRESS5RWIAV IOCALITV ♦' FDYW NEAREST 11 /� 'f'T 7' / [ L-� Date Applicant CITY C s ZIP CROSS ST. M 8 Go //G A Jrl CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF SIZE OF LOT NOW ON MAP BOORK S :) O 2? PAGE PARCEL O COMPENSATION INSURANCE USE ZONE MAP _ (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. �j NO. hundred dollars ($100)or less.) TEL. SPECIAL T I certify that in the performance of the work for which this OWNER U _AJ NO. CONDITIONS A. DISTRICT GROyyyPPP��� TYPE FIRE PROCESSED BY O permit is issued, shall not employ any person in any manner ADDRESS .. Cy ZONE V so as to become subject to the Workers'Compensation Laws. ('J /P . CK Date Applicant CITY ZIP STAT ISTICAL CLASSIFICATION APT. CONDO. O NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL V Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO, DWELL. UNITS= 1 Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N With comply with such provisions or this permit shall bez deemed revoked. ,�,� TEL' BK. PG, VALIDATION CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION tic. _ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS - NO. VALUATIONS (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS $ O C) G� , SQ. IT.&I�f�j NO.OF NO. OF CHECK OWM License Number Lia.Class SIZE t/C7 STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW 59 E F1 I am exempt under Sec. AD pR 0 FINAL _ 2 26.2 9 A B.BP.C. for this reason REPAIR � DATE 8� .# o s�o1e e I Date: USE OF DEMOL FINAL �l / EXISTING BLDG. LLN (p By J C.,T-�+.a..(�J 12'-'- 5 9.2 5 Signature APPLICANT TEL OWNER-BUILDER DECLARATION PRINT NO. _ 'o'o 0 59,25P2 hereby affirm that am exempt from the Contractor's License Law for the following reason (Section 7031;5, Business and ADDRESS , �O 6 Q�8—$�j Professions Code): PRESENT ❑ BUILDING 1, as owner of-the property, or my employees with ADDRESS wages as tbeir sole compensation,will do the work and the structure'is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. .. with licensed contractors to constructthe project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is ci construction lending agency for FRONT RIO pool - the performance of the work for which this permit is issued P.I. (Sea 3097, Civ. C.). - SIDE P.I, 7. Lender's Name j/ n Lender's Address P.C. Fee$ .Permit Fee 'j. ! `� w 'Sv It I certify that I have read this application and state that the Issuance Fee © - r above information is correct. I agree to comply with all County Investigation Fee Total Fee g ordinances and State lows relating to building construction, G and hereby authorize represent Lives of this County to enter 1 < upon t above- enti ed pr erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signatwe of Applico Agent Dale - Il RM'LO L es 6��- 2 WORKERS'COMPENSATION DECLARATION I hereby affirm that I have o certificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers'Compenstion Insurance, or a certified copy thereof (Sec 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company / Certified copy is hereby'furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS J ' 0 Certified copy is filed with the county building inspec- BUILDING /� 1/ ^ - � n lion department. ADDRESS q P / LOCALITY �. t7/" NEAREST Date Applicant CITYPbE C ZIP (/ CROSS ST BA J. 6 C111•D(_' Wfs CERTIFICATE OF EXEMPTION FROM WORKERS' r �( NO. OF BLOCS. ASSESSOR s COMPENSATION INSURANCE SIZE OF LOT :J /S NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP O OT LN . �� hundred dollars ($100) or less.) TRACT BLOCK 'SPlK 1 L OWNER � PEECIAL aO yy J CONDITIONS O� certify that in the performance of the work for which this NO J ! DISTRICT GROUP TYPE FIRE PROC SSED BY V permit is issued, shall not employ any person in any manner ^ ADDRESSBROAD )" Y' _ CONST. ZONE p: so as to become subject to the Workers'Compensa n Laws. y fj,T O�' 1 •Dara Q 6/A lican « - �,e+/ CITY — C.IIP✓ ZIP • 'fp(f `, r �'� V —� �- O PP ARCHITECT OR TEL STATISTICAL CLASSIFICATION APT. CONDO. W NOTICE O APP (CANT: If, after making this err if icai of ENGINEER NO. CLASS NO. a1 DWELL. UNITS_ d Exemption, you should became subject to the Workers' y Compensation provisions of the Labor Code, you must forth- - - Z with comply with such provisions or this permit shall be ADDRESS SEWER MAP deemed revoked. TEL' CONTRACTOR NO. gK.G PG, VALIDATION LICENSED CONTRACTORS DECLARATION ULIC I hereby affirm that I am licensed under provisions of Chapter 9 - ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and /I LIC Professions Code, and my license is in full force and effect. CITY, „ }' CLASS $ S.000 SO FFlI/ NO. OF NO. OF CHECK License Number Lic.Class SIZE hit(a, STORIES FAMILIES ONE Contractor Date DESCRIPTIONOF WORK NEW $ m a am exempt from the licensing requirements as I af ADD ❑ licensed architect or a registered professional engineer ALTER ❑ FINAL r/acting in my professional capacity (Section 7051, ❑ DATE USE OF Business and Professions Code). REPAIR . FI EXISTING BLDG DEMOL ❑ NAL6y Lic,or Reg. No. Date APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Law for the following reason.(Section 7031.5, Business and ADDRESS Professions Code): PRESENT ❑ I, as owner of the property, or my employees with BUILDINGADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered-forsole(Section LOCALITY 7044, Business and Professions Code), MOVING TEL. z 0 2 a 8 A ElI, as owner of,the property, am exclusively contracting CONTRACTOR NO. ' with licensed contractors to construct the project (Sec- # oo e • e tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY LFRONT YARD HWY TOTAL SETBACK FROM EXIST 2 e - 4300 PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for �� d OGO r a e e [( j 0 Othe performance of the work'for which this permit is issued(Sec. 3097, Civ. C.). 071, 10-8.1 Lender's Name Lender s Address t�J P Fee 5 Permit Fee 3 L w I certify that I have read this application and state that the Issuance Fee a .above information is correct. agree to comply with aIl,County Ines,gclloo Fee ordinances and State laws relating to building construction, J and hereby authorize representatives of this County to enter Total Fee J mupon/the above- entioned or perry for inspection purposes: /7C�t� Q g0 SEE REVERSE FOR EXPLANATORY LANGUAGE s r Signature of App Lcont or Agent Date �s