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Home My Public Portal About4523 ELLIS LN_Building__ ,.'WORKERS' COMPENSATION DECLARATION herb,affirm'that.1• have a certificate'of consent."to self DD n O O M O O O nn .'1 insure, or a certificate.of Workers"tompensation Insurance, [1�� O lJ V �O�` -L=/. or,a,certified copy'thereof ( c J� 000,, Lab. C.) y/ COUNTY OF LOS ANGELES BUILDING AND SAFETY. , Policy'No/ �C�an; 797W �rwo �yy BUILDING L� Certified copy is"h'ereby furnished. FOR APPLICANT TO`FILL IN ADDRESS �LL/S G�/✓L� BUILDING ❑ Certified copy is filed with the county building ins c �L L S `�Ne Tion department. ADDRESS O G Date Applicant' CITY' ZIP // 7,0 LOCALITY T�` NO. OF BLDGS. CERTIFICATE OF EXEMPTION" OM WORKERS' SIZE OF LOT NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT CJ BLOCK LOT NO. '( MAP BOOK PAGE 1�'49� PARCEL 1�57/0- hundred dollars ($100),or less:) TEL. OWNER ' L Ji?T P NO. USE ZONE MAP .• I certify that in the,pe'rform* ance'of the work for which this ( ti (y SPE /7 0' CIAL permit-is issuedy I shall not employ any person in any Manner ADDRESS LL "l A n/Q �J CONDITIONS a so as to become subject to the Workers'Compensation Laws. f O CITY. �/ L� :� ZIP U Date Applicant ARCHITECT OR TEL. ( DISTRICT GROUP TYPE. FIRE" 'PROCESSED BY NOTICE TO If, afterma'kin'gthis Certificate of ENGINEER. ( kv 4.,j NO. �{�f fl-70 CONST. ZO E. F Exemption, you 'Should become .subject to the Workers' / y w Compensation provisions of.the Labor Code;-you must forth- ADDRESS [ eee� ;e d rfi d with comply with such provisions or this permit shall be STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR N Z LICENSED CONTRACTORS.DECLAR%ATION a 9.LIC. CLASS NO.��DWEu. UMTS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. .-_ - LIC SEWER MAP (commencing,with Section 7C60)-cif Division 3.of the Business -- CITY IGGl1 :}.lt' t``! •0 3 and Professions Code;and my license is in'full force a effect BK PG VALIDATION SQ: FT. / / NO. OF N . OF CHECK License NumberC� Class SIZE .. �(p/ STORIES FAMILIES ONE. 1 i El=tla / VALUATION _ Contract DESCRIPTION OF WORK NEW I I-'.R HLA Ellam exempt under Sec. ` ADD 0 ALTER ❑ -._. B.&P.C. for this reason REPAIR ❑ $ •'/ L J ':S?•i . Date:: USE OF " ,n; iTl.` EXISTING BLDG. DEMOL ❑ _ 'Signature .. APPLICANT y TEL. Ili I"; ;i , OWNER-BUILDER DECLARATION (PRINT). NO . FINAC ""! -I DATE _ :sl�sli`_ -til v;e`iu •-, I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 70315,-Business.'and ADDRESS FINAL r�tf11�3 . Professions Code): PRESENT ® uil+i ❑ I, as owner"of the property, or my employees with BUILDING ADDRESS' t wages as their sole compensation will do the work and `%" - � r t i3 the structure is not intended or offered for sale(Section LOCALITY t.7 y , v 11 !11 .l 7044, Business and-Professions Code.) MOVING TEL. _ �... �Oy s '._ a _• ❑ I, as owner of the ro err CONTRACTOR NO. 1 AM � p p y,.am exclusively contracting /�7 77 with licensed.contractors to construct the 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 a construction lending agency for FRONT the performance of the work for•which'this permit.is issued P.L. (Sec. 3097, Civ. C.). SIDE Lender's Name J P.C. Fee.$ Permit Fee ` LDMA Ref. # Lender's Address I certify that I have read this application and state-that the / i Issuance Fee ` ' LDMA P/C# above information is correct. I agree to comply with all County Investigotion,Fee �.. Gjd' 8 ordinances and State laws relating to building construction, Total Fee p�,t /a LDMA Perm. q a and hereb y5WAHorize representatives of this County to enter upon theove a toned grope r.inspection rposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE CXX g re of#i o ,�VORKNS' COMPENSATION.DECLARATION R p i hereby affirm that L have a certificate'of consent' to self PIP � O D O insure, or a certificate of Workers' Compensation. Insurance, CAU [ FOR C M DD ]C� p C Q or a certified copy thereof (Sec. 3800, Lab.,C.) " 'Policy /OOy��/,3 COUNTY OF LOS ANGELES BUILDING AND SAFETY . Company_ � Ce BUILDING Certified copy is hereby furnished.. FOR APPLICANT.TO FILL IN ADDRESS ❑ Certified copy is filed with the county building insp - BUILDING tion department. ADDRESS E Z CITYr��nPLE -�:��- ZIP [ 8� LOCALITY.~ "6atel: Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT -14 4 NOW ON LOT ' - NEAREST_ CROSS ST. - COMPENSATION INSURANCE Q p ASSESSOR �j (This section need not becompletedif_the_permit is for one TRACT i ,: / BLOCK LOT NO. 1 O I MAP BOOK D.S�� PAGE OO/ PARCEL 014 hundred dollars ($100) or less.) OWNER L')L ♦) �/�, r'� Nqj s- �j�9p2 USE ZONE MAP .1 certify.that in the performance of the work for which this r`I� t j NO. P P Y Y.P y' 4 ELL 5 L.4 AA ' 1 :3': SPECIAL } ermit is issued, I shall not em to an person'in an manner ADDRESS4S-2,1 ��' \\\ o_ CONDITIONS so as to become subject to the Workers'Compensation Laws.. - G ' O CITY-• 1 r=mPLL • rr ZIP "7 ! 90. U Date Applicant ARCHITECT O TEL ry DISTRICT. GROUP. TYPE FIRE = PR CESSED BY NOTICE TO APPLICANT:, If;-after' making'this .Certificate of ENGINEER tJ .NW49 7666 CONST. ZONE Exemption, you'should become subject. to the Workers '. ,/� iV Compensation provisions of the Labor Code; you must forth- ADDRE '�" _ `A L'` �Pd `� d with.comply with such provisions or.this permit shall be N P Y P P STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked.- CONT CTOR N _ LICENSED CONTRACTORS DECLARATION �- L CLASS NODWELL,UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS IF NO. 3 &6_1 LIC. a2 SEWER MAP (commencing with Section 7000)of Division 3.of the Business - CITY [L�t CLASS -/ and Professions Code,and my license is in full.force and effect. BK PG a`It )V�}LIDATION SQ. NO. OF- NO. ,1 CHECK ' -License Number _ SIZ STORIES FAMILIES D' _ ONE lass = Q VALUATION Con}racto �/, DE� I OF WORK. . r NEW $ / y , ADD ..❑ jSr'= r ❑I am exem t'under Sec. C.t�. _ ... ALTER ❑ B:&P.C..for this reason` „' REPAIR ❑ $ Date:: USE OF ic.:� - - EXISTING BLDG+ s DEMOL`❑ Signature APPLICANT TEL:/�[� FINAL jy OWNER-BUILDER DECLARATION (PRINT). -No.7 or 1 .� DATE I hereby affirm that I am exempt from the'Contractor's License Law for.the followin reason' Section 7031':5, Business and ADDRESS � � o V -FINAL = Professions Code): PRESENT- -By, s °lam - moo: FTBUILDING I, as owner of the property, or,my. employees with ADDRESS wages as their sole compensation,will do the work and the structureisnot intended.or offered for sale(Section LOCALITY, V\t 7044, Business and Professions Code.). MOVING TEL.. _. V O fj, i1 L, a :'r - CONTRACTOR NO: �1 ` ❑ I, as owner of the property, am exclusively contracting "fir 4 .. with licensed contractors to construct the project (Sec- ' ADDRESS - tion 7044,:Business and Professions Code.) .. a REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE 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.L: s '_ (Sec. 3097, Civ. C.). SIDE. i) I i[ s[JU j P.L.. Lender's Name .• -- �,€ _ ._ Lender's Address P.C. Fee$ �. Permit Fee LDMA Ref. N. o 1 certify that I have read this application and state that the Issuance Fee OZ LDMA P/C# , above information is correct.I agree to comply with all County Investigation'Fee o ordinances and State laws relating to building,construction, Total Fee �c/ �/ LDMA Perm q a and hereby authorize representatives of this-County to enter upon:the a ioned propel4y for_ins'pection urpo es. - Z40 ��y / SEE REVERSE FOR EXPLANATORY LANGUAGE Date Syg/�nat f A a of _/�/v/ C/ r'