HomeMy Public PortalAbout10121 GREEN ST_Building__ WORKERS'COMPENSATION DECLARATION
I hereby gfflrm •thdt y have o"'ertiflc-64 of c9nsent to self
InsuYe, or a certificate of Workbrs' Compensation Insurance, APPLICATION FOR BUILDING PERMIT .
of a certified copy thereof (Sec. 3800, Lab ) '
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company,
�., Certified copy Is.hereby furnished. FOR APPLICANT TO FILL INBUILDINGL l AWRESSr
Certified copy Is filed with the county building Inspec- BUILDING / Z
tlort department. ' ADDRESS Q
Applicant CITY ZIP LOGALFfY C
CERTIFICATE OF D(ElAPT FROM WOR*-R:S' NO.OF Sa LOT NOW BLDGS. NEAREST
LOT CROSS
MYRENSATION INSURANCE _
(This section need not be com leted If the permit Is for one ZP 12e ,� ASSESSN
hundred dollars($1010)or.loss.�. I �.S BLOQC LOT NO. MAP BOOK PAGE PARCEL
TEUg
h certify that In the performance of the work for which this eAJ ( NO'
permit Is Issued, I shall not employ any Person In any rnanner ADDRr�ti (� �✓ CO�DfONS
to ai to become subject to'the Workers Compensation Laws. O
Date Applicant CITY 0/ ZIP O U
NOTICE TO APPLICANT: If, after making this Certificate of ARCHITIE-0 t 0
Mi ICig�JP TYPE B
Exemption, you should become subject to the Workers' y/ j
Compensatlon provisions of the Labor Dodi, you must forth- A1�55. L I�
with comply-with.s_uch provisions or,thls permit shall be
deemed revoked. TEL STATISTICAL C1AS31FIrATK)N AFT. rn
Ir
LICENSED CONTRACTORS DECLARATION • r_
CLASS NO._S1_�_DWELL UNfTS
I herby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1!0-16 NO. old
MAO
(comendrp with Section 7000)of Division 3 of the Buand d LIG gEWERm
Prof@"ova Code, and my license full force and effect. CITY CLASS PG 3 3 VALDATiON
Ll cense Number LIC.Cl
STORIES Z No.of o E
1 FAMW
VALVA �l/1
Contractor - pate WORK J� ADD OIJ��r�
I am exempt under Sec. ,
ALTER q
B.&P:C. for this reason — REPAIR _ 23'
' USE OF 6A-",
�� p l nr�r+T
Date' EXISTING BLDG. s/ t CL/ -", DEMOL rn•l;7 f-
..T.
PAK" —. ) TEL C
Slgrwturo OWNER-BUILDER DECLARATION I SUN No. 2 DAT1111 NAL •.a]
I hereby affirm thatI am exempt from the Contractors Lice,nsi Z(� 1 ITM
Low for the following reason (Section 7031.5, Business and ADDRESS �� �- PiTIILL 1l7 fRL ��� c
Professrons Code): III uu-_ J. _s�
I, as owner of the o BUILDING
property, or my employees with ADDRESS C.L cy .5J
wages at their sole compensation,will do the work and �OCAUTY
the sfracturo Is not Intended or offered for sale(Section ` . .00
7044,Buslnea and Professlons Code). - MOVING TEL
1, as owner of the property, am exclusively contracting OR, ti
with Ilcersed contractors to construct the project (Sec-
ADDRESS - 1- 1 L i� v1
tlon 7044, Buslness and Professions Code REQUIRED TOTAL
CONSTRUCT1OfJ-LENDING AGENCY SET YARD h11M1 FROM
PROP. UNE WI 7}i 1. AM 10:03
I hereby affirm that there Is a conWCictlon lending agency#or FRONT `
the performance of the work for which this permit'Is•Inued P.L
(Sec.3097, Gv. C ). 54 P.L. 'r+
P.L
Lenders Name --
LDMA Ref. I "C T—
$ Ion
Lendwrs Address
P.
rye$
' Permit Fee • s�� H �F
I certify I haveread this appllcatlon and state that the Iauance Fee i�J LDAM P/C f ►+
o above I on b correct. I agree to comply �b with all County Inv*W n Fee
oorclim nd State relating to bulldlnq conshoction, Taal Fee
a a Ze ntatives of this County to enter LDMA Peon'
U
a e-m b property for Inspection purposes. p
o M RKVWf[KW taPLAliAtO[Y LANGU^Gl {�r;� Q F■�} t■
Applko t or Agent
APPLICATION FOR BUILDING PERMIT
COUNTY OF LOS ANGELES BUILbING AND SAFETY
WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN eue�rt�.
I hereby afftrm se that I hesea certificate d corTseat to soff IrwKm BLk-DM ADDRESS d
or a oerttficade of Ykdors' Compensation neurance,or a certified 1
copy ffxxad(Sec.3800,Lab.C.) ` �^ z'p La,�
Pow No' T�J�? SIRE OF LOT NO.OF BLD03 NOW ON LOT
v❑l CerttM1ed copy b hereby furnished. NEARS r cRom ST.
7U CerdW copy is fled wtth blued I TRACT BLOCK LOT N0.
+` / 113E ZONE MAP NO _ ���
Date ApplLoant ASSESSOR MAP P°°" Do 3 310
Dv / 3PECLU_CONDITKIN.4
CERTIF OF EXEMPTION VMORKERS' T -No �1
COMPENSATION INS. E �� YUAN 1000 FT.OF 9CHCCC? 1.
YES �
(IT7b section need not be completed If the pwTW b for one hu rid red
dolars(b 100)or WM) D0 RICT aROL1P TYPE GON"ff F Dorf PROCEasEo BY
I ceriffy t&n ti-seperformance of performanof the work for which thie permft CITY Z P
Is issued, I ea not empioy &W person to any manner so as toOR 171OfrE�R TEL NO. �
bec me aJbOcC to the Alorkers'Compensation LBwE 3WT8T1C AL CL P�9FICJLTION APT CONDO
bete Applicant ADDRESS CLASS Na- _/ DWELL UrJT3
AOMEE TO AM W.. H, after makng this Certtffcate of REOUIfED TOpL SETBM',K FROM E)OST
F_aemp"i, you shook becorne &A*ct to the Wbrkers' p,TEL NO. SET BAC< YAFU HWY PROP LIE WUT-H
Corny wtlon provbbrti of the Labor Code, ypu most forttwlth FROM f
cony with suoh proviefons or this pernitt etrall be deemed revoked LIC.NO PL
LICENSED CONTRACTORS DECLARATIONS
/ 8D
�/7J LIC.CLASS PL
I hereby atTlrrr7 that I am licensed iarderprwbkxe Of Chapter 9 /lf , SEHER MAP
(cornm000 rip wfth Section 7000)Of Dfvbbn 3 of tfre Businom and SQ FT.SIZE NO.OF STORES NO.OF FAMILIES
Profeeslons Code,and my Ilcgrree Is n full ce forsot NEW 11 Bu PO 8
Lloenso Numbertrack�r cteee F to X// Ll 40ADD X wlwm
ConDate �` ALTER El $ ��• �7
I am exempt u Sec / x // /O REPAIR ❑ $ ?
BAP.C.for this reason ~X6 B DEMOL ❑. LDMA PSC+
Date ctr�Y URM El }��r���
ire TEL NO. LDMA Prarm 0 M71 1U4.Lr_)
❑J,as owner of the property, or my errocryees wtth wages as = 1
'their sole compersadc(- w10 do the work and the strt C re b
not irrbonclod or offered for sale (Section 7044, Blreiraees and s AST.
Professions Code.) Y&L T1i APPLIGWT OR FUTLFE BL DING CCCLFWT HMDLC A HAZ.AFDOUS M4EFNL � L
El 4 as owner d the property, em exCkiaivety CorTtteotirrg wtttl
OR A ID(TLFE COKMANG A FIAZAFDOUe AA4PliAL ECI W TO CR ORF DER hHH THE ]�] 3. 202.L5
ALOLWTS DPECFED ON TIE FLALAFtD(Xle M4Txua WCFBAAT"GLIDE? FIL46L BY
Ioerrsed oa trackxB to ooratlict the p QJad (Section 7044, q ? ITEftS
Blaness and Profeeal ne Code.) YES El •,
55LL THE INTDC&Uff OF TFE RAX24G BY TFE AF'FLIC'JJfT OR R1T1JFIE BULCMIO C'
OCCUWWT A PEF"T FOR CQ�TFiUC,ION OR N4CCr_QlON FROU THE SCUM ,( TuTAL 306 _ 05
CONSTRUCTIQN LENDING AGENCY COAST AFL r MAXACE err DW FScr cscwnD)SEE PEmK7140 a c+araT FOR �/C( � o?(iZT- 7 /'-r_r��•{� -}�,L ry�
I hereby atflmn that ttTere b e construction Iendfng egerxy for -tea❑ ,,,,yQ a3•�-�/° {�yy� I
N the perforrrenos of the work for which thie permft b blued(Sea No- t-f fa AGE .eo
FWE WOWIMON OLCE AND TFE 8CAOAD PWUTTNO Q
a 3087,CN.C.) i II1 LOCER THE LOB ANGELES COUNTY COOF_
2,C3H PTEA 100 T1fi0LKFi 2TO 140 CONCERNING HAZAFIX"
Loaders Name A PEF"T FF"A TFE 8CAOJa
Leaders Address OCOD D 1 2/22/9'
a I certify ffmd I have read this application and state under perrefty P.0 FEE Pp71A r FSE 4LI43 1 AM 11:03
of p"x y that the sbo hdormeflon Is correct I agree to oon#y /
Wth all Or�LrrerlOee State Laws rektvu to wung f�
repreeertaftvee of mire co F t�3UANCE F{E
er#x LpOn property for'nepecUon--%� C1
o � I4VE3TIOA7I0N FEE TQPL FEE /y
o.. SEE REVERSE FOR EXPLANATORY LANOUAGE