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HomeMy Public PortalAbout11002 GREEN TREE LN_Building__ d, WORKERS"COtMPENSATION DECLARATION t hereby affirm d f''co I;have r ,certificate of consent to self APPLICATION. FOR BUILDING PERMIT insure, ori cer'lificate of Workers' Compensation Insurance, ' or a certified copy theieof (Sec. 3800, Lab. C. I - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N 6mpany ° Certfd copy is hereby fu ished. FOR AP'AlC FI BUILDING /t ADDRESS (J A��Cert�,',fi'ecl copy is filed with the county building inspec- BUILDING Mon epartment. ADDRESS Date Applicant CITYZ;z ZIP LOCALITY a , CERTIFICATE OF EXEMPT IO 'FROM W RKERS' ' n G� NO. OF BLDGS. NEAREST _ COMPENSATION INSURANCE SIZE OF LOT /XJ NOW ON LOT O CROSS ST. (This section need not be completed if the permit is for one LOT NO. `-_/,? ASSESSOR hundred dollars ($100)or less.) TRACT //� BLOCK MAP BOOK PAGE PARCEL / TE� USE ZONE MAP j�^{2 I certify that in the performance of the work for which this OWNER ( N Q NO. permit is issued, I shall not employ any person in any manner / SPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS /� CONDITIONS �O CITY ZIP @lo Date Applicant ARCHITECT OR TE NOTICE'TO APPLICANT: If; after, making this Certificate of ENGINEER N DISTRICT GROUP. TYPE FIRE PRO ESSED BY 0 Exemption, you should become subject to the Workers' _/f CONST. ZONE Compensation provisions of The Labor Code, you must forth- �` S-. 0 V with comply with such provisions or this permit shall be ADDRESS TEL. deemed revoked. CONTRACTOR NO. Q STATISTICAL CLASSIFICATION APT. CO O. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS Ft J 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS rn N (commencing with'Section 7000)of Division 3 of the Business and SEWER MAP UC # 0 0 0 0 ti"f i Professions Code, and my license is in full force and effect. CITY �j(f(7 CLASS BK. PG VALIDATION j` SQ. FT. NO.OF NO.OF CHECKI o iJ ,2 License Number KS✓ Lir.Class SIZE STORIES FAMILIES ONE � VALUATION o o 1 54,92 c. M��� _ s Q DESCRIPTION OF WORK NEW $� 01 Contract +4/>u, ate ADD 7�� , :31/3 O I am exempt under Sec. _ ALTER 8.&P.C. for this reason REPAIR .� $ r-7 00 Date: USE OF EXISTING BLDG. DEMOL 9 Signature APPLICANT TEL. FINAL I 6 5,C" t OWNER-BUILDER DECLARATION (PRINT) NO. DATE hereby affirm that I am exempt from the Contractor's License 1 o 3 C,'.77 w) -- Low for the following reason (Section 7031.5, Business and ADDRESS FINA [ = Professions Code): PRESENT By ❑ BUILDING e i I, as owner of the property, or my employees with ADDRESS < wages as their sole compensation,will do the work and 0 J,0 '"5 the structure is not intended or offered for sale(Section LOCALITY ' 7044, Business and Professions Code). MOVING TEL. i I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed,contractors to construct the project (Sec- ADDRESS ' tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM I CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH a. 13 I hereby affirm that there is a construction lending agency for FRONT 11,' the performance of the work for which this permit is issued P.L. Ao 4 o ° a (Sec. 3097, Civ. C.). SIDE 6 6 Q, ;✓ m q P.L. n U 1� Lender's'Name . `� 3`71 �l 56 � LDMA Ref. # P.C. Fee$ (J Permit Fee (ft - - Lender's Address ' 5 1� t I certify that I have read this application and state that the !t '2 Issuance Fee kLDA P, # above information is correct. I agree To comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee6 LDMA Perm. # d and eby author' rep s ntatives of this County to enter u n t e above- en io d ty for inspection purposes. �� SEE REVERSE FOR EXPLANATORY LANGUAGE 7 \ O J Signature of Ap licant or Agent Date WORKERS' COMPENSATION DECLARATION hereby affirm that I 'haver certificate of consent to Self APPLICATION FOR BUILDING PERMIT insure, or d certificate of Workers' Compensation Insurance, � or a cern i o copy thereof (Sec. 3800, L b. C.) i• COUNTY OF LOS ANGELES BUILDING. SAFETY Po(icy No Company ..- .. _. . - ..._. ... -_ 0, Certified copy is hereby furnis ed.;'_ : FOR APPLIC NT TO FILL IN BUILDING Q •. ADDRESS XCertified copy is filed with'the ty wilding`inspec- BUILDING ' tion'd'epartmenT: �' ADDRESS Date i i Applicant CIT ZIP. LOCALITY CERTIFICATE OF=EXEMPTION FROM RKERS' NO. OF BLDGS.- NEAREST .COMPENSATION INSURANCE ' SIZE OF LOT NOW ON LOT CROSS ST. (This section need not red be completed if the permit is for'one - - - ASSESSOR hunddolfars.($100) TRA or less.) CT. BLOCK LOT NO. MAP BOOK PAGE PARCEL I' TEL. I Z^ USE ONE MAP J I certify that in The performance of the work for which this OWNER' N NO. permit is;issued, I shall not employ any person.in any manner SPECIAL. /, 9 G O Cf-� so as to become subject to rhe-Workers'CompensaTi'on Laws. ADDRESS- — CONDITIONS CI.TY_._... Date Applicant tit NOTICE'TO APPLICANT: If, after making this�Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED.BV ENGINEER Exemption, you should become subject to the Workers' . -"' n�/ C ZONE � Compensation`provisions of the Labor Code, you must forth- ADDRESS V _3� �� - LM with comply-with such provisions or this permit shall be - - of T STATISTICAL CLASSIFICATI APT. CONDO., deemed revoked. .• CONTRALTO IN LICENSED CONTRACTORS DECLARATION LIC. UASS NO. DWELL: UNITS I hereby affirm_ that.I am licensed under provisions of Chapter 9 ADDRES NOiJ (commencing with Section 7000)of Division 3 of the Business and _ ` / .LIC. SEWER MAP PG Professions Code; and my license is in full force End a ect. CITY 6 CLASS BK VALIDATION' SQ. FT. NO. OF NO. CHECK License Number Lir.Class SIZE STORIES FAMIL ONE 6 VALUATION ' II DESCRIPTION OF WORK' - NEW-- Contractor Date I � ADD _ M I am exempt u er Sec. W Q Pilo. • r ALTER B.BP.C. for this reason REPAIR USE OF DEMOL Q _ Date: EXISTING BLDG. S.> n Signature APPLICANT r f TEL_ ,7 X 6 4�I � A - FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE �� �GC1 =2• # © o'o o.o I hereby affirm that.I am exempt from the Contractor,'s License Law for the following reason (Section 7031.5, Business and ADDRESS FIN 10',0'4 9 8 8 Professions Code); ... PRESENT._ .. _ - By ❑ BUILDING + I, as owner of the property, or my employees with ADDRESS °'°' ° 4.9 8`8 wages as their sole compensation,will do the work and . the structure is not intended or offered for sale(Section LOCALITY Q 1,2 9.'•-;8 T' 7044;Business and Professions Code)." MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). _.REQUIRED YARD HWV' TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK 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 P.L _ Lender's Name o LDMA Ref. # ' P.C.-Fee$- ._ ... _• Permit Fee-..- -kDMA Lender's Address_,I certify that I hove read this application-and state that the Issuance Fee- fil1 P/C# -- a above information is correct. I agree to comply with all County . Investigation Fee 0 ordinan s and State laws relating.to building construction, -Total-Fee r- LDMA-Perm. #' d and h by authorize representatives of this County to enter u o e bove- ent' ned proprty for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Applicant or Kg Date