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Home My Public Portal About11003 GREEN TREE LN_Building__ WORKERS'COMPENSATION DECLARATION t hereby affirm fica I hover certificate of consent to self APPLICATION:. FOR BUILDING PERMIT insure, or a certificate of Workers' Com lensation Insurance, or a certified copy thereof(Sec. 3800, L . C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company BUILDING Certified copy is hereby,furnished. ' FOR APPLICANT TO FILL IN ADDRESS a Certified copy is filed with the county building inspec- BUILDING V tion department. ADDRESS Date _ Applicant CITY ZIP V LOCALITY CERTIFICATE OF EXEMPTION FRO ORKER NO. OF BLDG& - NEAREST COMPENSATION INSURA CE SIZE OF LOT NOW ON LOT CROSS ST. .(This section need not be completed if the permit is for*one •- ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL USE ZONE MAP I certify that in.the performance of the work for which.this OWNER > O. �% NO. ��7 permit is issued, I shall not employ any person in any manner- ////II SPECIAL - tL so as To become subject to the Workers'Compensation Laws. ADDRESS 1- CONDITIONS O u CITY ZIP_ QP Date Applicant ARCHITECT OR TEL. O NOTICE TO'APPLICANT: If, after' making this Certificate of DISTR . .,GROUP ONST ZONE PROCESSED BY ENGINEER NO. Exemption, you should become subject to the Workers' S //�f Compensation provisions of the Labor.Code, you must forth- ADDRESS • -1 � EL with comply with such provisions or this permit shall be - �/� Z deemed revoked. . TE 9"'1d STATISTICAL CLASSIFICATION APT. CONDO. — CONTRACTOR NO 'TO LICENSED CONTRACTORS DECLARATION J LIC.- CLASS NO. DWELL. UNITS I hereby affirm that I am licensed,under provisions of Chapter 9 ADDRESS/ NO. SEWER MAP (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 .06 BK PG VALIDATION SQ. FT. NO. OF NO. F CHECK License Nu r Lic.Class SIZE STORIES FAMILIES ONE C VALUATION - --. DESCRIPTI N OF WORK EW / Contractor Date — ADD ❑ $ —' I am exempt u r Sec. ' ALTER B.&P.C. for this reason REPAIR $ -"- Date: USE OF DEMOL Q Z EXISTING BLD �6 4-3 9-A- A A Si nature APPLICANT r TEL. g PRINT r NO. FINAL # o"o 0 0.o OWNER-BUILDER DECLARATION DAT I hereby affirm that I am exempt from the Contractor's.License ,o-- 4.9,8.8 Law for the following reason,(Section 7031.5, Business and ADDRESS FIN Professions Code): PRE ENT gY o o b'(a 9 8 8BUILDING 0 I, as owner of the property, or my employees with ADDRESS /) 3Y l 0 1,2 9:i°8.7 rk wages as their sole compensation,will do the woand l I 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 construct the project-(Sec- ADDRESS Tion 7044, Business and Professions Code), REQUIRED YARD HWY TOTAL SETBACK FROM T.:. 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 i m P.L. a Lender's Name m 2 �/ LDMA Ref. #- Lender's Address P.C. Fee$ - Permit Fee ✓ IM- I — I certify that. I have read this application and,state that the _ -- Issuance Fee D1kLD P/C# • a above information is correct. I agree to comply with all County Investigation Fee f� ordinances and State laws relating To building construction, Total Fee t U LDMA Perm. # u and hereby authorize representatives of this County to enter u the above-mentioned property for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica t or ent - Date �° WORKERS'COMPENSATIC,N DECLARATION ? `� hereby affirm that I havea certificate consent to self APPLICATION FOR B U I L p I N G- PERMIT Tnsue;roi-a certificate of WorRers' Compensns ation Insurance, or a-certifio copy thereof (Seca 3800, L c. COUNTY OF LOS ANGELES' BUILDING AND'SAFETY Policy N -I;f GC�Company ❑ Cert'fied copy is hereby furnished. FOR APPLI j BUILDING ADDRESS ertrfied copy is filed with the county building inspec- BUILDING / `s tion department.' ` ADDRESS / �f Date Applicarit c� CITY ZIP 1 ( 6 LOCALITY ( [ CERTIFICATE OF EXEMPTION FROM WORKERS' 7 ✓G� / NO. OF BLDGS. Q NEAREST r COMPENSATION INSURANCE' SIZE OF LOT �T K ✓ ! NOW ON LOT CROSS ST. (Th'is'section`-need not be completed if the permit is for one / ASSESSOR ' hundred dollars ($1.00)or.less.) TRACT BLOCK LOT NO. ( MAP BOOK PAGE' PARCEL ` TEL. OWNER NO USE ZONE MAP If f1 7 I certify that in•'the.performance of the work for which this ,/)�� NO. (J V / 'IC` permit is issued, l shall not employ any person in any manner SPECIAL so as'to become subject to the Workers'.Compensation Laws. ADDRESS , / CONDITIONS i . Date 'ApplicaCITYZIP ARCHITECT OR nt NOTICE TO APPLICANT: If, after making this 'Certificate of ENGINEER ..��` DISTRICT, GROUP TYPE, FIRE PROCE ED.BY 0 Exemption, you should become subject to'the Workers' J CONST. ZONE W Compensation provisions of the Labor Code, you must forth- ADDRESS AVuA �" V J with comply with such provisions or this permit,shall be TEL STATISTICAL CLASS( (CATION APT. COND deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS � _ (commencing with Section'7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK VALIDATION �{//��1 SQ. F2'.'y NO. OF NO. OF _CHECK License Number �U`� Lic.Class SIZE w�i� O STORIES � FAMILIES ONE �� .S- uanoH DESCRIPTION OF-WORK NEW Contractoy ate ❑ $ six r_ /J ADD ❑ I am exempt under Sec. �G• ❑ , ALTER B.&P.C. for this reason REPAIR ❑ $ "? J �� USE OF / 121 3.2 A Dote: EXISTING BLDG. DEMOL ❑ APPLICANT TEL. Signature FINAL # 0-o 0 0 ?y OWNER-BUILDER DECLARATION (PRINT) NO. DATE C ' hereby affirm.that Lam exempt from the Contractor's License I - 38 690 Law for the followingreason' Section 7031.5, Business and ADDRESS FIN o 0 ( s _ 386.9C::- Professions Code):' PRESENT •❑ BUILDING - - 1 7 I, as owner of the-property, or my employees with ADDRESS G�J�—g wages as their 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. ' M,2 1 3 A ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. �I with licensed contractors to construct the project (Sec- # 0 0 0 0 0 1 tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH, 16 6 0,75 I hereby off irm that there is a construction lending agency for FRONT the-performance-of the work for--which this permit is issued P.L. 0 a 66 0,7 5=, (Sec. 3097, Civ. C.). SIDE P.L. =8 5 o Lender's Name _O �a 5 �� Lender's dress LDMA Ref. # AdP.C. Fee$ -- _ Permit Fee certify that I .have read this application and state that The t Issuance Fee t LDMA(P%C:# above information is correct. I agree to comply with all County Investigation Fee m ordinances and State laws relating to building construction, Total Fee - LDMA Perm. # v and eby autho ' ere a entatives of this County to enter m up t e above do r rty for inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Applicant o Agent - Date