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Home My Public Portal About11006 GREEN TREE LN_Building__ f; WORKERS'COMPENSATION DECLARATION insureboraafcertifcafirm t horteoaWorkes' CompensatonInsuranelf - APPLICATION FOR BUILDING PERMIT .ora certified cop'Ohereof<(Sec. 3800, ) COUNTY-OF LOS ANGELES BUILDING AND SAFETY Policy `G Company Q Certified copy is hereby furnished.: . BUILDING FOR APPLICANT TO FILL IN ADDRESS �(J�j ,�. 001.., Certified copy is filed with the county building-inspec- BUILDING tion department.' ADDRESS • t_L DateApplicant CITY ZIP 2606 LOCALITY �. CERTIFICATE OF EXEMPTION FROM WORKERS' "' NO.OF BLDGS.- NEAREST COMPENSATIONJNSURANCE.`•' SIZE OF LOT �/rg NOW ON LOT CROSS ST. (This'section 'need not be completed'if the'permit is for one TRACT L BLOC LOT NO. MAP BOOK' PAGE•ASSESSOR PARCEL F hundred dollars ($1.00)or less.). , ry(� - „ -, OWNER ® ( / USE Z NE' OP 9 I certify:that in.the performance of the work for which this �p - O '4� IL permit is issued,'l shall not employ any perso" in any manner r'�� SPECIAL• - so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS U CITY ZIP Date Applicant, ARCHITECT OR DISTRICT G OUP TYPE FIRE _ PROC SED BY o NOTICE' TO APPLICANT:'Af, after making this 'Certificate of �� 0 ENGINEER CONST. ZONE V Exemption, you should. become subject to the Workers' _ W Compensation provisions of-the Labor Code; you must forth- ADDRESS G �' X -3 - .with comply,with,.such ,provisions or this permit shall be TEL. STATISTICAL /JCLASS L FCop.ICATION APT. Z deemed revoked. CONTRACT NO. LICENSED CONTRACTORS DECLARATION LIC CLASS NO. 01 1 DWELL. UNIYS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESSN (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 PG. - VALIDATION SQ. FT�n',� STC OF _ NO. OF CHECK License Number Lic.Class /J SIZE iL O .J STORIES FAMILIES ONE . . _ LUATION lJ DESCRIPTION/OOFF�WORK - NEW,e $ Contractor ��/ � jiC Date /G_ ADD R_21 5.4 A M I am exempt under Sec. —' , ALTER•' ��+ 606 s / # a ° aa23 - B.&P.C. for This reason ❑.REPAIR ' _. Date: USE OF DEMOL , ❑ EXISTING BLDG.. I- o394,94 Signbture APPLICANT TEL.' FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE '. o a 3 9 4,9 4 5 I.hereby affirm that I am exempt.from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions-Code): PRESENT B o,�30=85 .: BUILDING F 0 I;, as owner of the property, or my employees with ADDRESS y _ wages'as their sole compensation,will do the work and a f' the structure is not intended or offered for sale(Section LOCALITY ' 4• }; 7044, Business-and Professions Code). MOVING " TEL. i z'2 1' 5 n I, as owner of the property, am exclusively contracting CONTRACTOR NO. -with licensed contractors to construct the project (Sec- ADDRESS #-0 0 0 0 6 1 Tion 7044, Business and Professions Code). T. CONSTRUCTION LENDING AGENCY' SETT BACKK YARD HWY TOTAPSETBACKOEFROM yylDlH I -64A25 I hereby affirm that there is a construction lending agency for FRONT o a 64 /� 2 5 5 the performance of the work for which this permit is-issued P.L. - (Sec. 3097, Civ. C.). SIDE i• if3 0-8 5. P.L. Lender's Name m 53 C'� LDMA Ref. # Lender's Address RC:fee$ Permit Fee V - > Q t I certify that 1.have read this application and state.that the ( L Issuance Fee- SO -LDMA P/G# Q above information is correct. I agree to comply with all County Investigation Fee ordi ces and State jaws relating to building construction, Total Fee -, X414 12LDMA Perm:-# - - u h reby authorize�resZentatEiivesof this County to enter po he abov ntnspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent- Date - '• - - - - '_ - - WORKERS'COMPENSATION DECLARATION iosurt'or'af e�rtif carte of Worke s' Compensat on a certificate ofconsentInsuto sf ran e, A P P L I CAT I O.N...FOR ,BUILDING PERMIT or'a certified copy the of (Sec. 3800, Lab. C-.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No_Company �� 1 fT I IL �� ❑ Certified co is hereby furnished. FOR.APPLICANT TO FILL IN BUILDING f copy y ADDRESS -„ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS L�J CSNrZ.F— LAI Dater Applicant CITYfZ_M ifEY ZIP. / O LOCALITY CERTIFICATE OF EXEMPTION FR M WORKERS' "' NO. OF BLDGS. NEAREST - COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (Thjs 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 rr TEL. -- OWNER (� 1+r NO. Q' " 7�'� USE NE MAP I certify that in the performance of the work for which this NO. permit is issued,'I shall not employ any person in any manner SPECIAL !� ADDRESS so as to become subject to the Workers'Compensation Laws. CONDITIONS r - CITY 7Q IM Date' Applicant ARCHITECT OR TEL. O DISTRICT G OUP:. TYPE FIRE PR ESSED BY. NOTICE TO APPLICANT: If; after'making this Certificate of ENGINEER NO. ' CONST. NE I.- Exemption, you should become subject to the Workers' / ,M, Compensation provisions-of the Labor Code, you must forth- ADDRESS /// �/ 9L with comply-with such provisions or,this, permit shall be - TEL. STATISTICAL CCA,SIFIfATION APT. NDO. deemed revoked. CONTRACTOR S NO LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affjrm that I am licensed under provisions of Chapter 9 ADDRESS I,,.` '4 f L NO. -1 Ll k;)L� (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 (�Q I�f CLASS "IU BK PG VALIDATION SQ. F_T. �j NO. OF NO..OF. CHECK License Number�a2/ Lic.Class ` SIZE �1 STORIES FAMILIES ONE • `e qe�� r• /1 [ VALUATION Contrbctor Live-'s Y Date 4 b ' / "C7 DESCRIPTION OF WORK S' C �, q' A D ❑❑ $ .70 ❑ I am exempt under Sec. -L'T %L(-' ❑ Poo. ALTER .B.BP.C. for this reason REPAIR ❑ $ --. Date: USE OF DEMOL ❑ EXISTING BLDG. Signature APPLICANT TEL. *��j FINAL g OWNER-BUILDER DECLARATION PRINT) l)SS � -N NO• 7~ J' ' DAJE �� 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 B 2453. 1 A BUILDING ❑ I, as owner of the property,_or my employees with ADDRESS # 4 ;0.a 0. a 1 _. wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' a o 3 3,Q 0 7044, Business and Professions Code). -- MOVING TEL CONTRACTOR NO. 5 ❑ I, as owner of the property, am exclusively contracting o 0 o3 � Q Q� with•licensed contractors'to construct the project (Sec-. ADDRESS tion 7044, Business and Professions Code). O 4,24-86 . CONSTRUCTION LENDING AGENCY' SETT BACKK YARD HWY 'TOTA SETBACK F OM 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 _ � CDMA Ref. # Lender's Address P.C.-Fee$ Permit �� ' I certify that I have.read this application and state that the Issuance Fee J (/ CDMA P/C# a above information is correct. I agree to comply with all County Investigation Fee /� ordinances and State laws relating to building construction, Total Feer rV -CDMA Perm. # v and hereby authorize representatives of.this County to enter u on the a o -m tioned p o er or inspec.tIO5 purp ses. a SEE REVERSE FOR EXPLANATORY LANGUAGE I Signature of Applicant or Agent- - Date