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HomeMy Public PortalAbout11007 GREEN TREE LN_Building__ WORKERS' CO MPENSATION'DECLARATION I hereby affirm.that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, -APPLICATION FO.R BUIALDINGPERMIT ' or a certified copy thereof (Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY •. Policy No. Company El Certified copy is hereby furnished FOR APPLICANT TO FILL IN • BUILDING ADDRESS Certified copy is filed with_the county building inspec- BUILDING tion-department. ADDRESS ��/ Date' Applicant• 1 CITY ZIP / LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS`',` "` NO-OF BLDGS. - - NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. w (hunThis'section need not be completed if the permit"is for,one - - " ASSESSOR dred,dollars ($100)or„less.,) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL Q (2 9TQ- TEL.` - J USE ONE MAP � k7/T I / //�q I certify that in the performance of the work for which this OWNER' NO: NO. permit is is ued, I shall not employ any person in any manner ( �j r /I SPECIAL ADDRESS / �/ �� CONDITIONS �O so as to b ome su ie5t to the Wor 'Comp ensatioL�a)wss. %1✓f V. CITY L �' ..ZIP Date pplican't ARCHI CT OR . TEL NOTI E TO APPLICANT: If, afte m6 ing this Certificate of DISTRICT. _GROUP- TYPE ONST. FIRE PROCESSED BY 0 ENGINEER NO. Exemption, you should become subject to the Workers' 2 b Compensation provisions of the Labor Code, you must forth- ADDRESS -5,.( �� �f � CL with comply with such provisions"or'•this, permit shall be -" TEL: 7 STATISTICAL CLASSIFICATION APT. C DO.' deemed revoked. CONTRACTOR (, �(� NO LICENSED CONTRACTORS DECLARATION 'C CLASS L/ ( CLASS NO. !i DWEiC. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Z NO. (commencing with Section 7000)of Division 3 of the Business.andLIC. SEWER MAP Professions Code, and my license is jn full force and effect. CITY J�' CLASS BK pC VALIDATION �/� SQ. F . NO. OF NO OF• CHECK Nu License b' i 6 UC'.Class SIZE STORIES FAMILIES J ONE V ION Contracto ' )b Date. •, �: rax✓ DESCRIPTION OF WORK1_0}C /t=, NEW � [ L ADD ❑ am exempt under Sec. 062 'E]ALTER r• B.&P.C. for this reason REPAIR $ USE OF Date: DE EXISTING BLDG. �' �+� �t[�� .��+ � - " • -- - Signature APP A �S lel PRINT) ` � FINAL r�rt OWNER-BUILDER DECLARATION DATE 2:5 12 6 A "- I hereby affirm that I am exempt from the Contractor's License r � !7,�/_� Law-for the following reason (Section 7031.5, Business and ADDRESS rC. FINAL ` - - # 0 0 0 0 0 1. Professions Code): PRESENT BY BUILDING i o - 4(150 F1 I, as owner of the property, ormyemployees with ADDRESS _ wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' °'o o 4 Q 5 051 7044, Business and Professions-Code).' MOVING -` TEL: 1, as owner of the property, am exclusively contracting CONTRACTOR NO. 2 4 c 8 �' `with licensed contractors to construct the project (Sec- ' 0 7 6' tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL.SETBACK.FROM XI _ CONSTRUCTION LENDING AGENCY SET BACK . :YARD HWY''" PROP. LINE WIDTH, 1 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 m P.L. _ Lender's Name /� LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee V pool- 1 certify that I have-read this application and state that the - Issuance Fee- ,V LDMA P/C# - above information is correct. I agree to comply with all County Investigation Fee �r ordinances and St laws relating to building construction, ,_. Total LDMA Perm. # v and h by auth r resentat' i County to enter - u th above nti ed pro in ectio purp ses. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o pplicant or Agenr 7 Date WORKERS' COMPENSATION DECLARATION A insverz'r'or.afcertifoate of WdrkersrtComtpensat on elnsuran ificae of consnt to elf APPLICATION, FOR BUIL DING PERMIT or a certified copy thereof (Sec,.3800, Lab. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Company ,Cer 'ed copy is hereby furnished. . FOR APPLICANT TO FILL I BUILDING ADDRESS ,Certified copy is filed with the county buildin inspec- BUILDING a Ti on•department., r ADDRESS /11NCTS d DateApplicant CITY Z / LOCALITY r CERTIFICATE OF EXEMPTION OM ORKERS' / NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT (��l NOW ON LOT CROSS ST. (This se6Tion-need,not be completed'if-the permit is for one ASSESSOR hundred_'dollars•($100)or less.,) TRACT ' BLOPr, LOT NO. MAP BOOK PAGE PARCEL TEL. USE ZONE MAP I certify that in the performance of the work for which this OWNER N 7 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 r� CONDITIONS O V CITY ZIP Date 'Applicant ARCHITECT OR NOTICE TO'APPLICANT: If, after making this Certificate of DISTRICT. GROUP. TYPE FIRE PROC 5ED BY ENGINEER CONST. Exemption, you should become subject .to the Workers' ' / ZONE `J LU Compensation provisions,of the Labor Code, you must forth- ADDRESS ✓ �✓ �/.- with comply,with such provisions or this permit. shall be F TEL. STATISTICAL CLASS FICATIONAPT. I CO DO. deemed,re_yoked. .. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LI CLASS NO. DWELL. UNIiS _ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP Professions Code, and'my Iicense-is in full force.`and effect. CITY CLASSBK` VALIDATION SQ. FT. NO. OF NO. OF CHECK og License Number © Lic.Class SIZE STORIES FAMILIES ONE cLUATION RK NEW Contractor ��/ / •' ��LY�r/Date DESCRIPTION OF WO❑ ADD ;2 3 2 1 5 2 A I am exempt under Sec. - ❑ ,. ALTER B.BP.C. for this reason REPAIR $ # go' o o 23 ❑ �aJ Date:" DEMOL USE OF ❑ EXISTING BLDG. 13 9 4 9 4 Signature APPLICANT TEL. FINAL +g /'' _ (PRINT) �j„(/ NO. / '1 ` a a 3 9_u,9 4.0. OWNER-BUILDER DECLARATION DATE G` 4.J I hereby affirm that I am exempt from the Contractor's License Law for the following:reason (Section 7031.5, Business and ADDRESS FIN OS3 0-8 5 Professions Code): PRESENT BY ❑ BUILDING I, as owner of the property, or my employees with ADDRESS . . „. wages as their•sole compensation,will do the work and The structure is not intended or offered for sale(Section LOCALITY z 2 ilS,3 A '7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. # 0 0 0 0 01 with licensed contractors To construct the project'(Sec- tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK.FROM EXIST. 644,25 CONSTRUCTION LENDING-AGENCY- SET BACK YARD HWY PROP. LINE WIDTH " I hereby affirm.that there is a construction lending agency for FRONT 0 0 6 4 IL 2 5 x the performance of-the-work for-which this permit is,issued P.L. — -- - (Sec. 3097, Civ. C.). SIDE t P.L. S3 0•-8 5 Lender's Name m 313,-7 LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee- [ > z I certify that I have read this application and.state That the (l9 t ( Issuance Fee J 1/ LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ordinances_ and State laws relating To building construction, Total Fee , LDMA Perm. # - v and re y authorize re ese five of this County to enter m u n Th above-menti n d eri or inspection purposes. Q SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pplica;t or Agent ^ Date