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Home My Public Portal About11010 GREEN TREE LN_Building__ WORKERS'COMPENSATION DECLARATION I hsure, y a certificate that I h for certificate of consent to self A P P L I CATION FOR. BUILDING PERMIT C insure, or o certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800; L' COUNTY OF'LOS ANGELES BUILDING AND SAFETY Policy J qAVffVZ�(0m' pany Cer ed copy is hereby furnished.. FOR APPLICANT TO FILL IN BUILDING ADDRESS 11616/O �o A��: Certified copy is filed with the county:buildirig inspec- BUILDING Tion deportment ADDRESS �.y. Date Applicant CITY G� ZIP V LOCALITY CERTIFICATE OF EXEMPTION fROM WORKERS' NO.•OF BLDGS. NEAREST -COMPENSATION INSURANCE SIZE OF LOT y�/�9 NOW ON LOT CROSS ST. ' (Tkissection need not be completed if'the.permit is for one ASSESSOR hundred dollars,($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL OWNER USE ZONE MAP 12-77 (.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 - CL so as 10 become subject to the Wackers'Compensation Laws. ADDRESS Gv CONDITIONS O CITY ZIP O Date 'Applicant' ARCHITECT OR O NOTICE TO APPLICANT'.'If, after making this`'Certificate of DISTRICT GROUP. TYPE-_ FIRE PRO ESSED BY I-. ENGINEER CONST. ZONE V Exemption, 'you should become subject to the Workers' - 5`'(� 3LU Compensation provisions of the Labor Code, you must forth- ADDRESS ` Q. r� ✓ ' y with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSLUC TION APT. CO Z deemed.-revoked. CONTRALTO NO. l/1/) LICENSED CONTRACTORS DECLARATION a/ CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS CJ•1 (commencing with Section 7000)of Division 3 of the Business and LIC. /�� SEWER MAP Professions Code, and my license'is in full and effect. CITY CLASS �7 BK VALIDATION SQ. F_ NO. OFNO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE �/,p& &140 ; _ val ATION Contract tate DESCRIPTION OF WOK NEW - � � ADD I am exempt under Sec. -� ` ALTERB.& SE OF P.C.C. for this reason REPAIR -0 S � -' -221 `a d A ' Date: DEMOL EXISTING BLDG. Signature APPLICANT' TEL. FINAL # o o 0 o 2 3 OWNER-BUILDER DECLARATION PRINT) NO. DATE (� •1 hereby affirm that I am exempt:from-the Contractor's License I o394,94 Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code')' PRESENT 'BY BUILDING EJ I, as owner of'the property, ormy employees with ADDRESS f ', .+• � 6�;}U�'�J� 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. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS o tion 7044, Business and Professions Code). 2 5 A CONSTRUCTION LENDING AGENCY SETT BACKK YARD HWY TOTAPREOP.LINE WIDTH EXISWIDTH # 0 0 0 0 0 1 hereby affirm that there is a construction lending agency for FRONT ° 6 4 4,2 5 the performance of the work.for which-this permit is issued P.L. - 0 0 6 4 4 (Seca 3097, Civ. C.) SIDE �ZSc 5 Lender's Name �. 1 uL7 LDMA Refs W, P.C. Fee$ Permit Fee .s 75 Lender's Address + ' _I certify.that I have read this application and_state that The 3 A 9 Issuance Fee (/ LDMAtP/C#1; 1<, a above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee-• r LDMA Perm. # v and by authorize prese tive of this County to enter up n e above-men d e for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of pplicant or Agent - Date -• - - - -- OP WORKERS'COMPENSATION DECLARATION su� qOta certificate of consent self a certifcate of Workes' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certifieb'copy thereof (Sec. 3800, Lab. C.') COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company - Certified copy is hereby furnishedBUIL . FOR APPLICANT TO FILL IN ADDRDESSING Certified copy is filed with the county building inspec- BUILDING t tion department. ADDRESS LOCALITY NEAREST Date Applicant CITY C— ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' % NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT •^r NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be.complete l if the permit is for one US ZONE MAP �[ Z hundred dollars ($100)or less.) TRACT / BLOCK LOT NO. NO. TEL. _/� SPECIAL 1- I certify that in the performance of the work for which this OWNER NO. CONDITIONS permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYP FIRE PRO ESSED BY O so as to become subject to The Workers'C pe tion Laws. ADDRESSCi �`)d NST. ZONE ` UU CIT Date Applicant C ZIP STATISTICAL CLASSIFICATION APT. JC0NDO. NOTI TO APPLICANT: If, after making this Certificat o ARCHITECT OR TEL. Exemption, you should become subject to •the Wor ENGINEER NO. CLASS NO. DWELL. UNITS � Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions.or this permit shall be TEL deemed revoked. CONTRACTOR NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm That I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. J Professions Code, and my license is in full force and effect. CITY CLASS SQ. FT. ` NO. OF NO. OF CHECK License Number Lic.Class SIZE (� STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK NEW $ I am exempt under Sec.' DD ALTER E] FINAL B:&P.C. for this reason REPAIR DATE ' 09 e USE OF ❑ Date: EXISTING BLDG. DEMOL FIN N Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT NO. 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 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 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). ;2 5 9 0 6 A REQUIREDTOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH # 0 0 0 0 0,1 I hereby affirm that there is a construction lending agency for FRONT ' P p r' Ioa4050 the performance of the work for which this permit is issued P.L: (Sec. 3097, Civ..C.). SIDE Lender's Name PA. 0 0 0 4(] 5 0 $ Lender's Address P.C. Fee$ Permit Fee ' 1 1, 1 O�8 6 I certify that I have read This application and state that the Issuance Fee G above information is correct. I agree to comply with.all County Investigation Fee $ ordinances and State laws relating to building construction, Total Fee u and hereby authorize repress tatives'of this County to enter upo he above-mentioned r p f r inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE ro• c+ - ®s ' Sig Lure of Applicant or Agent Date