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Home My Public Portal About11014 GREEN TREE LN_Building__ WORKERS' COMPENSATION DECLARATION ~I sure .aff�m-that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS / Certified copy is filed with the county building inspec- BUILDING ❑ tion department. ADDRESS �i c 0, il LOCALITY Date Applicant CITY' W, ZIPEAREST 'TiiCROSS ST. -CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one ONE MAP 2-7hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. ! J v c TEL. '�/ SPECIAL � I certify that in the performance of the work for which This OWNER O NO. Jr'2' CONDI S permit is issued, I shall not emplo any person in any mann PP pp � DISTRICT G UP TY FIRE PRO SSED BY O so as to become s bject To the W r ers'Comp n ti n Co ADDRESS ON G w1 �./f� �. C ST. ZONE V CITY�_� ��T ZIP O Date Applicant STATISTICAL CLASSIFICATION APT. CONDO. V NOTICE TO APPLICANT: If, after%making this Certificate of ARCHITECT OR TEL. Exemption, you should become subject to the Workers' ENGINEER NO. CLASS NO. '2-4 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. 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 DESCRIPTION OF WORK NEW $ Contractor Date ❑ ADD ❑ I am exempt under Sec. ALTER ❑ FINAL _ 1 B.&P.C. for this reason ❑ DATE G REPAIR Date: USE OF FIN: EXISTING BLDG. DEMOL ❑ By Signature APPLICANT (�, ` _- TEL.�-^� OWNER-BUILDER DECLARATION PRINTtC.G�fT NO.� C`��Z Cv I hereby affirm that I am exempt from the Contractor's License ''`` r ► 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. ' t 5 8 8,2 A ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. w'r #,a a C oil -with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). ;� o o 4 9 8 8 REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH = I hereby affirm that there is a construction lending agency for FRONT ° ° ° 4 9 8 8 5 the performance of the work for which this permit.is'issued P.L. , 11,06-86 (Sec. 3097, Civ. C.). SIDE m P.L. Lender's Name Lender's Address P.C. Fee$ Permit Fee /� •JT I certify that I have read this application and state that the Issuance Fee / above information is correct. I agree to comply with.all County Investigation Fee $ r 'n races and State laws elating to building construction, Total Fee nd hereby authori r pr ent tives,of this County to enter � p the above-m i ne pro ty for in�ection a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ®s :J WORKERS'COMPENSATION DECLARATION � _ I he�•eb affirm that•I have a certificate of consent to self insure; or a certificate^of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a cert' ' d copy thereof (Sec. 3800;' L ) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy _ BUILDING j A^n Cert' ed copy is'hereby furnis ed.. FOR APPLICAN TO FILL I /Q ADDRESS Certified copy is filed with'FROM unty buildin inspec- BUILDING Tion.departments` ADDRESS ��^^ 1�L CAS Date Applicant CITY �C�. ZIP ( � LOCALITY CERTIFICATE OF EXEMPTION ORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT �V NOW ON LOT b CROSS ST. (This'section need-not be completed if the permit.is for oneASSESSOR' hundred dollars ($100)or less.) TRACT BJQCIZ LOT NO. 0 MAP BOOK PAGE' PARCEL USE ZONE MAP _ • ' I certify that''in`the performance of the work•for which,this OWNER - NO. permit is issued, I shall'not employ any person in any manner (�/i J �I �- SPECIAL - d so as to become subject To the Workers'Cornp-ensotion Laws. ADDRESS �l w I" CONDITIONS u Date 'Applicant CITY ZIP 19O NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR DISTRICT GROUP TYPE FIRE PRO SSED BY ENGINEER �' (� CONST.• ZONE Exemption, you should become subject to the Workers' ,�^�1 / ^� v (fd n/ W Compensation provisions of the Labor Code, you must forth- ADDRESS ' V A- with comply with,such-provisions or this,permit shall be �► TEL. STATISTICAL CLASSIFI ATION APT: CO deemed revokeds CONTRACTOR 1 NO. Q LICENSED CONTRACTORS DECLARATION., - U CLASS NO. DWELL. UNITS hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (commencing with Section 7000)of Division 3 of The Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS /.? gK PG - VALIDATION SQ. F NO. OF NO. OF CHECK License Number (i�S Lic.Class SIZE STORIES FAMILIES ONE' q ,,// VALUATION. Contract,WJAa Date S' DESCRIPTIONNOOF WORK ADD El F-11 am exempt under Sec. ALTER ❑ , (� B.$P.C. for this reason ❑ $ - Date: - USE OF DREPAIR DEMO[[ ❑ z L1'-4,6 A EXISTING BLDG. Signature APPLICANT TEL. '(PRINT) NO. FINAL # o 0 0 0 `�3 OWNER-BUILDER DECLARATION DATE I hereby affirm that I am-exempt from the Contractor's License ^+ - 39.4,94 Law for the following reason (Section 7031.5, Business and• ADDRESS FIN - `Professions Code): PRESENT BY •' x BUILDING 0 0 3 9 U,9 4 0- ❑ I_ as owner ofthe property, or my employees with ADDRESS t e' wages as their sole compensation,will do the work and LOCALITY r 0;.3 0 -85 the structure is not intended or offered for sale(Section ' 7044, Business-and Professions Code). MOVING TEL. - ❑ I, as owner of the property, am exclusive) contracting CONTRACTOR NO. P P Y, Y 9 �2 1, �7_� • with licensed contractors to construct,The project (Sec- ADDRESS tion 7044, Business.and Professions Code). # 0 0 0 0 0- REQUIRED TOTAL SETBACK FROM EXIST, CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I a 6 4 (t 2'5_ I hereby affirm that there is a construction'lending agency for FRONT the performance of`the-wor for•which'this permit is issued P.L. - ®' 0 (L x (Sec: 3097, Civ. C.). SIDE P.L. Q Lender's Name o 53. 7� LDMA Ref. # P.C. Fee$ Permit Fee ✓ ' ry Lender's Address ' certify that_I have read.this application and state that the L.t Issuance Fee [-(J J V LDMAIP/C# ` `L 1 •� r above information is correct. I agree to comply with all County Investigation Fee ordinances and ST Te law elating to building construction, Total Fee •- LDMA Perrp. # wtiL U an er by autho'i r sen tives of this County to enter u on t above- ti e p pertyJor inspection purposes. 3 / 77 .� SEE REVERSE FOR EXPLANATORY LANGUAGE 7`� ofApplicantor Agent - Date -- - - - - .�