HomeMy Public PortalAbout11015 GREEN TREE LN_Building__ WORKERS'COMPENSATION DECLARATION
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•insure boraffirm
certif certificatethat
off Wp ke s' Comcertificate
pensation Insuran e, APPLICATION- FOR BUILDING PERMIT c
or a'certified copy thereof (Sec. 3800; fit.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy 4.. ompony ( BUILDING
❑ Certifi dlcopy is hereby furnished. FOR APPLICANT TO FILL IND
ADDRESS
ertified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
r
Date Applicant `' CITY t/ ZIP [ LOCALITY
CERTIFICATE OF EXEMPTION ROM WORKERS' /x NO. OF BLDGS. NEAREST r
COMPENSATION INSURANCE SIZE OF LOT / NOW ON LOT CROSS ST. a.;L
(This section need not be completed if the permit is for one ASSESSOR
hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
USE ZONE MAP
I certify that in the performance of the work for which this OWNER " NO �7 },
permit is issued, I shall not employ any person in any manner SPECIAL tZ
so as to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS V
CITY , ZIP /
Date Applicant O
NOTICE TO APPLICANT:''.If, after makingThis Certificate of ARCHI ECT OR DISTRICT GROUP TYPE FIRE- PRO ESSED BY i—
ENGINEER �' CONST. ZONE V
Exemption, you should become subject to the Workers' LU
Compensation provisions of,the Labor Code, you must forth- ADDRESS �/t k3 �- y
with comply with "such provisions or This permit shall be TEL. STATISTICAL CLASSIFICATION APT. CO O. Z
deemed revoked: CONTRACTOR NO.
LICENSED CONTRACTORS.DECLARATION LI CLASS NO. DWELL. UNITS
I hereby affirm That I am licensed under provisions of Chapter 9 ADDRESS N e,
(commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP
Professions Code, and my license is in full force and effect. CITY CLASS 00 BK VA49D]►>rj159d(( A
,t�(7 SQ. FT. NO. OF 2 NO. OF CHECK
License Number Lic.Classl SIZE STORIES FAMILIES ONE # a a a a 2 3
ALUATION
Cantracf DESCRIPTION QL WORKO,
NEW
❑ ( 0 1 43-45
AD
❑ I am exempt under Sec. �� ,
❑ Vl�, 006
B.&P.C. for this reason ALTER REPAIR 1 4 3.4 5=
Q �USE OF c7
Date: DEM 11
EXISTING BLDG.
APPLICANT TEL. ,3
Signature FINAL # o o o o 2
OWNER-BUILDER DECLARATION (POINT) NO. DATE o420,7 5
I hereby affirm that I am exempt from the Contractor's License
Law for the following-reason (Section 7031.5, Business and ADDRESS FINA
Professions Code): PRESENT BY t o a 4 2 Q 7 5 0
❑ BUILDING
I, as owner of The property, or my employees with ADDRESS L)3 O 8_.$Jr -
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).
REQUIRED
CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL SETBACK LINEWIDTH �2 1 4,5 A
PROI hereby affirm that there is a construction lending agency for FRONT 1
the performance of the work for which this permit is issued P.L.
# 6 4 4,2 5
(Sec. 3097, Civ. C.). SIDE
P.L.
Lender's Name `
m s LDMA Ref.�#
Lender's Address P.C. Fee$ S Permit Fee 3 J
>
I certify that I have read this application•.and.state that the Issuance Fee LDMA P/C#
a above information is correct. I agree to comply with all County Investigation Fee
0 ordinan sand State laws rel ting to building construction, Total fee r v LDMA Perm. #
and by authori epre tali sof this County to enter
m up a above-m i ne p p y for inspection purpos�s.
-- Sr _
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o Applicant or gent ate