HomeMy Public PortalAbout11020 GREEN TREE LN_Building__ WORKERS'COMPENSATION DECLARATION
hereby affirm that I have certificate of consent to self APPLICATION FOR B U I L D I N'G PERMIT `
insure, or a certificate of Workers' Compensation Insurance,
or ac ied copy thereof (Sec. 3800, b. C.)
' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Polio Company
1:1 Ce d copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING
ADDRESS
ertified copy i•s filed with the county building inspec- BUILDING /^
tion department. ADDRE
Date Applican CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' [(g,rg� NEAREST ST.
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT C
(This-section need not be completed if the'permit is for one / ASSESSOR -
hundred dollars ($1,00)or less.)
TRACT 1/ BLOC LOT NO. MAP BOOK' PAGE PARCEL
ER USE ZONE MAP .�^
I certify that in the performance of the OWN
work for which this ' NO. v O- }
permit is issued, I'shall not employ any person in any manner SPECIAL - 0
so as to become subject to the Workers'Compensation Laws. ADDRESS / '` CONDITIONS
' CITY , ZIP (S �
Date Applicant ARCHITECT OR
NOTICE TO APPLICANT: If, after making this''Certificate of DISTRICT GROUP I TYPE FIRE_ • PRO E ED BY I.
Exemption, you should become subject to the Workers' ENGINEER CONS-T./ ZONE W
Compensation provisions of the Lobor'Code, you must forth- ADDRESS 5'.6{( . f-3 �l - 9'
with comply with such provisions or this permit shall be TEL, STATISTICAL CLASSIFICATION APT. _J.CONDO. Z
deemed revoked. CONTRACTOR NO. U
LICENSED CONTRACTORS DECLARATION N CLASS N� Lt—DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Q'Y� 40 J
(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 /G.7 BK PG -VALIDATION
SO. FT. /' NO.OF NO. OF CHECK
License Number v Lic.Class SIZE �✓�� STORIES FAMILIES ONE
®�/�� ��/ � VALUATION
DESCRIPTION OF WORK NEW g
Contracto -ate ❑ $d ..
❑ I am exempt under Sec. ADDALTER ❑ ,
B..&P.C. for this... USE OF El reason REPAIR $
. ... -
Date: DEMOL ❑ 1 6 58-A
EXISTING BLDG.
'Signature APPLICANT /�� �/ TEL. FINAL HMO PRINT) (/�/f / NO. t� ° p� y�{
OWNER-BUILDER DECLARATION DATE ° ° o V
I hereby affirm that I am exempt from the.Contractor's License
Law for the following reason.(Section 7031.5, Business and ADDRESS FIN O 3.08-8 5
Professions Code): PRESENT BY
EJBUILDING i
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. rs
❑
I, as owner of theCONTRACTOR NO. o (�
property, am exclusively contracting #8
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
REQUIRED TOTAL SETBACK-FROM XI '� ° 5
CONSTRUCTION LENDING AGENCY '" SET BACK YARD HWY PROP. LINE WIDTH 09-11
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 2 1 3 5.A
P.L. _
0 0 0 0 0 1
Lender's Name -3 MOS
LDMA Ref. # ( ° 6 4 G,2 5
P.C. Fee$ / Permit Fee t - a
Lender's AddressLt o o b 4 4'2 5
it
I certify that I have read this application and state that the �- il-5 Issuance Fee- V LIMA P/C#.�,�; '•'
a above information is correct. I agree to comply with all County Investigation Fee i - '' t "053 0-85
0 ordinances and State laws relating to building construction, Total Fee LDMA Perm'# f
u and y authorize repr ntat'ves of this County to enter
m up t above- ion op ty for inspection purpXes.
a .7 0SEE REVERSE FOR EXPLANATORY LANGUAGE
0
Signature of Applicant or gent Date -•- - - -• - -- i