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Home My Public Portal About11021 GREEN TREE LN_Building__ WORKERS' COMPENSATION DECLARATION I hereby that I have a certificate-ofto self insure!orairm afce*if cate of Workers' Compensation consent Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFET Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING d JAA .ZA Certified copy is filed with the county building inspec- BUILDING ADDRESS tion.department. ADDRESS I I Q iZ I /za" L/}nll- Date Applicant CITY g1. ,-F— C I rX ZIP 917?Ci LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT S4(X 7 NOW ON LOT I NEARESST. COMPENSATION INSURANCE (This section need not be completed if the permit is for oneASSESSOR hundred dollars ($100)or less.) TRACT +3111 BLOCK LOT NO. MAP BOOK PAGE PARCEL E ZO TEL. USE MAP I certify that in the performance of the work for which this OWNER t,961�1?pq J. t Jr�pyJ. At+U N0.�818)S7S-271 NO. permit is issued, I shall not employ any person in any manner i SPECIAL so as to become subject to the Workers'Compensat' Laws. ADDRESS 1021 G E L:/ayVE 1 CONDITIONS O CITY EA J A-� C f zip R l?f O I U Date 1 8� Applicant � � NOTICE TO APPLICANT: If, after making'thi Certif' ateof ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCES D BY O Exemption, you should become subject 'to the Workers' ENGINEER NO. CONST ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS ✓I V fJ W with comply with such provisions or this permit shall be t1:' deemed revoked. TEL• STATISTICAL CLAS FIC TION APT. CO to CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS A ACZNO. SEWER MAP (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 BK PG VALIDATION SQ. FT NO.OFNO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES I ONE -A-Coo OFNEW VALI�ATION� a DESCRIPTION OF WORK 00 $ OOH]`] 5- Contractor Date / ADD I am exempt under Sec. 710 C'0vrX1WC- d, 20 ALTER B.BP.C. for this reason REPAIR $ Date: USE OF a EXISTING BLDG. IQ EE 5 L 0 E�JCGDEMOL Signature APPLICANT TEL FINAL OWNER-BUILDER DECLARATION PRINT) ORporl J . F w Nd'18 37$-27f7 DATE 2,(� A I hereby affirm that I am exempt from the Contractor's License ADDRESS I1 a1.1 Gia reEC LANG TEnP Cir 918 Law for the following reason (Section 7031.5, Business and FINA ' # 0 0.o ® o 1 Professions Code): PRESENT BY BUILDING I, as owner of the property, or my employees with ADDRESS I a 59.25 wages as their sole compensation,will do the work and" _ the structure is not intended or offered for sale(Section LOCALITY o,0 a 5 9,2 5 5 7044, Business and Professions Code). MOVING TEL. aCONTRACTOR NO. a25 .88 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS 0 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY REQUIRED YARD HWY TOTAL SETBACK FROM SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name LDMA Ref. R Lender's Address P.C. Fee$ Permit Fee /7 1 7-5 / I certify that I have read this application and state that theIssuance Fee J (/ LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee S ordinances and State laws relating to building construction, Total Fee 5 � ° 2 LDMA perm. # 6 and hereby authorize representatives of this County to enter upon the above-mentioned erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ap cant or Acfent Date WORKERS'COMPENSATION DECLARATION " insure hereboraffirm certif cathat te of Worke sf lComte of pensat on ent to Insuran e, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, ) ' COUNTY OF LOS ANGELES BUILDING AND SAFETY P �L�Cicyompany Cert' 'ed copy is hereby furnished. 1. FOR APPLICANT TO FILL IN BUILDING /I� L. ADDRESS (f jE SAAA Certified copy is filed with the county building inspec- BUILDING D tion department. ADDRESS Date Applicant CITY 7 ZIP LOCALITY CERTIFICATE OF EXEMPTI N ROM WORKERS' //'' �/ NO. OF BLDGS. /+1 NEAREST COMPENSATION INSURANCE SIZE OF LOT�'f9 V.91 NOW ON LOT v CROSS ST. (This section need not be-completed if the permit is for oneASSESSOR hundred.dollars ($100)or less.) 7 TRACT Ill BLO LOT NO. MAP BOOK PAGE. PARCEL OWNER C�L.f- NO. I USE ZONEMAP L.certify that in the performance of the work for which this !J (/ permit is issued, I shall not employ any person in any manner SPECIAL 0. so'a's'to become subject to the Workers'Compensation Laws. ADDRESS CONDITIONS CITY ZIP Date Applicant ARCHITECT OR -22 NOTICE,TO APPLICANT: If, after'making this'Certificate of ENGINEER a DISTRICT GROUP TYPE_ FIRE PROCESSED BY Exemption; you'-should become subject to the Workers' ` CONST. ZONE Compensation provisions of the Labor Code, you must forth- v`O� ADDRESS with comply with such provisions or this permit shall be ♦ TEL./ STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTO NO. U/ LICENSED CONTRACTORS DECLARATION LIC CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N b SEWER MAP (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 � BK VALIDATION SQ. FT. �/D NO. OF NO. OF CHECK License Number Lic.Class SIZE �.R� STORIES 2 FAMILIES ONE VALUATION �f�� DESCRIPTION OF WORK NEW - C❑oniractq ate . ADD ❑ s , 1 am exempt under Sec. ❑ PG ALTER r B.&P.C. for this reason REPAIR ❑ "` $ L, �J V 0 Date: USE OF. DEMOL ❑ tttfff"" EXISTING BLDG. Z Signature APPLICANT TEL. FINAL 2 1 3,6 A OWNER-BUILDER DECLARATION (PRINT) NO. DAT I hereby affirm that I am exempt from the Contractor's License # o o 0 -23 Law for the following reason (Section 7031.5, Business and ADDRESS A Professions Code'): PRESENT B I - J94,94, ❑ I, as owner of the property, or my employees with DIDR SS LDING ° ° 9 U 9 4 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY , 3 O`-8 5 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). 9 2 1 3.7 A REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. o 0 0 0 a ' CONSTRUCTION LENDING AGENCY � SET BACK PROP. LINE WIDTH # 1 hereby affirm that there is.a construction lending agency for FRONT a .. 644,2 5 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE o o b 4 4 2 5 v m " P.L. < Lender's Name 41(3 0_8 5 --�-- LDMA Ref. # - - P.C. Fee$ V-.-Nry— Permit Fee Lender's Address `l t I certify.that I have.read this application and state that the 13 qq,21 Issuance Fee /O V 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 S LDMA Perm. # v andh eby authorize re sentatives of this County to enter upo a above- ti a pr erty for inspection pu�qoses.� a ✓ r�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent - Date - - -