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HomeMy Public PortalAbout11024 GREEN TREE LN_Building__ WORKERS'COMPENSATION DECLARATIONIh ' J•insuFe, or carte of Worke srlComipensat on eInsurancef L'CAT'O O U'L,D I ■p RMI or a'ceitified copy thereof (Sec. 3800, L .) COUNTY OF LOS ANGELES BUILDING.AND SAFETY Policy r_ Company BUILDING D- Certifie .opy is hereby furnished.. FOR APPLICANT TO FILL IN ADDRESS '� /�, 4te ertified copy is filed with the county building inspe - BUILDING / ' tion departrnent. y ' ADDRESS24Z Date' Applicant CITY .(.� ZIP LOCALITY CERTIFICATE OF EXEMPTIO OM W RKERS' NO. OF BLDGS. NEAREST . c COMPENSATION INSURANCE' SIZE OF LOT G/�1' NOW ON LOT © CROSS ST. (This section need not be completed if the permit is for one / p ASSESSOR hundred dollars ($100)or less.) TRACT ( BLOCK LOT NO. O MAP BOOK I PAGE PARCEL ,n OWNER e USE-ZONE MAP ISO , I certify that in the performance of the work for which this NO. J (/ permit is issued, I shall not employ any person'in any manner /, t SPECIAL A. so as To becorne subject to the Workers'Compensation Laws. ADDRESS I.GJ CONDITIONS u • '• _ CITY e ZIP .. ®G Dare Applicant ARCHITECT OR NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER DISTRICT GROUP TYPE FIRE PROCESSED BY po Exemption; 'you should become subject •to the' Workers' _ /n�27 CON ZONE ZONE Compensation provisions of.the Labor Code, you must forth.- ADDRESS I I ✓ V with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CON O. Z deemed.revoked. CONTRACTOR NO. /y LICENSED CONTRACTORS DECLARATION LIC /�� .N" CLASS NO. v DWELL. UNITS I hereby'affirm that I am licensed under provisions of Chapter 9 ADDRESS (commencing with Section 7000)of Divisi6r3 of the Business and _ .LIC. SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK VALIDATION SQ. FT NO.OF NO. OF CHECK License Number Lic.Class, SIZE STORIES FAMILIES ONE ,G/� LUATION // Contract or^�` �vIW�✓r-nate S DESCRIPTION OF WORK NEW ❑ ADD E , I am exempt under Sec. ALTER B.&P.C. for this reason REPAIR $ (/ l0 2 1 4,2 A Date: USE OF DEMOL' EXISTING BLDG. APPLICANT TEL. # o o o o 23 Signature FINAL OWNER-BUILDER DECLARATION PRINT) NO. - DATE' o37Q84 .bhereby•affirm that Lam exempt the Controctor.'s License , Law for the following reason,(Section 7031.5, Business and ADDRESS FIN PPofessions'Code): PRESENT B o 0 3.7 0.8 4 5 ❑ BUILDING — I, as owner of the property, or my employees with ADDRESS a Yc ` e 3 0 8 5 wages as their sole,compensation,will do the work and r 'lam LOCALITY the structure is not intended or offered for sale(Section •t �• , 7044, Business and Professions Code). MOVING TEL. ' CONTRACTOR NO. k p _❑ I, as owner of the property, am exclusively contracting z 2 1 �,3 A with licensed contractors to construct the project (Sec- ADDRESS Tion 7044, Business and Professions Code). # o 0 o Ze o 1 REQUIRED .TOTAL SETBACK FROM EXIST. a 0 0 7 5 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH' o 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. 0 06 3 3 7 5 v r (Sec. 3097, Civ. C.)./ SIDE (/// _ .. � P.L. �3 p=85 - Lender's Name //__ S LDMA Ref. # Lender's Address P.C.-Fee$ Permit-Fee �/ t 1 w3-70, \ . I.certify that I have read this application and state that the ,.. V[ H Issuance Fee LDMA,P/C# \' a above information is correct. I agree to comply with all County Investigation Fee • .. `� m ordinances and State laws relating to building construction, Total Fee LDMA Perm. # u andh y authorize pre tative of this County to enter upo th above-me ne r per for inspection purposes. — — , — t SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date - -