HomeMy Public PortalAbout11025 GREEN TREE LN_Building__ _ WORKERS'COMPENSATION DECLARATION '
\ I hereaffirm that I• have. certificate of consent to Self APPLICATION
FOR BUILDING PERMIT*
• iris'ure, or'a certificate of Workers' Compensation Insurance,
or a cert' ' d copy thereof (Sec. 3800, )
COUNTY OF LOS ANGELES- BUILDING AND SAFETY
Policy,t _''Company
F17Certified copy is
he furnished. FOR APPLICANT TO FI IN BUILDING -
ADDRESS
�ertified'copy'is filed with the county building inspec- fADDRES.-M0.
ILDING n
tion depdrtmeni. r 2 -G..Date. Applicant Y L/ ZIP
LOCALITY :T6.
CERTIFICATE OF EXEMPTION ROM WORKERS' ► NO. OF BLDGS. NEAREST t
COMPENSATION INSURANCE SIZE OF LOT ✓rte NOW ON LOT d CROSS ST.
(This section need not be'completed if the permit is for oneASSESSOR
hundred,dollars ($100)or-less.) TRACT BLOCK'- ' LOT NO. MAP BOOK PAGE PARCEL
, e� 1 /�• _
I certify that in the performance" OWNER of the 3vork-for which this USE Z E OP �* —0 2"7
perniit..is issued, I shall not employ any person in any manner ) SPECIAL
9116
so as to become subject to the Workers'Compensation Laws. ADDRESS +(/�' ' CONDITIONS 0
CITY / ��e�•� ZIP p OC
Ddte' Applicant ARCHITECT OR O
NOTICE TO APPLICANT:-If, after making this Certificate of ENGINEER ., D TR14T / GROUP TYPE FIRE PROCESS BY. U
Exemption, you should become subject• to, the -Workers' ,U\/Vx/ 3 CONST. ZONE LU
Compensation provisions of the Labor,Code, you must forth- ADDRESS H
,with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CON
deemed revoked. CONTRACTOR NO. e
LICENSED CONTRACTORS DECLARATION - CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS C��nl 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/q..,, O.NOF NO. OF / CHECK
License Number ) Lic.Class SIZE STORIES FAMILIES ONE
ALLIATION _
NEW
Contractoy��� !/l� ate 5' DESCRIPTI NOF WORK A D ❑ $ �
❑ I am exempt under Sec. -- ALTER
B.&P.C. for this reason REPAIR $ 7q,USE OF X21 i.OA
Date: EXISTING BLDG. DEMOL ❑
Signature - APPLICANT TEL. FINAL # o o o o 2 3
OWNER-BUILDER DECLARATION (PRINT) NO. DATE
-1 hereby affirm that I am exempffrom.the Contractor's License Z'
Law for the following reason (Section 7031.5, Business and ADDRESS FINA ° 3.7 Q 8 4
Professions Code):' PRESENT BY 7 _
BUILDING ° ° 3.7 0 8 4 5-
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole-compensation,will do the work and t 03 0 8.5
f
the structure is not intended or offered for sale(Section LOCALITY ' '` •'".-� t
7044, Business and Professions Code). MOVING TEL.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 92 1 IL 1 A II
with licensed contractors to construct the project (Sec- ADDRESS' Irl
tion 7044,-Business and Professions Code). I # 0 0 0 Z0 0 1
REQUIRED .. YARD ` HWY -TOTAL SETBACK.FROM.. ST. 6 3 J 7 5
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH 0
1 hereby affirm that there is a construction lending agency for 'FRONT '
the performance of the w9rk for which this permit is issued P.L. 4 ° 6 7J 7 5
(Sec. 3097, Civ. C.). / SIDE Oq 3 — 5
n (///
P.L. J
v Lender's Name �' LDMA Ref. #
Lender's Address P.C. Fee$ Permit Fee
I.certify that I have read this application and state that the V Issuance Fee 101,5-0 LDMA P/C#
' above information is correct. I agree to comply with all CountyInvestigation Fee �J
ordinances and State law relating to building construction, Total Fee -3 . / � LDMA Perm. #
and her y auth ' e r sentatives of this County to enter
m upon above o pr erty for
A
inspection purposes.
a r SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of of Applicant or Agent Date