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Home My Public Portal About11026 GREEN TREE LN_Building__ % WORKERS' COMPENSATION DECLARATION 1 I .hereby ga cer that I h,ave_,a certificate.of consent to self A P P L I C AT I'O N FOR• BUILDING PERMIT ti sure,'or a certificate of Workers' Compensation Insurance, ora c Pied cop thereof (Sec. 3800, L' .) COUNTY OF LOS ANGELES BUILDING AND SAFETY P�Cert�f ollcy�lWAN/Company ' opy is hereby furnised. FOR APPLICA T TO FILL BUILDING ADDRESS opy is filed with the county building inspec- BUILDING L/�ptment. ADDRESS p Date Applicant r CITY a, ZIP �� LOCALITY - i CERTIFICATE OF EXEMPTION ROMA WORKERS' NO. OF`BLDGS. NEAREST _ COMPENSATION INSURANCE SIZE OF LOT rr NOW ON LOT CROSS ST. (This section need not be completed if the-permit is for oneASSESSOR hundred dollars ($100)or less..) TRACT BLOCK LOT NO. 7 MAP BOOK PAGE' PARCEL OWNER T USE ZONE MAP I certify'that in the performance of The work for which this `� NO. ��77 �- permit is issued, 1`shall not employ any person in any manner /', SPECIAL •- - so as to become subject To The Workers'Compensation'Laws. ADDRESS !N CONDITIONS O lJ :. •. .. CITY ZIP Date Applicant ARCHITECT OR NOTICE TO APPLICANT: If, after making'Th is Certificate of r. DISTRICT, - GROUP TYPE. FIRE PROCE SED.BY 0 ENGINEER CONST.. ZONE U Exemption, you should become subject To the 'Workers' .� VILA 1.1 Compensation provisions of the Labor Code, you must forth- ADDRESS F —•5 with.comply with. such provisions or this permit shall be 44 - y deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. CON Z CONTRALTO NO. �j) _ LICENSED CONTRACTORS DECLARATION - w' �� NO CLASS NO. 61 DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .� 9VAI W N (commencing with Section 7000)of Division 3 of the Business and -LIG SEWER MAP Professions Code, and my.Iicense'is in fu11 force"and effect. CITY �G U'Ct CLASS Lam./ BK PG. VALIDATION J} SQ, FT NO. OF NO. OF CHECK License Number + �' ` Lic.Cldss� SIZE STORIES - FAMILIES ONE ATION Contract ADD !/LGite VALU DESCRIPTION OF WORK NEW' _ ADD ❑ , � 1 6 5,6•AEl - I am exempt under Sec. ALTER ❑ # 0 0 0 0 2'3 B.&P.C. for this reason REPAIR ❑ S q a - 378.05 Date: USE OF DEMOL EXISTING BLDG. ❑ Signature APPLICANT /� TEL. ° ° 3 7&0 5 C OWNER-BUILDER DECLARATION PRINT) C�lic� NO. FINAL DATE �' [ 008-85 I hereby affirm that I am exempt from the.Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FI "Professions Code): """ - PRESENT g ❑ BUILDING. _ 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. ' �21 3,8 A I, as owner of the property, am exclusively contracting CONTRACTOR NO. # 0 0 0 o 2 3' with licensed contractors to'construct the project (Sec- 0 U Tion 7044, Business and Professions Code). ADDRESS g. _ REQUIRED YARD HWY TOTAL SETBACK FROM T. e F{. CONSTRUCTION LENDING AGENCY SET BACK PROP. UNE 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.). t SIDE :221 3 9 A' m r P.L. # 0 0 0 0 0 1 Lender's Name 1 . 63375 m /� f lam' LDMA Ref. #. Lender's Address P.C. Fee$ (J`) Permit:Fee J 0 0 6-3�J,7 5,53 N I certify that I. have read this application.and state that the Issuance Fee (/- LDMA-P%CI# ,I -- a above information is correct. I agree To comply with all County Investigation Fee ordinances nd State laws rel 'ng.to building construction, _ r� O°' 3 O`8 v and her authorize res t tives f this County to enter Total Fee �! LDMA Perm. # upon a bove-me on d o ert or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 6 Signature-ofApplicant or Agent -Date - - -- -- - - - - - - • ` (k) d WORKERS' COMPENSATION DECLARATION I'hereby affirm that I have certificate of consent to Self A P P L I CATION FOR * BUILDING PERMIT insure, or a•certificate of Workers' Compensation Insurance, or o certified copy th r pf�(,Sec. 3800; Lab. C.) �/L ' f% S NS COUNTY OF LOS ANGELES BUILDING AND SAF T•Y Policy N040-9 Company . Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 2-4 ADDRESS (� Certified copy is filed with the county building inspec- BUILDING /a L(� ..ti..0 dep r�Tmnent. fi ADDRESS �ow Date C�' o"' ApplicantCITY �! ZIP LOCALITY CERTI KATE OF EXEMPTION FROM WORKERS' - NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT N/O/./,¢ MAP BOOK PAGE PARCEL TEL.`T'7O USE ZO E NOP sD��27 7 I certify that in the performance of the work for which'this OWNER f"� NO. permit is issued, I shall not employ any person in any manner �n //,� � _ SPECIAL - so as'to become subject to the Workers'Compensation Laws. ADDRESS C/ VJ "�<r.'C� � r✓ CONDITIONS �O CITY ZIP_ 119 Date'' Applicant O ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PRO SSED BY NOTICE'TO APPLICANT: If, after making this Certificate of ONST. ZONE /"& lJ ENGINEER NO. (/ Exemption, .you should become subject to the Workers' �j LU Compensation.provisions of the Labor Code, you-must forth- ADDRESS 1� ✓ � with comply with :such provisions or this permit shall be TEL.y� -�- STATISTICAL CLASSIFICATION APT. CONDO. W deemed revoked. CONTRACTOR NO.Jl� /.710 LICENSED CONTRACTORS DECLARATIONLIC• !tet CLASS NO. DWELL. UNITS . I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 7_7 P/8& VC NO. ` 7 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. y� Professio6s Code, and'my license is in full force and effect. CITY ( iJ� CLASS /J`I BK VALIDATION �j�" 9- 1 SQ. FT. NO.OF NO. OF CHECK License Number, 'TWO-7 Lic.Classes SIZE STORIES FAMILIES ONE //ff VALUATION v`� �CO r Date /0 DESCRIPTION OF WOR d/qJ` &k7" NEW O® Contractor ADD $ on I am exempt under Sec. t�pak � � C � ALTER ❑ , B.&P.C. for this reason N &V nr OW REPAIR $ "c 4 1 9.7A A Date: USE OF DEMOL E EXISTING BLDG. # 0 0 0 0 0 1 Signature APPLICANT TEL. FINAL / OWNER-BUILDER DECLARATION PRINT) NO. DATE l/CEJ, I 0 o59.25 I hereby affirm that.)am,exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIN:rZ a o p U -Professions Code): PRESENT BY - 5'9,2-5 aBUILDING F I, as owner of the property, or my employees with ADDRESS Q `/ wages as'their sole cfompensation,will do the work and �G6, v 3 1 Q—$b the structure is not intended or offered foi sale(Section LOCALITY ' 7044, Business and Professions Code). MOVING TEL. ryryry I, as owner of The property, am exclusively contracting CONTRACTOR N NO. // �F� -with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM T. CONSTRUCTION LENDING AGENCY SET BACK "'YARD HWY PROP. LINE WIDTH " I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name g LDMA Ref. # m - - P.C. Fee$- Permit Fee - - - - - Lender's Address r I certify that I.have,read this application and state.that the Issuance Fee LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee m ordinances and State laws relating to building construction, Total Fee S 9 LDMA Perm. # and hereby authorize representatives of this County to enter upon t a ve-mentioned property for inspection urposes. a I b SEE REVERSE FOR EXPLANATORY LANGUAGE -- - Signature of Applicant or•Ag t Date - - -- -