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HomeMy Public PortalAbout4931 HELEO AVE_Building__ ORKERS' COMPENSATION DECLARATION ,•-�,.:. eye'^ - e.reb� affirm that, I have a certificate of consent, to self, Lrt1 ° lJ L/-�1 ( M Ll lJ`1LI V LI ID insure, or;a ce,rtificpte-of Workers' Compensation Insurance, „ s>or a certified copy thereof (Sec. 3800, tab C.)„ r COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company, ❑ Certified co is he furnished.. FOR APPLICANT TO FILL IN BUILDING PY , Y ADDRESS ,❑ Cert'ifie'dcopyis filed with thelcounty building inspec- ', BUILDING Tion.department. ADDRESS Date ApplrcanA CITY" /lam/ G/C`1 1��.. ZIP. ( LOCALITY CERTIFICATE OF'EXEMPTION FROM WORKERS ` SIZE OF LOT NOW ON LOT (2(f NEAREST '• COMPENSATION INSURANCE CROSS ST. _: ASSESSOR (This.sectron need not be completed if,the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less,,) TEC. / OWNER �'/(� NO. USE:ZONE MAP I certify that in;the,perfoimance of the work for which this q � [CPCI . CT/ permit,is issued, I shall not employ any person in any.manner ADDRESS'' /�� ��I//44 CIAL" O so as Jo become subject.to the WR ers:Compenaation`L ' c �/ a.. U ® p�. CITY � ZIP (!'� 0 7C NDITIONS Date Applicant' ARCHITECT OR' Th. DISTRICT ."'GROUP TYPE � FIRE: ESSED BY NOT E TO 'APP.ICANT:..If, afte' a m this Certi icc. f ENGINEER NO. Exemption. you should become -subject to; the• Workers' _ _ CONST ZONE, U Compensotion,provisions of the'Labor Code; you must forth- ADDRESS LCL U with comply with..such.provisions 'or,this' permit.shall be T STATISTICAL CLASSIFICATION _ APT. CONDO. Z deemed revoked CONTRACTOR.. NO. " LICENSED CONTRACTORS.DECLARATION LIC.; CLASS N0. ?'/ DWELL. UNITS Y - .. - -,- _ ADDRESS NO. I herebyaffirmthat-I am licensed under provisions of Chapfer9 ._ . E •, . (commencing with Section 7000)of Division,3 of the Business SEW MAP / ' LIC. R and Professions Code;and my license is m full force and effect. 0 C BK_ �pG VALIDATION 5 F N OF CHECK 'CITY LASS Q:FT. NO. O / License-Num* Lic Class" SIZE -,. STORIES !: FAMILIES .- ONE. " :. VALUATION; Contractor Date DESCRIPTION OF-WORK' NEW.. ADD ❑ $�4 00-0 Uv D. ❑I,am exempt under Sec .ALTER- ❑ B.&P.C: for this reason �•-�� ^^•'""— REPAIR ❑ $ _ Dates _ ,. USE OF. . M . . EXISTIN "BLDG: DEMOL ❑ - APPLICANT• TEL. p Signature' PRINT du FINAL OWNER BUILDER.DECLARATION >' C NO: I hereby affirm that I am exempt from the Contractor s License DATE' Law for the following ieason (Section-7031.5,, Business and - ADDRESS FINAL 1Professions Code) _' PRESENT By - =a 3 BUILDING I, as owner of the property :or my employees with v ADDRESS'. wages as their sole compensation will do the work and the structure is not intended or offered for'sale(Section -" LOCALITY D 1 7044, Business and'Professions Code.) MOVING TEL: CONTRACTOR NO. = ❑ I,l as owner.of the property, am exclusively contracting , with licensed'contractors to construct.The ro est Sec- g -•,:"r P I ( ADDRESS. tion 7044, Business and Professions'Code.) REQUIRED. TOTAL SETBACK FROM .''EXIST. I hereby affirm thereisa construAGENCY ction lending.agency for FRONACK YARD HWY PROP.LINE WIDTH. 'ti s y3 F T Y g g Y the performance of the work for which'this.permit is issued (Sec: 3097 Civ. C.). Lender's Name. �`. 4^ S. ? \ \''` \ . €��� €1'i' ,y t r f Vit: $ ���� LDMA Ref. # ,a. * i tF - P C.Fee Permit Fee `� m y i f Wit• Lender's Address ' I certify that I have read this application'and state that the Issuance Fee �' v LDMA P/C# a above information is correct. I agree to'comply with alICounty Investigation._Fee 8 ordinances and State laws relating to building construction, Total Fee- - V Q ,63 1. LDMA Perm. #' a and hereby authorize representatives of.this County to enter upon the above-mentione pr erty for.inspeciion purposes. oC �~� SEE REVERSE;FOR EXPLANATORY LANGUAGE , Signature of, pp icant o ,Agent Date' i �i ••:iNORKERS' COMPENSATION DECLARATION L I >reb� firm that I have a certificate of consent to self p O �O , D D n� rFure o0 certificate of Workers' Compensation Insurance, "� //1111 r �Ln�U�,O-,IJV -IJgy©� .v D C� p �19 V 17 u p;,o certified copy thereof (Seca 3800, Lab. C.) „` J °COUNTY OF;LOS ANGELES BUILDING AND S�.FEYY Policy No Company- `' - E]` Certified co is hereby furnished. 'o. t BUILDING PY Y -� _,FO.R APPLICANT TO'FILL"IN; ADDRESS Certified copy is filed with the county building inspec- BUILDING J' - /i . :� tion department. ADDRESS 1v A Date Applicant CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NO.OF BLDGS.ON LOT ,NEARESST. �--�� COMPENSATION INSURANCECROSS (This section need not be completed if the.permit is for,one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK i0T NO. MAP BOOK PAGE PARCEL c- ^° L :.. OWNER 1 O USE Z NE. MAP I certify that:in the performance of the work for which this NO. permit is issued, I shall not employ ariy person in any manner 3S �I e p a v� — SPECIALi so as to become subject to the ers'Compenspt' Laws. ADDRESS CONDITIONS - O CITY �YY\ ZIP C Date a�' APPlico NOTfeE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O ENGINEER NO. J ZONE Exemption;, you should become subject to the Workers' CONST.1// Compensation provisions of the Labor Code, you must forth- ADDRESS •" W with comply with such provisions or this permit shall be 3 iL - deemed revoked. NOTEL• STATISTICAL•CLASSI ICATION APT.. �ONDO. .N CONTRACTOR LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS Z I hereby offirm'that I am licensed under provisions of Chapter 9 ADDRESS NO. (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 BK l �� VALIDATIONSQ. FT NO:OF NO. OF CHK License Number Lic.Class SIZE O EC STORIES FAMILIES ONE IF LLUATION 1 DESCRIPTION OF WORK t��i.(/ �((�ZL/Al.� NEW _ Q S I;9 A Contractor Date q ADD I am exempt under Sec. vo Ir",12P�.-+1 ALTER '-# o o:o 0 23 B.&P.C. for this reason J Y - 'a'' REPAIR .Q $. ) ° 8 8'�'6 7 Date: USE F w' ` _ , L)EMOL.'❑ >.. .. EXISTING BLDG. - 0 0 88 1.675 Signature APPLICANT, ";' TEL:. G FINAL 1 OWNER-BUILDER DECLARATION (PRINT) r`AI CJ -oL r NO. o� DATE A y o-a 2 4-t_8_8_ I hereby affirm that I am exempt from the Contractor's License d2CS7-67� Law for the following reason (Section 7031.5, Business and ADDRESS FINAL _� � yn -IV,tEl. � .^ Professions Code): PRESENT BY BUILDING x -• r I, as owner of the property, or my employees with ADDRESS •f I�1�` wages as their sole compensation,will do the work and pa+N = 1i 114 Qf� 7c• the structure is not intended or offered for sale(Section LOCALITY D i'1_+(n�at••{3 7044, Business and Professions Code). MOVING TEL. l _. a 1{ ?•° :+ I�(I I,.as owner of the property, am exclusively contracting CONTRACTOR NO. . - SW with licensed contractors to construct the project(Sec- ) JLj�,`�J s.¢1' ' 41r. —'-7—.E�1 L ADDRESS tion 7044, Business and Professions Code). ` JJ k REQUIRED TOTAL SETBACK FR ,f 1 CONSTRUCTION LENDING AGENCY YARD WY I .�U SET BACK PROP. LINE WIDTH _ I herebyaffirm that there is a construction lending agency for �•,'+ 9 9 Y FRONT 0111 , 11 L; t`-•. the performance of the work for which this permit is issued P.L. ".'' '; - (Sec. 3097, Civ. C.). SIDE "- "� _ +-^i* -7 {3 -, •'1 "Ai J t7.°° ti�.,.. 0 P.L. r"L �•'- Lender's Name r �1 !�� 1 :I _v LDMA Ref. P.C. Fee$ Permit Fee , Lender's Address _ �'�', 1 Cl g I certify that I have read this application and state that the a Issuance Fee (/ f LDMA P/C k >::�i o above information is correct. I agree to comply with all County Investigation Fee +7+ 0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. q.. R reby authorize representatives of this County to enter ! �+ on t ove'ment' ed proerty for inspection purposes. % + FY 41.' a J'C-9 SEE REVERSE FOR EXPLANATORY LANGUAGE �rwtureafAplic.�arAg*e�nt � Date ►� 1 T . T