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HomeMy Public PortalAbout6132 IVAR AVE_Building__ WORKERS'COMPENSATION DECLARATION M' ' 10 ID insure, oraaffirm certif certificate of Worke s' Compensation e of eInsuran ent to lf� � O L1 V ' O O �:�.dD GAJC pL G3G or a certified copy thereof (Sec. 3800, Lob. C.) ' COUNTY OF LOS ANGELES BUILDING ARID:SAFETY Policy,No. Company BUILDING Certified is hereby furnished.,. FOR APPLICANT TO FILL IN El ❑ copy ADDRESS (� L ""_'. •,..• - r ` Certified copy is filed with the county building inspec- BUILDING //�n r r 7' /► ^7 p- tion department. ADDRESS (� pl//j Q ,r �}� Date - Applicant CITY 4. LG• , V ZIP ! 1 Sy . LOCALITY" CERTIFICATE.OF EXEMPTION FROM WORKERS' --�j NO. OF BLDGS. NEAREST ��l, �L� COMPENSATION INSURANCE . SIZE OF LOT Q NOW ON LOT CROSS ST:, (This section need not be completed if the permit is for one ASSESSOR`.•, hundred dollars ($100)'or less.) TRACT• 9BLOCK /� LOT NO. ,P q MAP BOOK PAGE ` PARCEL ,�1oIZ � C1 TEL. �� NO2 —�lSS / USE ZONE MAP I certify that in the performance of the.work for which this OWNER NO. permit is issued,'I shall not employ-any person.in any manner /� C SPECIAL so os to become subject to the Workers'Compensation La s. ADDRESS l9 I cJ L `'N VL I / CONDITIONS' .. � Z+Gf fN OIC.(�L �l�i v CITY E7'� t ( (i ZIP <I Date Applicant ARCHITECT OR TEL. NOTICE T AENGINEER NO.PPLICANT:' If, after making this'Certificate of 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- ADDRESS 7c D with comply with.`such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR NO. LICENSED.CONTRACTORS DECLARATION LIC. _ _ CLASS.NO. DWELL.'UNITS- I hereby affirm 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'Ijcense Is in full force and effect. CITY CLASS. VALIDATION SQ. FT. NO.OF NO. OF CHECK• BK. PG. a, License Number Lic.Class ` SIZE STORIES FAMILIES ONE VALUATION V DESCRIPTION OF WORK NEW Contractor Date ADD ❑ $ O ❑ lam exempt under Sec. / ❑ ?e` ALTER. ❑ �. 8.8P C. for this reason REPAIR ❑ $USE OF Date: EXISTING BLDG. DEMOL ❑ s ;`I ° e'49, 8 Z Signature APPLICANT TEL. FINAL o.o a 4 q'g g OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am ezempt,from the.Contractor's License "°� 4_:8 8 Law for the following reason (Section 7031.5, Business and ADDRESS FIN Professions Code): PRESENT � ;�� _ • BUILDING I, as owner of the property, •or.my employees with ADDRESS g wages as their sole compensation,will do.the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. I, as owner of theproperty;.am exclusively contracting CONTRACTOR. NO' with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH J hereby,affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.I. (Sec. 3097, Civ.C.). SIDE P.L. Lender's Name m CDMA Ref. q P.C. Fee$ Permit Fee Lender's Address 3 $ I certify that I have read this application and state that the . Issuance Fee , .�.Q LDMA P/C q . o ' above information is correct. I agree to comply with all County Investigation'Fee 0 ordinances and State laws relating to building construction, Total Fee LDMA Perm. q ' o and hereby authorize representatives of this County to enter w upon-the above-m!nt' d pr erty for inspection p rpo s. �l SEE REVERSE FOR,EXPLANATORY LANGUAGE Signature of Applicant Agent D to 9 PP or 9 WORKERS' COMPENSATION DECLARATION _ I have d' ificae of consent to,se nsurebor pfcertif catte.of Worke srtComipensation Insuran elfG°� UMV. :R D M. o M D d D O-[ .0 G?'C .QG 10` or a,certified copy thereof (Sec 3800, Lab C.) I POicy Company CO 111NTY OF"LOS ANGELES. `BIJiLDIWG'AND SAFETY r BUILDING Certified copy is hereby furnished. y. FOR.APPLICANT TO'FILL.IN ADDRESS: Certified copy 1s.filed-with.the county building:inspec- BUILDING ,d - z tion department. ADDRESS { CITY. ��. ZIP LOCALITY. Date Applicant - CERTIhCATEI OF EXEMPTION FROM`WORKERS SIZE'OF LOT ., NOW ON LOTS NEOSSSST CR COMPENSATION INSURANCE ASSESSOR- , (This'sectron need fiot be completed if The permit is'for one TRACT BLOCK LOT:NO. MAP BOOK PAGE PARCEL i hundred! dollars"($100) or less.) TEL. 'g ,y/� i. •.•:. - - OWNER' �/1+/Y,r7� •NO "y�5 `'� .. I certify:that,in-the performance of the work for"which This ' E MAP , ermit is issueclj sQl not.em to an erson°_in an manner ADDRESS " o} US ON P employ Y P y iQ5 !'� so as to become.subiect'io the,Workers'Compensation Laws. O � y CITY':�E/Y1 L ZIP SPECIAL CONDITIONS •Date APPlicant'- ARCHITECT OR TEL. - DISTRICT "''GROUP TYPE FIRE SSED BY O' NOTICE JO APPLICANT:: If, after.making,this Certificate .of, ENGINEER -NO. :Exemption you should become subject to. the "Workers V ST.' 1,_ u CON,.��' ZONE Compensation provisions of the Labor Code, you';must'fortli-- ADDRESS V..•- /" - a 3 with comply•with such provisions or:,this permit shall.be TEL STATISTICAL CLASSIFICATION. APT. CONDO. - deemed,revoked CONTRACTOR NO' '�1�. _ N t LIC CLASS NP..' DWELL:UNITS I Z LICENSED,CONTRACTORS DECLARATION I hereby.affirm that am ljcensed'under provisions of.Chapter9 ADDRESS J.A�• 4,S AD NO.V 98��� _ LIC. SEWER MAP (comme,ncing.with Section 7000)_of Division 3.of-the Business A ? and Professions Code;and my license is io full forc�e1 and a#ect CITY �(�itG/Zi-c CLASS' C� J BK` pG ' VALIDATION~ License.Number y3�f33 8" Lid,Class SIIZEFT STORIES FAMILIES ONECHECK.. r „:..` :. r . DESCRIPTION OF WORK > ©p� NEW _ V �•/ ALUATION ContractorL7/�h��Ht:IQ[70F+IJ` Date ❑I`am exempt under-Sec. 'B:&P C.for this reason $ _ ALTER. 0 USE:OF S / _ (v REPAIR Date: _ EXISTING BLDG. DEMOL ❑ Signatu ,PPLICANTr TEL. FINAL R-BUILDER.DECLARATION DATE I hereby affirm that*1 am exempt from the Contractors License Law foF;the,following,reason (Section 7031.5,'Business and ADDRESS LC FI 4 Professions Code) PRESENT El BUILDING wages;as their compensation,will do'the wo ` 1[ t_•, I, as owner,of-,the.property, or my employees'with ADDRESS rk.and the structure is not mrid teed'o�offered for sale"(Section -- LOCALITY -- 7044;.Business'and Professions Code.) MOVING TEL I ❑ I, as owner of the<property,.am exclusively.contracting, r CONTRACTOR NO with'license&contractors to construct:the project (Sec- "' i ., q 8" tion 7044, Business'and Professions Code:) .F A REQUIRED - TOTAL SETBACK ROM EXIST.' ' CONSTRUCTION LENDING AGENCY SET BACK HWY PROP.•LINE' WIDTH YARD_ 'I I hereby affirm that there _ 'is�a construction lendingagency for FRONT +=„3._ theperformance_of,th'e Lvork for which'this;peirmit'is-issued P.L. { (Sec. 3097, Civ..C..). SIDE.. .•, Lender's Name, - . LDMA Ref. #. X. =Y. Lender's Address PC: Fee$ Permit Fee - �+� y I certify that I have read this..a. s � - pplication'and'state:that the _ Issuance fee� �•- -� 'LDMA P/C.# above information is correct.:)agree to comply with'aIl County Investigation Fee Q 8 ordinanc d Sidte laws'.relating fo building construction, Total Fee + �V LDMA Perm.'# a ere rize represenI t' es "f this County.to enter upo a rationed pr rty for inspection•purposes. a � SEE REVERSE FORU .EXPLANATORY LANGAGE gnatuie of Applicant,or Agent 'Date