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HomeMy Public PortalAbout10300 KEY WEST ST_Building__ •r r I WORKERS'COMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING PERMIT ` insure' or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY ompany j' L-= Policy A/. Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS C1 -�• � i ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS , t 7', Date Applicant :5=VL_f_s'EfQZL— CITY7,'e4r, ZIP 9' ' LOCALITY J,6,10 CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT rf CROSS ST. (This section need not be completed if the permit is for one .+ ASSESSOR hundred dollars ($100)or less.) TRACT ' �� BLOCK LOT NO. MAP BOOK PAGE PARCEL OWNER TEL USE TE MAP I certify that in the performance of the work for which this a NO. NO permit is issued; I shall not employ any person in any manner ADDRESS SPECIALi so as to become subject to the Workers'Compensation Laws. CONDITIONS 0. CITY ZIP- U Date Applicant Ll' TEL. ARCHITECT OR NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GR UP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' CONST. ZONE U Compensation provisions of the Labor Code, you must forth- 2 Lil with comply with such provisions or this permit shall be ADDRESS TEL CL deemed revoked. CONTRACTOR NO. STATISTICAL CLASSIFICATION Aft. CONDO. - N LICENSED CONTRACTORS DECLARATION ID LIC CLASS NO. �� DWELL. UNITS Z I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS IM 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 iu ca k7ove CLASS — VALIDATION ,v SQ. F NO. F NO. OF CHECK BK. PG. License Number 'S -� S Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractorfiux Date ?47 DESCRIPTION OF WORK NEW ; ❑ Q ,El ADD I am exempt under Sec. 1:1ALTER B.&P.C. for this reason REPAIR ❑ $ Date: USE OF ❑ EXISTING BLDG. DEMOL Signature APPLICANT TEL. ItI� FINAL t OWNER-BUILDER DECLARATION (PRINT) . NO. DAT —� et 9 2 'A I hereby affirm that I am exempt from the Contractor's License _ # ° 0.0 °l;o`'J Law for the following reason (Section 7031.5, Business and ADDRESS FI Professions Code): PR SENT pI. °,° b 8 6 3 . F-11,I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and , ' ; 'e rO-0 6 a 6 35 the structure is not intended or offered for sale(Section LOCALITY " 7044, Business and Professions Code). MOVING TEL. ® .0 12 8':,`8 8 ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIREDTOTAL SETBACK 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 LDMA Ref. # P.C. Fee$ Permit Fee ✓J / Lender's Address �0 I certify that I have read this application and state that the Issuance Fee 16115-0 LOMA P/C#. o above information is correct. I agree to comply with all County Investigationi Fee 0 ordinances and State laws relating to building construction, Total Fee / ` • •' and hereby authorize representatives of this County to enter r f� LDMA Perm. #• upon th obove-ment'oned rope ty for inspection purposes. _ ../d lCc� °.�`21 .�� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date I i+ ✓YORKERS'COMPENSATION ECLARATION - i�liere6 aYfirm that I�have a certificate of consent to self ifrsure, or-a certificate of Workers' Compensation Insurance, A P P'L I CATION FOR ' BU.IL D I N G PERMIT or a certified copy thereof (Sec. 3800,'Lob. C.) COUNTY OF LOS ANGELESt BU AND SAFETY Policy No. Company, i a Certified copy is hereby furnished... ��F APPLICANT TO FILL IN BUILDING C / ADDRESS u Certified copy'is filed with the county building inspec- [ADDRESS DING tion department. RE � Date Applicant /GIST Gam/ ZIP / - LOCALITY �Le CERTIFICATE OF EXEMPTION FROM WORKERS' _ ' ' -• NO-,OF BLDGS. NEAREST COMPENSATION INSURANCE OF LOT ��'� NOW ON LOT d CROSS,ST. (This section need not be completed if the'permit is for one T. � - ASSESSOR hundred dollars ($100)or less;) . / BLOCK v LOT NO. MAP BOOK PA E• PARCEL ER � QG�(/G"_/rf' vc NO USE ZONEMAPI certify that in the performance of the work for which this NO.permit is issued, I shall not employ any person in any manner /G J SPECIAL so'as to become subject to the Workers'Compensation Laws. RESS / � � /f/�v�iTifY1 �`'1 CONDITIONS J,td, _ ZIP.Date Applicant NOTICE TO APPLICANT: If, after -making this'Certificate of HITECT OR TEL. O DISTRICT GROUP_ TYPE FIRE PRO ESSED BYINEER NO. CONST. ZONE rExemption, you should become subject to the Workers'Compensation provisions of the Labor Code, you must forth- t or with comply with such provisions or this permit shall be TEL. deemed revoked. CONTR l��/�fl�� NO '�� STATISTICAL CLASSIFICATION APT, CONDO. LICENSED CONTRACTORS DECLARATION 'LIC�:�/ CLASS NO. DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS N(r����4✓ r. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force'6nd effect: CITY CLASS Iff_ BK. PG. VALIDATION SQ.,FT NO. OF NO.,OF- / CHECK_ License:Number Lic.Class SIZE 2©,i?1� STORIES Gr FAMILIES ! ONE A.2 67 1 A- VALUATION DESCRIPTION*OF WORK "' NEW #•0 0 0 0 0 1 Contractor Date ADD $ ®� F] I am exempt under Sec. ✓< ' L` � ALTER "I0 7 5 5.25 � _ • l B.&P.C. for this reason REPAIR .-� o o 7 5,2 5 5 Date: USE OF DEMOL. EXISTING BLDG. / f/}�(}/,/f, Signature APP PRAM N J� FINAL rill V /! 0 8. 1 2-8 OWNER-BUILDER DECLARATION �K DATE I hereby affirm that I am exempt from the Contractor's License S��/!� Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By 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: t. \ T '' I, as owner of the property, am exclusively contracting CONTRACTOR NO._ _ �.�t � � -� -2 6 3, 4 A with-licensed contractors to construct the project (Sec-. ADDRESS \ a tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM. XIS . -- - -#-a 0 0_0 2 3 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH s ` I hereby affirm that there is a construction lending agency for FRONT i the-performance of the work for which this permit is issued P.L. ( ° 6 3 3.0 5 (Sec. 3097, Civ. C.). SIDE o P.L.. 4 ' lender's Name - _ •" a a 6 J 3J,0 5`•_ o LDMA Ref # m `Lender's Address - - - P.C. Fee$ >� -Permit Fee > 1 - I' ` I!•.`7 > Q 8 08-'e5 I certify that I.have read this application and.state that the _3 W Issuance fee ` .�✓ LDMA P/C# - above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building,construction, uand hereby authorize.representatives of this County to enter - Total Fee LDMA Perm. # a upon th above-mentioned ropert or insp ction purposes. a, SEE REVERSE FOR EXPLANATORY LANGUAGE Si Lure of, plica or ent Date1-41 4 J