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Home My Public Portal About10303 KEY WEST ST_Building__ EWORKERS' COMPENSATION'DECLARATION hherieby_a certificate that I have rk certificate of consent to self APPLICATION 'FOR B�U I L D I N G PERMIT insure, ora certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILD IN AND SAFETY Policy No. Company F-1- Certified copy is hereby furnished. BUILDING 7G E� FOR.APPLICNTTO FILL IN ADDRESS ElCertified copy is filed with the county building inspec- BUILDING Tion department. ADDRESS Date Applicant CITY ZIP P / LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.`OF BLDGS. NEAREST COMPENSATION INSURANCE ' SIZE'OF�LOT d NOW ON LOT CROSS ST. (This section need not be completed if,the permit is;for oner / ASSESSOR hundred dollars,($100)or less.) TRACT BLOCK LOT NO. MAP'BpOKPAGE PARCEL TEL USE ZONE FSPECIAL AP O OWNER I certify that in the.peiformance,of the work for which this NO. O. / y, permit is issued, I shall not employ any person in any manner // /�, !� so as'to become subject to the Workers'Compensation Laws. ADDRESS/� �� . /yam /`I l ONDITIONS Date Applicant CITY ZIP /�QV NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. DISTRICT, GROUP- TYPE. FIRE PRO ESSED 8Y ENGINEER NO. � Exemption; you should become subject to the Workers' CONST. ZONE � Compensation provisions of the Labor Code, you must forth- /� ADDRESS V with comply with such provisions or this permit shall be r A0 deemed revoked. CONTRACT - /i/'/��iQ� N 6 STATISTICAL CLASSIFICATION APT. CONDO.- LICENSED ONDO. LICENSED CONTRACTORS DECLARATION LIC.��.�• CLASS NO.� DWELL. UNITS I•hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NOf-�✓��G`. (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/ VALIDATION SQ. FT. NO.OF NO. OF CHECK BK. PG. 2blyQp _ License Number Lic.Class SIZE = STORIES FAMILIES ONE 6/ VALUATION # 0 0 0 0 0 1 DESCRIPTION OF WORK Contractor Date NEW ❑ $ pp I ° 755.2 5 ❑ I am exempt under Sec. -- L �s! ALTER B.BP.C. for this reason REPAIR ❑ $ ° ° 7. 5.5 2 5 5 USE OF i I•/_ f Date: EXISTING BLDG. DEMOL ❑ 0 8 1 2-85 APPLICANT / TEL. a o o J Signature PRINT) �� LE1�nj�/`��Ilp, FINAL j_�� OWNER-BUILDER DECLARATION DATE 1. c 6 - F I hereby affirm that I am exempt from the Contractor's License �" `� 0' Law for the following reason (Section 7031.5, Business and ADDRESS �IZL FIN Professions Code): .•.J •... .:�. U PRESENT - B C, ❑ I, as owner of the property, or my employees with BUILDING C ADDRESS 6, 21 —3.4 _ _ wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY o 7044, Business and Professions Code). MOVING TEL. z�633A ❑ CONTRACTOR NO. t Y , I, as owner of the property, am exclusively contracting ''•, �. � ° ° ° ° 2 3 with licensed contractors to construct the'project (Sec- ADDRESS tion 7044, Business and Professions Code). I - 6 3 3.05 REQUIRED - .TOTAL SETBACK FROM S . CONSTRUCTION LENDING AGENCY - SET BACK YARD' HWY PROP. LINE WIDTH hereby affirm that there is a construction lending agency for FRONT °'o,6,3 3.0 5Z the performance of the work for which this permit is-issued P.L. (Sec. 3097, Civ. C.). SIDE 08,08-85 P.L. _ Lender's Name ` v 3 d Permit Fee t LDMA Ref. # s -l. .- IP7 �j,9 A .. P.C. Fee$' i ,;�.. - Lender's Address t I certify that I have read this application and state that the (t Issuance Fee LDMA P/C# ' #above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building-constructionTotal FeeLDMA Perm: q # 5.5 u and hereby authorize representatives of this County to enter m upon the above-mentiongd o ert or inspection purposes. oe SEE REVERSE FOR EXPLANATORY LANGUAGE Si vre of plica n r t Date WORKERS'COMPENSATION DECLARATION I o heretaffirm I have. certificate of.consent to self " " '� A P P�L I CA_ TION �F O R . B U I L'D I N G PERMIT '. insure, or o certificate of Workers' Compensation Insurance, ' or a certified copy thereof (Sec. 3800, Lab. C.)' - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No..' Company _ Certified copy'is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS El` Certified copy is filed with the county building inspec- BUILDING ` �� _/__ tion,department. ' ADDRESS W l Date Applicant CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM.WORKERS' NO. OF BCDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. hundred.dollars $100 or,less.p the•permit is for one - ASSESSOR This section need not be complefed :f ( ) ) TRACT BLOCK LOT NO. MAP BOOK PAGE; PARCEL TEL E ZONE MAP I certify that in the performance of the work for which this OWNER / TEL Z" n NO. NO permit is issued,1 shall not employ any person in any manner SPECIAL f� so as to become subject to the Workers'Compensation Laws.^ ADDRESS CONDITIONS "l?/�'�J�� il'/Y y CITY ZIP 09 Date Applicant ARCHITECT OR TEL. O NOTI TO APPLICANT: If, after making t is Certificate of DISTRICT- .GROUP TYPE FIRE. PROCESS BY - .. ENGINEER .�' NO., Exemption, you should become subject to the Workers' - d', CONST.I, ZO EE Compensation'provisions of the Labor Code, you.must forth- ADDRESS ILS V ✓ with comply with.such provisions or this permit shall be' NA TEL ��// STATISTICAL CLASSIFICATION APT. 7DO. deemed revoked. CONTRACTORAl- O. 7�s'7�l LICENSED CONTRACTORS DECLARATION - - - - LIC• �j V�j CLASS NO. DWELL. UNITS I.hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ci �✓ s(�5C �a.- NO./-�Y (commencing with Section 7000)of Division 3 of the Business and . . i.._ LIC. / SEWER MAP' Professions Code, and my license is in full force and effect. CITY CLASS BK VALIDATION SQ. FT. NO. OF• NO.,OF. CHECK License Number��/O Lic.Class SIZE p2s� STORIES FAMILIES ONE ,'�5� �� VALUATION DESCRIPTION OF WORK NEW $ f Contracto ate J (j(� 1 am exempt under Seca ADD a ► ' - ALTER , _ _ �4.7 2.9 A� ' B.&P.C. for this reason _ REPAIR- O $ # o,o,o o•231 - USE OF Dater EXISTING BLDG. ' kff DEMOL Q A, o 0 7 3.3 2 Signature APPLICANT TEL. FINAL 6 OWNER-BUILDER DECLARATION PRINT) NO. DATE ��z1G- _ o o o-7 13 2 1' I hereby affirm that I am exempt from-the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL .0 52 9 8 6 Professions Code): PRESENT BY t QBUILDING ; I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section ' 7044, Business and Professions Code): MOVING TEL.' ` I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- - ""- 4 8 1 A ADDRESS o 0 0 0 0 tion 7044, Business and Professions Code). �#• .�.. � REQUIRED TOTAL SETBACK FROM T. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH �.23.43 - 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. - - - o o a 2,3 4 3,c5 (Sec. 3097, Civ. C.). SIDE P.L. .. _ Lender's Name 0 $i$6 o _a� _ �r �} - •� LDMA Ref. # m _ - �f �J oi.a Permit'Fee 3( J - Lender's Address > I certify that I have read this application ond.state-that.the Issuance Fee U "D LDMA P/C It a above information is correct. I agree to comply with all County Investigation Fee2 22 0 ordinances and State.laws_relating to building construction, Total Fee J LDMA Perm: # and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature p scant or Agent - to - -` - -' -' -' - .. I '