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Home My Public Portal About10306 KEY WEST ST_Building__ WORKERS' COMPENSATION DECLARATION faereby affirm that I have a certificate of,consent to self A P P L I CAT I OWFOR_O R 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 Policy No. Company Certified copy is hereby furnished. „FOR•APPLICANT.TO;FJLL'IN BUILDING C; . v ADDRESS ❑ Certified copy is�filed with the county building inspec- B1ILDING' Tion department) _ ADORES _' . . y x',41 moi. _ a• ,.;� Date Applicant CITY �~ ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS'' NO. OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT , Z p NOW ON LOT _ fF� CROSS ST. (This-section need not be completed if the permit is for one - - ASSESSOR . -hundred dollars ($100)or less.) TRACT 3� BLOCK LOT NO. MAP BOOK" PAGE PARCEL -�° TEL. USE ONE MAP OWNER,7 -/�� N � I certify that in the performance of the work for which this / / SPECIAL D - permit is issued, I shall not employ any person in any manner ADDRESS �6 /��Li�� EL so as to become'subject to the Workers"Compensation Laws. CONDITIONS O CITY. L-//" ZIP /D!PI�6_ Date Applicant ARCHITECT OR TEL. O NOTICE TO APPLICANT: If, after making this.Certificate of ENGINEER NO DISTRICT GROUP TYPE FIRE: PROC SED BY e¢�; Exemption, you"should become subject to the Workers'' " _ �? p CONST. ZONE Compensation provisions of'•the Labor Code, you must forth- ADDRESS �� ^" ^� a. with comply with such. provisions or this permit shall be' �/`,. �� +t STATISTICAL CLASSIFICATION T. CONDO: deemed revoked. CONT k,0 //[�ff//E �� fJO.e �J�w/� LICENSED CONTRACTORS DECLARATION 1. - - LIC. ` / CLASS NO.��DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS /Y�/ NO. SEWER MAP (commencing with Section 700 0)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS / BK ' PG VALIDATION SQ. NO. OF 7 NO. OF / CHECK License Number Lic.Class SIZEF STORIES Cr FAMILIES/ ONE VALUATION... . DESCRIPTION OF WOK NEW- - �jj Contractor Date ADD ❑ f poll❑ 1 am exempt under Seca ALTER ❑ 2 1 7,0 A B.&P.C. for this reason I REPAIR ❑ $ <, o o o 23 Date: USE OF EXISTING BLDG. DEMOL ❑ 2 ° ,; 1 1 Q Signature APPLICANk /, / �}tEC � FINAL OWNER-BUILDER DECLARATION i�T+ d{! !/f/� l/ DATE 2� � o n 1 0 1 C= -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 C 1 —84 ❑ BUILDING 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. ❑ \ CONTRACTOR NO.I,.as owner of the property, am exclusively contracting \': _ with licensed contractors To construct The project (Sec- ADDRESS A. ;2263.5A tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM IS . -a 0 0 0 23 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH n, ,C4. '' I hereby affirm that there is a construction lending agency for FRONT o 6 1 0, 1 0. the performance of the work for which this permit is issued P.L. ` (Sec. 3097, Civ. C.). SIDE 61 0, 1 w P.L. Lender's Name %t m LDMA Ref f+ l Ota y.L, °V j ° � 1k Q 8,0 8=8 5 . Lender's Address P.C. Fee$ • o Permit Fee •7 1 /� o 'o o' No ' > ,l o IV certify that I have read this application and state.that the - - Issuance Fee - SV kLD P/C It t N o O a above information is correct. I agree to comply with all County Investigation Fee '909a o-12 +1 m ordinances and State,lows relating to building construction, Total Fee S LDMA Perm. N NPV° 04 U and hereby authorize representatives of this County to enter upon the above-mention d o- rt inspection purposes. CH a / SEE REVERSE FOR EXPLANATORY LANGUAGE n , Sig re of /P lica/Ara t Date t ' / _ I WORKERS'COMPENSATION DECLARATION here,- affirm'that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT • `insure,-8r a certificate'of Workers' Compensation Insurance, or a certified,copy thereIV 4ec. 3800, Lab. C ) COUNTY OF LOS ANGELES BUILDINGI AND SAFETY Policy No.� 4ompany ^ Certified copy is hereby furnished. 7 DU'LDN FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING q tin dep rtment. ADDRESS ! LOCALITY NEAREST Date Applicant P L CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM ORKERS' NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE / SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one3&7USE ZONE MAP 7-3hundred dollars ($100)or-less.) TRACT BLOCK LOT NO. NO. i 7 T e/ GTEL. / l SPECIAL > I certify that in the performance of-the work for which this OWNER '�- Q NO. CONDITIONS IL ermit is issued, I shall not employ an person in an manner r�ry �/� DISTRICT IGRO PE FIRE SED BY p p Y Y p y ADDRESS V�� ONST. ZONE C/ 09 so as to become subject to the Workers'Compensation Laws. �^ � Date ?� Applicant fz/ L�/ w CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO. NOTIC TO APPLICANT: If, after making t Certificate of ARCHITECT OR TEL. is ENGINEER NO. CLASS NO. DWELL. UNITS Exemption, you should become subject to the Workers' �. Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N with comply with such provisions or this permit shall be deemed revoked. CONTRACTOR I T L BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I•am licensed under provisions of Chapter 9 ADDRE O e, f(' I ty-�L LQ NO. -0S.-03?3? VALUATION (commencing with Section 700000 )of Division 3 of the Business and LIC. I $ � Professions Code, and my license 's in-full force and effect. CITY / -' CLASS , SQ. FT. NO.OF NO. OF CHECK License N b r� Lic.Class SIZE STORIES FAMILIES ONE VI C NEW $ Contract Date It DESCRIPTION OF WORK L ❑ I am exempt under Sec. �QQitif k) C I ADD ALTER ❑ FINAL � � B.&P.C. for this reason � Z� /9� ` REPAIR ❑ DATE _71314— _ - 7� �' USE OF DEMOL FINAL^ EXISTING BLD J ❑ !t Jii A Signature, ` APPLICAN L. l- BY '', 4,0� -' WNO-BUI R DECLARAT,1 PRINT z NO. pq i I hereby affirm that I am e e pt from th ntractor's License /� -7 � Law for the following re n (Section 7031.5, Business and ADDRES `�/ 0,L ►tea- (no_:_i%k 1 14 polo Professions Code): PRESENT 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 I 7044, Business and Professions Code). MOVING TEL. ❑ I, as owner of The property, am exclusively contracting CONTRACTOR NO. I with licensed contractors to construct the project (Sec- ADDRESS tion 7044; Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH , ; :26028A 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 o o (Sec. 3097, Civ. C.). SIDE I o a 59.25 m P.L. Q Lender's Name o m 0 7� 5925 $ P.C. Fee$ Permit Fee Lender's Address ,I 1,2 6-86 I certify that I have read this application and state that the issuance Fee • `��, above information is correct. I agree to comply with.all County Investigation Fee g ordinances and State laws relating to building construction, Total Fee J d and hereby authorize representatives of this County to enter upon a ove-mentioned pr erty f r inspectio purpo es. a _�� SEE REVERSE FOR EXPLANATORY LANGUAGE S gnotu of Applicant or A e t Date ®s