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HomeMy Public PortalAbout10311 KEY WEST ST_Building__ WQRKERS' 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 rtified co the eof jSec. 3800, lab. ) i/) COUNTY OF LOS ANGELES BUILDING AND SAFETY ' ,c o0 7 i ocol Po icy o. Company J BUILDING ❑ Certified copy is hereby furnished.H Q_ FOR APPLICANT TO FILL INADDREss 3 IL _ Certified copy is filed with the county building inspec- BUILDING 10-3 l tion department. ADDRESS 71 Datea� Applicant CITY. ZIP LOCALITY I NO. OF BLDGS. NEAREST RTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE I PARCEL hundred dollars ($100) or less.) TEL. OWNER NO. _ Z SE ZONE MAP I certify that in the performance of the work for which this '''nnn NO. permit is issued, I shall not employ any person in any manner ADDRESS 3 S SPECIAL CONDITIONS a- so as to become subject to the Workers' Compensation Laws. 0 CITY CJ:qZIP (> Date Applicant ARCHITECT OR I . DISTRICT GROUP TYPE 0 ENGINEER NO. PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of n CON57. / FIRE ZONE 0 Exemption, you should become subject to the Workers' ' Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR L NO. 2 Z LICENSED CONTRACTORS DECLARATIONIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS (commencing with Section 7000)of Division 3 of the Busi LIC. SEWER MAP and Professions Code,and my license is in full force and ect.' CITY e✓ 90,nAn BK. PG. VALIDATION p SQ. FT. ! NO. OF . NO. OF CHECK License umber 2 b oo IQ Lic. Class f^a SIZE 13'0 STORIES FAMILIES ONE VALUATION Contractor L Date DESCRIPTION OF WORK NEW ❑ $ L+000 Elam exempt under Sec. 3 S(1 ADD —i i LTER ❑ ► g B.BP.C. for this reason {CQOJ�pI P $ AL-'`•'(°g REPAIR ❑ USE OF • -,3 •7 7 Date: EXISTING BLDG. DE ❑ ��"�' i ITEMS �'�°r Signature APPLICANT TEL. _ FINAL 1 I)Et tL OWNER-BUILDER DECLARATION (PRINT) _ L NO. � � DATE � --° � I hereby affirm that I am exempt from the Contractor's License L`� e` IT/ TO AL 93 ® 7v Law for the following reason (Section 7031.5, Business and ADDRESS 4 FINAL Professions Code): PRESENT B CHECK 9*3° BUILDING Y ElI, as owner of the property,.or my employees with ADDRESS CHANGE wages as their sole compensation,.wilI do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. ► y { r, f' CONTRACTOR NO. 013130 —13001 2[ i,f'0 ❑ I, as owner of the property, am exclusively contracting I with licensed contractors to construct the project (Sec- ADDRESS ��74*2`. 1 ACi10'.011 tion 7044, Business and Professions Code.) CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAPREOTPA LINE WIDTH 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 P.C. Fee$ Permit Fee LDMA Ref. # Lender's Address r� o I certify that I have read this application andstate that the Issuance Fee `fV LDMA P/C# pop 8 above information is correct. I agree to comply with all County Investigation Fee !�I 6 ordinances and State laws relating to building construction, Total Fee ` LDMA Perm. # a and hereby authorize representatives of this County to enter up the akve-mentio property or inspection purposes. Ch A n� /tN� �- O SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Dc6e WORKERS'COMPENSATION DECLARATION I hereby affirm that I have 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 BUIM AND SAFETY Policy No. Company r Certified copy-is hereby furnished. i.. BUILDING %, , L _N. / ADDRESS (.[/ ElCertified copy is filed with the county building inspec- BUILDING �h �" tion department. Date Applicant CIT o ZIP (/ LOCALITY l� CERTIFICATE OF EXEMPTION FROM WORKERS' t` NO: OF BLDGS. _ NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON-LOT ®` CROSS ST. (This section need not be completed if'ihe permit is for one 2� ASSESSOR - hundred dollars ($100)or less.) TRACT< e, BLOCK LOT NO. MAP BOOK' PAGE PARCEL TEL. USE ZONE MAP I certify that in"the performance of the work for which this V O.' '""'NO. permit is issued, I shall not employ any person in any mannerSPECIAL so-6s to become subject to the Workers'Compensation Laws. ADDRESS y� ��� /�/L" ' CONDITIONS �,• , U CITY .�G /� ZIP Aa4 �t Date' Applicant ARCHITECT OR TEL O NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE . FIRE PROC SSED.BY� ENGINEER NO. CONST. ZONE U Exemption, you''should become subject to the Workers' � Compensation provisions.of the Labor Code,.ryou must forth- ADDRESS �r.0 0 -3 V 0. with comply with such provisions or this permit shall be _' "' TEL STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked.:. CONTaI�3R� !�///���41y,�7 N �3'�✓r�a /� f LICENSED CONTRACTORS DECLARATIONLIC. �6 ,./ CLASS NO. DWELL. UNITS 1 hereby affirm that I'am licensed under provisions of Chapter 9 ADDRESS C NOS�a�'7 SEWER MAP (commencing with Section 7000)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. FT. NO. OF NO. OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE C VALUATION DESCRIPTION OF WORK' 'f✓w-&e, NEW Q� Contractor Date ADD $ c I am exempt under Sec. L ALTER 2 7.4A B.&P.C. for this reason REPAIR Q $ a o a 0 23 USE OF Date: DEMOL EXISTING BLDG. �p 2 Signature APPPRA. 7� /� TN' � �.��✓� FINA ° 6 04,3 5 OWNER-BUILDER DECLARATION DAT '�L-` O hereby affirm that I•am exempt from the Contractor••s License Law for the following reason (Section 7031.5, Business and ADDRESS y - Professions Code): PRESENT 0 6 2-1 8,4 BUILDING I, as owner of the property, or my employees with ADDRESS a 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 the property, am exclusively contracting CONTRACTOR NO. ,. with-licensed contractors to construct the project-(Sec- tion-7044, roject-(Sec-tion 7044, Business and Professions Code).. 1 ADDRESS 9 2 6 3 1 A REQUIREDTOTAL SETBACK FROM T. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 1 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 ti - m Lender's Address P.C. Fee$ �� J Permit Fee t © a I certify,that.I have read this application and state that the60�, a � , 1 - 604,3.5 Issuance Fee ®�V -L6AWPV@# a above information is correct. I agree to comply with all County Investigation Fee '7— ° o ° 6 0 4.3 5 cs� ordinances and State laws relating to building construction, - Total Fee / 115 0 LIU^Pc�tr . # ° �• v and hereby authorize representatives of this County to enter 00 8 0 8 —8 5 uponupan•�e-mentioned ro ert or inspection purposes. CN - _•. SEE REVERSE FOR EXPLANATORY LANGUAGE • •Si ure of pelican or a Date • `- - - - ' ' ' I