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HomeMy Public PortalAbout10312 KEY WEST ST_Building__ 'WbRKERS' COMPENSATION DECLARATION to self l insurebor afcertif certificate of Worke s' Compensat on a certificate ofconsent Insurance, A P P L I C AT I ON_ FOR BUILDING PERMIT' or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDI G AND SAFETY Policy.No. Company BUILDING ❑; Certified.copy is hereby.furnished. FOR APPLICANT.TO,.FILL IN ADDREss -Certifiedcopy is filed with the county building inspec- BUILDING tion department. ADDRESS/�= v /LGA Date Applicant CITY ZIP 7. O.r. LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLD NEAREST COMPENSATION INSURANCE SIZE OF LOT �tid NOW ON LOT T CROSS ST. _ (This section need not be completed if the permit is for oneASSESSOR, � hundred dollars ($100)or less.) TRACT 7 3 5 BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL USE ZONE MAP r� I certify that in the performance of the work for which this OWNER' j¢f/ N .-�� NO. Gt l A permit is issued, I shall not employ any person in any mannerSPECIAL so as to become subject to the Workers'Compensation Laws. ADDRESS �7' '� �-ate �C CONDITIONS t CITY _ ,� I�• ZIP ld Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP TYPE. FIRE PRO ESSED BY ENGINEER. NO. ' CONST. ZONE Exemption, you should become subject to the Workers' ' Compensation provisions of the Labor Code, you must forth- ADDRESS ��c� ` 3 with comply with such provisions or this permit shall be / STATISTICAL CLASSIFICATION PT. CONDO. deemed revoked. CONTRACTAR:L-_� lv �/r�11�!O o. d3lr�� LICENSED CONTRACTORS DECLARATION LIC. G�` CLASS NO. 0 � DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Gz N Y 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 VALUATION DESCRIPTION OF WORK "` NEW - Q Contractor Date ADD ❑ $ go 6 ❑ I am exempt under Sec. —SSG "�� ALTER ❑ , 2 1 b 9 A B.BP.C. for this reason REPAIR ❑ $ Dater USE OF DEMOL ❑ ,o o 0 0 2 3 EXISTING BLDG. _ 2 � 610, 1Q Signature APPLICA TEL. �p FINAL OWNER-BUILDER DECLARATION PRIt �� /�Y //y� =��/✓ NO:vp �� DATE I hereby affirm that I am exempt from the Contractor's License / mac Law for the following reason (Section 7031.5, Business and ADDRESS FIN _ 06.21 —84 Professions Code): PRESENT By , F11, 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. `' _• 4 `'t, CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS Tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SETBARE CK YARD UIRED HWY TOTAPREOTPAINEFROM WIDTH h -. -A263.6 A hereby affirm that there is a construction lending agency for FRONT # aoao23 the performance of the work for which this permit is issued P.L, y' (Sec. 3097, Civ. C.). SIDE �� � ° 61Q10 m _ _ P.L. _ _. ; � • Lender's Name ,, "�_ _ _ m LDMA Ref.:,# '.`:v> ..�. .�1 ©, ° - 6 1 0, 1 0 r,.' P:C. Fee$ Permit Fee I '""e .. ? .o;•e a~10 - lender's Address i�, "' o fV 08.08='85 . I certify that I have read-this application and state that the Issuance Fee f/ Q ILDMA P/C#' r,,)-o C> a above information is correct. I agree to comply with all County Investigation F e L PO-CO o v ordinances andStatelaws relating to building construction, Total Fee O LDMA Perm. # �� o Cn u and hereby authorize representatives of this County to enter (nU1--`:�C:- upon the above-mentioned property for inspection purposes. CH Q SEE REVERSE FOR EXPLANATORY LANGUAGE nature Applic t o ent • Date