HomeMy Public PortalAbout10319 KEY WEST ST_Building__ I WORKERS'COMPENSATION.DECLARATION -
*)erebyaffirm that I have,a certificate of consent to self q p p.� qT O N r-101"
.R BUILDING. PERMIT
Msure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lab. C.) •COUNTY OF LOS ANGELES BUILDING D SAFETY
PoliSy.No. Company
(LTJ' Certified copy is hereby furnished. FOR APPLICANT-TCO FILL IN , BUILDING
%k t ADDRESS
Certified copy is filed with the county building inspec t gUIUANG
tiontdepartment. ADDRE Qj ,C E
Date Applicant CITt ZIP. p Q LOCALITY
CERTIFICATE OF EXEMPTION.FROM WORKERS' ; NO. OF BLDGS. NEAREST `
COMPENSATION INSURANCE SIZE OF LOT 7 NOW ON LOT CROSS ST. I
(This section need not be'completed if the permit is for one ` ASSESSOR
hundred dollars ($100)or less.) TRACT-56,~ BLOCK LOT NO. MAO BOOK PAGE PARCEL
wl► °Y} �' TEL '.. // USE ZONE MAP ..
1 certify that in the performance of the work for which this OWNER ` N [7 NO. U�Q
permit is issued, I shall not employ'any person in any manner �/ SPECIAL
so as to become subject to the Workers'Compensation Laws. ADDRESS /y/ - CONDITIONS
Date " Applicant CITY ZIP
ARCHITEC R TEL.
NOTICE TO APPLICANT: If, after making this Certificate of / /J DISTRICT GROUP TYPE FIRE PRO ESSED BY _
ENGINEEl /Y P� 6a r� NQ3�9Y�y� 10
U
Exemption> you should become subject to the Workers' CONST/ ZONE - �
Compensation provisions of the Labor.Code, you must forth- ADDRESS
with comply with such provisions or this permit, shall be
deemed revoked. �/ �• TEL- 2 STATISTICAL CLASSIFICATION APT. CONDO.
CONT Q� YY�L`�F� �P N c5>g
LICENSED CONTRACTORS DECLARATION LIC CLASS-NO. in DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS L� NOZO�;/
(commencing with Section 7000)of Division 3 of the Business and SEWER MAP
LIC: p/
' Professions Code, and my license is in full force and effect. CITY CLASS BK - � VALIDATION
SQ. FT. NO.OF _ NO.OF CHECK
License,Number Lic.Class SIZE STORIES l FAMILIES ONE
VALU TION
DESCRIPTION OF WORK/!`/ f� NEW 64 yy
Contractor' Date S C�
//❑ ❑I am exempt under Sec. �s % ADD
❑ pill. :--2175A
ALTER
B.&P.C. for this reason REPAIR ❑ $ - c a 0 23'
Date: USE OF
EXISTING BLDG. DEMOL ❑
2 . 61010
Signature APPLICANT TEL: FINAL
OWNER-BUILDER DECLARATION PRINT (�C/l�E�/y�NO. DATEL- c ( .1 7-
I hereby affirm that-I am exempt from the Contractor's License - 1'e'�
Law for the following reason (Section 7031.5, Business and ADDRESS FI' r
Professions Code): PRESENT B
r _r' c1 -.84
❑ 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.
❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS 5' 2 2,6 IL 3-A
tion 7044, Business and Professions Code). # 0 0 0 0 2 3
REQUIRED TOTAL SETBACK FROM..
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. UNE WIDTH
hereby affirm that there is a construction lending agency for FRONT -1 •Q, 1:0
the-performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE - \y 0 0 (j 10, 1 0
P.L. =
Q Lender's Name �,� 0 8_$ rJ
LDMA Ref. # '� 11 :J °
' P.C-Fee$ Permit Fee $�p`�o o,'•oNo
Lender's Address r� ` e �7 J a%,N
>
I certify that I have read this application.and state that the Issuance Fee /O rV iDNA P/C# 'N N N o O
a above information is correct. I agree to comply with all County Investigation Fee I. pp gp o �D
w ordinances and State laws relating to building construction, Total FeeZS7
LDMA Perm. # N N a N
and hereby authorize representatives of this County to enter CJI 01 C11—:I:.
m upon th above-mentioned property for ins ection purposes.
CH
a -zt� SEE REVERSE FOR EXPLANATORY LANGUAGE
0
Si Lure of pplica or ent Date _ OO