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HomeMy Public PortalAbout10324 KEY WEST ST_Building__ -.WORKERS'COMPENSATION DECLARATION :` •' APPLICATION FOR BUILDING PERMIT I hereby affirm that I have'a certificate'of consent tf&'self ' rksure, or a certificate of Workers' Compensationlnsurance, or a certified'copy thereof (Sec. 3800, Lab C )° " COUNTY.OF LOS,ANGELES BUILDING.AN SAFETY Policy No. Company. BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN � Certified copy is filed with the county building inspec- BUILDING . tion department. ADDRESS /�� �© E �S Date Applicant CITY L� _ - L ZIP LOCALITY �. CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST-. . . COMPENSATION INSURANCE ' SIZE OF LOT � NOW ON LOT CROSS ST. (This section,need not be completed if The permit is for one ASSESSOR - -hundred dollars ($100)or less.).., TRACT BLOCK LOT NO. MAP BOOK PAGE. PARCEL TEL USE ZONE MAP I certify that in the performance of the work for which this OWN Ei1/ C ' N (a�E' '�' NO. permit is issued, I'shall not employ any person in any manner / C SPECIAL - - sops To become subject To the Workers'Compensation'Laws. ADDRESS/��S � CONDITIONS �i�L �f.� ,-�-- CITY • . Date_` Applicant ' � - •' NOTICE TO APPLICANT:,If, after making this Certificate of , ARCHITECT OR TEL. DISTRICT ,. GROUP .TYPE_- �/_ FIRE PRO ESSED BY_, ENGINEER NO. CONST. ZONE Exemption, you should become subject to the Workers' roLu f' Compensation provisions of the Labor Code; you must forth- ADDRESS Q. - 3- 916 with comply-with.such -provisions or this permit shall be" TEL L`,�•/ STATISTICAL CLASSIFICATION APT. COND0.'deemed,revoked.,, CONT / y9�/l�,� N �UJ6 � LICENSED CONTRACTORS DECLARATION- LIC _ �r CLASS NO. LDWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9. ADDRESS (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 BK. _ "PG `- VALIDATION SQ. FT. �/ NO. OF NO. OF CHECK License Number Lic.Class SIZE !�� IS FAMILIES I ONE VALUATION_ Contractor Date DESCRIPTION OF WORK' ' NEW ADD a ❑ /rte / El I am exempt under Sec: � � . ALTER B.&P.C. for this reason ' S - REPAIR -1r,2-1 6.4 A: USE Of s Date: DEMOL ' EXISTING BLDG. o.o a a 23 -. Signature APPLI L - TE���Q FINAL OWNER-BUILDER DECLARATION k&kf DATE 12 0;6 1 Q].0. -1 hereby affirm that I-am exempt from the Contractor's License �� � _ Law for the following reason,(Section 7031.5, Business and ADDRESS o o fJ"I Q' 1 Q Professions Code): - PRESENT _. . BUILD1 MING 0 8'G- , , z - I, as owner of The property, or my employees with ADDRESS * w ` t 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 ❑ CONTRACTOR NO. ', v I, as owner of the property, am exclusively contracting •,i • with licensed contractors to-construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK FROM XIS ._ l CONSTRUCTION LENDING AGENCY SET BACK YARD' "HWY" PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT } ' H x'2'6 U A the performance of the work for which this permit is issued P.Lr 1 #. ) `~ `. (Sec. 3097, Civ. C.). SIDE ° i # 0 0 0 0 2,3 n P.L. - Lender's Name i o 'o 061' 0. 1 o / LDMA'Ref. #, i P:C. Fee$ CL/�Yl. _ _.. PermitFee- Lender's Address \ J a o a 6 U 1 Q 1 Q= j Y I certify that I.have read this application and state that the �- Issuance Fee f/ V® LDMA P/C#- N.N N a a above information is correct. I agree to comply with all County Investigation Fee Ph Q 8_8 5 ordinances and State laws relating to building construction, Total Fee. - LDMA Perm. # N N a t and hereby authorize representatives of This County to enter upon the above-menTior�ed property for inspection purposes. CH d �' SEE REVERSE FOR EXPLANATORY LANGUAGE S} ature of pylic t or