HomeMy Public PortalAbout10342 KEY WEST ST_Building__ WORKERS'COMPENSATION DECLARATION
I hereb affirm that I have a'certificate of consent to self -
insure, or a certificate of Workers' Compensation Insurance, A P_ P L I CAT I O N FOR R BUILDING PERMIT
or o ceftified copy thereof (Sec. 3800, tab. C. COUNTY OF LOS ANGELES BUILDI AND SAFETY
Policy No. Company
E-1 Certified Certified copy is hereby furnished. FOR APPLICANT-TO:FILL IN
ADDRESS
❑ Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Date Applicant CITY ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. - NEAREST * _
COMPENSATION INSURANCE SIZE OF LOT 42 NOW ON LOT CROSS ST. L
(This section need-not be completed'if the permit is for one / ASSESSOR
hundred,dollars ($100)or less,) TRAC� BLOCK LOT NO. / MAP�BOOK PAGE PARCEL
TE 4U/3 t USE ZONE MAP
1,certify that in the performance of the work for which this OWNS / "ri/y! /- �" N Ems- !a / NO. V.7 y_
permit is issued, I shall not employ any person in any manner ADDRESS /y�G�/y/ _. tet SPECIAL CL
so as to become subject to the Workers'Compensation Laws. CONDITIONS O
. U
A . CITY Aozwlsa ZIPZZ1 �
Date' Applicant ARCHITECT OR TEL.
NOTICE TO APPLICANT: If, after making this Certificate of DISTRICT GROUP I TYPE FIRE PRO ESSED.BY
ENGINEER NO. `'b
Exemption, you should become subject to the Workers' CONST. ZONE U
Compensation provisions of the Labor Code, you must forth- OV
with comply with such provisions or -this permit shall be ADDRESS g
deemed revoked. CO0B "//zL11111112STATISTICAL CLASSIFICATION APT. CONDO.
LICENSED CONTRACTORS DECLARATION LI ET` J CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS `Sj� N �S���%
(commencing with Section 7000)of Division 3'of the Business and LIC p SEWER MAP
Professions Code,.and my license is in full force and effect. CITY CLASS rO BK PG VALIDATION
SQ. FT. /j NO. OF NO. OF _ CHECK
License Number Lic.Class SIZE /� STORIES / FAMILIES ONE
VALUATION
Contractor Date 'DESCRIPTION OF WORK. - NEW
❑ $ 68 ,
1
❑ I am exempt under Sec. ���/C �. ADD.- "2 E.7 A
ALTER ❑
B.&P.C. for this reason REPAIR..❑ $- t,' °:° ° 2.3
Date: USE OF
EXISTING BLDG. DEMOI ❑ .2:-,6 1 0, 1 0
Signature APPL Nli , /� FINAL
NO. o ° 6 1 C .1 0
OWNER-BUILDER DECLARATION DAT
-1 hereby affirm that I-am exempt from the Contractor's License '��ADDRESS 0 62 1 —8�I
Law for the following'reason:(Section 703 1.5, Business and FI
Professions C(ide): PRESENT
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and !• ` '
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code): MOVING TEL. z 2 6 3.8 A
CONTRACTOR NO. ? `'
❑ I, as owner of the property, am exclusively contracting - _Y_.�'\ V,��_; 4 `.- �`j .,�,. .�
with licensed-contractors to construct the project (Sec- ADDRESS 1 v N w # 0 0 0 0 '2 3
tion 7044, Business and Professions Code). a '
REQUIRED TOTAL SETBACK FROM T. ,
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ,� ,.'.��'�,�, : t� ) °`6 1 .�, 1 O
1 hereby affirm that there is a construction lending agency for FRONT 1 Y
the performance of the work forwhicK this permit is issued - P.Lr ° ° 6 1 Q 106
(Sec. 3097, Civ. C.). SIDE
P.L. 08.08=85
Lender's Name
m LDMA,Ref`#ti, c� o —�
P:C. Fee$ (, Q Permit Fee711
' 9p o 0 o No
Lender's Address _J"� _
I certify that,I have read this application and state that the lF� Issuance Fee v LDMA P/C# N NNoO
a above information is correct. I agree to comply with all County Investigation Fee
ordinances and State laws,relating to building construction, _ I Aa9ao J
u and hereby authorize representatives of this County.to enter Total Fee LDMA Perm. # NFV owl
U1 Cn crn_p
m upon th above-mentio ed roper for insp tion purposes. CH
o SEE REVERSE FOR EXPLANATORY LANGUAGE
1� Si
jure-of ppli,, nt ent Date"