The URL can be used to link to this page

Home My Public Portal About9826 LEMON AVE_Building__ WORKERS'COMPENSATION DECLARATION r.� v r� , . .. *,- _.r• } -.•- - ;y I hereby affirm that I have a certificate of consent to self ✓i sure or a certificate of Workers' Compensation Insurance, APPI CATION F O R" B U1 L D I N G, P E RM I T- � or a certified copy thereof (Sec 3800, Lab C ) - COUNTY OF LOS ANGELES BUILDINGIAND SAFETY' „ Policy No - • Company L Certified copy is hereby furnished FOR APPLICANT TO FILL IN ; ADDRESS Certified copy is filed"with the'county building mspec- BUILDING' ` tion department ADDRESS Ddte�y Applicant ,, c 1} CITY ZIP LOCALITY CERTIFICATE,OF EXEMPTION FROM WORKERS', - - - " NO OF-BLDGS - ••• i NEAREST COMPENSATION*-INSURANCE SIZE OF LOT NOW ON LOT CROSS ST (This se -ction need not be completed if the'permrt is for one -- -• - - _ ASSESS r hundred dollars ($100)or lesCT s,) TRABLOCK LOT NO MAP B : PAGE PARCEL TEL SE ZONE MAP ' I,,certrfy'that,ine the performancof the work'for which this OWNER NO NO L permit is issued, I shall riot employ any per son'in any manner p^ 1 SPECIAL r-•- d so'as to become sublect to the Woike Compe anon Laws ADDRESoic AC v d /- CONDITIONS, V Q rj CITY t _ ZIP Note-I �� Applicant' - 0 .NOTICE-.TO APPLICANT If; after making this-Certificate of ARCHITECT OR TEL DISTRICT GROUP I TYPE FIRE - PROCESSED BY ENGINEER NO CONST t ZONE ) Exemption,--,you should become'subject to the Workers' Y r W Compensation provisions of the Labor•Code,,you must forth- ADDRESS r�0 �� - - - 1-:-- d 44 with comply with such provisions or. this-permit shall. be -•- - TEL STATISTICAL CLASSIFICA ION APT NDO z deemed revoked - CONTRACTOR NO I LICENSED,CONTRACTORS DECLARATION ,,; LIC- - CLASS NO '' Z DWELL UNITS I hereby affirm that I am licensed under provi'srons of Chapter 9. ADDRESS NO (corrnrigencmwith Section 7000)of Drvision'3 of the of and r _ r LIC :. SEWER MAP Professions Code, and my license is,in`'full force and effect r CITY CLASS BK PG VALIDATION'- - '' SQ FT NO OFNO OF CHECK License Number �"' Lic Class SIZE STORIES FAMES` ONE . . _ ILIVALUATION DESCRIPTION-OF WORK NEW S✓ OD Contractor Date ADD s `.00�� s, I amexempt under Sec Q P $ t. T _ ALTER` , B&P C for this reason REPAIR_ 93'8,26 2 A USE OF Date' t/c r EXISTING BLDG DEMOL Signature _ - APPLICANT` /� "r- TEL (4 .{, FINAL g PRINT u,0/�'�G nJ NOv4" Sid.Sa `� l/'� t' OWNER-BUILDER,DECLARATION g DATE' •o c 3 3 0.0 I hereby affirm that I am exempt from the Contractor's License - O 7 G ' ADDRESS FINAL Low for-the following-reason (Section 7031 5, Business and _o_to 0-3 3.0 0' Professions Code),' , . PRESENT _ "." w -- - By ^; BUILDING _ - - -- - lU I, as owner of the property, or my employees with ADDRESS -4I $b wages as their sole comperisation,will do the work and n' the structure is not intended or offered for sale(Section LOCALITY , - 7044;Business and Professions Code)• - --- MOVING - -TEL I, as owner of the property, am exclusively contracting CONTRACTOR r NO -with licensed-contractors to construct the project (Sec- ADDRESS ` tion 7044, Business and Professions.Code) :•REQUIRED TOTAL.SETBACK FROM- ' CONSTRUCTION LENDING-AGENCY` '" SET BACK ` YARD, HWY PROP LINE -WIDTH' hereby affirm that there is a construction lending agency for FRONT 4r the performance of the-work for which this-,permit-is,issued PL (Sec 3097, Civ C ) SIDE Lender's Name i ` LDMA�Ref b l Lender's Address P C-Fee$ Permit Fee certify,that,l_have-read this application and state,that the _ Issuance Fee CDMA P/C-1t - ' _ r• ' v' -i above information is correct 1 agree to comply with all County Investigation Fee 1 $ ordinances and State jaws relating to building construction, 4 _ Total Fee --•- - 3. r O `- - u -and hereby authon representatives of this County to enter CDMA Perm-q upon the above- nti ed property for inspection purposes ; dSEE REVERSE FOR EXPLANATORY,LANGUAGE ' ignature of-Applicant or Agent •• ••Date - - •-- - -- - -•- - - ••� -• - --- •- - -�- — _ .. 1 Oi WORKERS'COMPENSATION DECLARATION F her! t§y affirm that I have a certificate•of.consent to self insure; or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING* PERMIT or a certified copy thereof (Sec 3800, Lab C ) COUNTY OF LOS-ANGELES BUILDING AND SAFETY Policy No Company i Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS t 1 ❑ BUILDING /erified copy is filed with the county building inspec- BUILDING Mtn ADDRESS LOCALI11,074 NEAREST Datepplica �� CITYO-P ZIP CROSS CERTI LATE OF EXEMPTION FROM WORKERS' OF BL GS ASS R COMPENSATION INSURANCE IZE LOT W ON LO MAP BOOK PAGE PARCEL (Ths section need not be completed if the permit is for one USE ZONE MAP hundred dollars ($100)or less ) ABLOCK T NO / NO TEL I SPECIAL } I certify that in the performance of the work for which this OWNER N — CONDITIONS Q permit,is issued, I shall not employ any person,in any manner - DISTRICT GROUP TYPE FIRE PRO SSED BY O so as to become s�to the Workers'Co nsation Laws ADDRE ` "' �r/ F 3 CONST ZONE V 7 b �" Dot. Applica AIR ITECT P TEL STATISTICAL CLASSIFICATION APT NDO V NOT E TO PPLICANT If, a er making this Certificate of CLASS NO _DWELL UNITS W Exemption, you should become subject to the Workers' ENGINEER O CL Compensation provisions of the Labor.Code, you F must forth- ADDRESS SEWER MAP V) with comply with such pra\hsions or this permit shall be _ TEL deemed revoked CONTRACTOR NO BK PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC ��O Professions Code, and my license is in full force and effect CITY CLASS $ , SQ FT �} NO"OF NO OF" CHECK License Number Lic Class SIZE ��/ STORIES FAMILIES ONE DESCRIPTION OF WORK NEW Contractor Date ❑ ❑ ADD I am exempt under Sec ALTER ❑ FINAL -. B&P C for this reason V REPAIR C] DATE � '!/) Date USE OF FINAL EXISTING BLDG DEMOL ❑ By :9255,9A Signature APPLICANT TEL OWNER-BUILDER DECLARATION PRINT (v NO —� # 0 0 0 0 0,1 =r I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Business and ADDRESSF( o o 7 a p Q —,Professions Code) N BUILDING I, as owner of the property, or my employees with ADDRESS o ® 0 7 8 p wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7,2 9—85 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 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY, • REQUIRED TOTAL SETBACK FROM EXIST SET BACK YARD HWY PROP LINE 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 m PL o Lender's Name Lender's Address P C Fee$ Permit Fee l�o I certify that I'have read this application and state that the Issuance Fee S` above information is correct I agree to comply with 611 County Investigation Fee ordindnces and St to laws relating to building construction, Total Fee t� and h y out r representatives of this County to enter b v - a coned property f r inWqcti n pur oses� SEE REVERSE FOR EXPLANATORY LANGUAGE OF Signature of App scant or Agent Dote ®s