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HomeMy Public PortalAbout5304 NOEL DR_Building_1/14/1975_ WORKERS COMPENSATION DECLARATION - 10 IF hereby taffirm that I have a certificate of consent to self Insure or'a certificate of Workers Compensation Insurance _ APPLICATION- FOR BUILDING PERMIT C11 or a certified copy thereof(Sec 3gpp Lab ) T,[i 7i>�IC .� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No 71 WW Company -1 - ' ❑ Certified copy is hereby furnished 0 , FOR APPLICANT TO FILL IN BUILDING ADDRESS ARESS r Certified copy is filed with the county building mspec BUILDING tion department I ADDRESS O`� tT 01 Date 3- a17-dJ-Applicant-;e—A ^2?1AApX2- CITY ZIP LOCALITY - CERTIFICATE OF EXEMPTION FROM WORKERS - - OF BLDGS NEAREST COMPENSATION INSURANCE SIZE OF LOT WON LOT O CROSS ST WWI (This section need not be completed if the permit is for one 'A ASSESSOR hundred dollars($100)or less ) TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL' TELUSE ZONE P f I certify that in the performance of the work for which this OWNER G T/d P?LLt6W NO NO } $.: '7 IL permit is issued I shall not employ any person in any manner ADDRESS x.25 1. r-W W F-S-r t/ # I I OECIAL NDITIONS O so as to become subject to the Workers Compensation Laws AA U CITY /Ci ZIP 9100 G oC Date Applicant ARCHITECT OR 0 NOTICE TO APPLICANT If after making this Certificate of ENGINEERTEL DISTRICT GROUP TYPE FIRE PROCESSED BY Exemption you should become subject to the Workers CONST1/ ZONE W Compensation provisions of the Labor Code you must forth- ADDRESS J`�(1 ✓ 3 with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT I COND6 deemed revoked CONTRACTOR NO LICENSED CONTRACTORS DECLARATION - LIC - CIASS NO _ Q�DWELL UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER MAP (commencing with Section 7000)of Division 3 of the Business and _ LIC Professions Code and 1 my license is in full force and effect CITY r CLASS BK �fl PG ,3 VALIDATION SQ License Numbe ` S� Lic Class SIZE/-'r`f J STORIIES M F IOLIES CHECK rd a ONE �j�. �,���, �j VALUATION Contractor&, `' �`^^"r- Date J' DESCRIPTION OF WORK e7 ADD ❑ $ J , ;! 1 5 6,2 A ❑I am exempt under Sec ALTER ❑ # • • • • 2.3 B&P C for this reason REPAIR ❑ $ � ) 1942075 Date USE OF ❑ �" EXISTING BLDG DEMOL Signature APPLICANTTEDATE L FINAL ) • • 420.750' PRINT OWNER BUILDER DECLARATION NN Sr N LLF./✓NO StiS-oZ.2 / p -1 hereby affirm that I am exempt from the Contractor s License ADDRESS o as GU L D �/ W QST ,�'//EY ' +� FIN 02-21 —85 Law for the following reason (Section 7031 5 Business and Professions Code) R 90o BY ❑ BUILDING V-u� ki I as owner of the property or myemployees with ADDRESS wages as their sole compensation will do the work and the structure is not intended or offered for sale(Section LOCALITY TEL ' 21 7 6,9 A 7044 Business and Professions Code) MOVING ❑ I as owner of the property am exclusively contracting CONTRACTOR NO _ # • • • • • 1 with licensed contractors to construct the project (Sec ADDRESS tion 7044 Business and Professions Code) 1 - 64050 REQUIRED YARD HWY TOTAL SETBACK FROM EXIST CONSTRUCTION LENDING AGENCY SET BACK PROP LINE WIDTH • 0640 5 0 1 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 ` C a 2 9-8 5 P L Lender s Name /� LDMA Ref # $ P C Fee$ =20,-E- Permit Fee V D Poo. Lender s Address ' 1 7 7 0 A 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# above information is correct I agree to comply with all County Investigation Fee ,' # • • • • 2 3 g ordinances and State jaws relating to building construction Total Fee LDMA Perm # u and hereby authorize representatives of this County to enter • 1 IL 7 5 upon the above mentioned property for inspection purposes 1 P—kr SEE REVERSE FOR EXPLANATORY LANGUAGE . ' Signature of Applicant or Agent Date - - - WORKERS COMPENSATION DECLARATION hereby a certificate that I have certificate of consent to self APPLICATION FOR BUILDING P E RM I T insure or a certificate of Workers Compensation Insurance br a certified copy thereof (Sec 3800 lob C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company BUILDING r _ ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUD IS 5w4 ��L l� tion department ADD Date Applicant CITYL� 0 MJ ZIP S© LOCALITY l - /� NO OF EL OT CROSS ST +Ve CERTIFICATE OF EXEMPTION FROM WORKERS SIZE OF LO,�-I® A NOW ON LOT COMPENSATION INSURANCE V � I"1g ASSESSOR (This section need not be completed if the permit is for one LOT NO MAP BOOK PAGE PARCEL hundred dollars ($100)or less ) ,/ j. OWNERPIFI ) W 0 Z)� USE ZONE NO a I certify that m the performance of the work f hi this /n� SPECIAL }a permit i issued, I shall not empl any n i y nner ADDRESS 8 /1 I CONDITIONS O so as t be am subject to the ker p ti J� /� / Qy') CITY 4g9'1 �{/ G ZIP L p✓ V Date Applica ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE OCESSED BY Q NOTICE TO PLICANT If after m king this ertificat of ENGINEER �=�_ NO CONST E Exemption you should become s b ect to the Wor ers _ P Y I w Compensation provisions of the Lab r Code you must rth- ADDRESS `'� 3 /Y `� N with comply with such provisions or this permit shall be ! TEL STATISTICAL CLASSIFICATION APT CONDO Z deemed revoked CONTRACTOR 4. NO LICENSED CONTRACTORS DECLARATION LIC CLASS NO DWELL UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS No SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC and Professions Code,and my license is in full force and effect CITY CLASS BK PG 3 VALIDATION SQ FT ) go NO OF NO OF CHECK License Number Lic Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK VEL NEW $ Of /'1011 El am exempt under Sec ADD ❑ '0 ALTER ❑ ► 1 B&P C for this reason Date REPAIR ❑ $ f a A{.T■, USE OF g� 3307 49■8J EXISTING BLDG /■y II�� DEMOL ❑ Signature ' APP(PRINT) E� QC �{/ O7� FINAL 1 ITEMS OWNER BUILDER DECLARATION DATE eq I hereby affirm that I am exempt from the Contractor s License L TOTAL. 49'.$8 Law for the following reason (Section 7031 5, Business and ADDRESS FINAL CE v p ssions Code) PRESENT , By {IlL{ 47■Li I as owner of the property, or m employees with BUILDING HL�4�M�-� P P Y� YADDRESS � CI'1rx7VG ■Qyl wages as their sole compensation will do the work and 4 the structure is not intended or offered for sale(Section LOCALITY 7044 Business and Professions Code ) MOVING TEL , nMn rfM e „ 8 ❑ I as owner of the property am exclusively contracting CONTRACTOR NO OWO-0001 711318 with licensed contractors to construct the project(Sec- ADDRESS 5681 1 AM11:27 tion 7044, Business and Professions Code ) CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAL ROPi IGCE FROM WID I hereby affirm that there is a construction lending agency for FRONT Q the performance of the work for which this permit is issued P L (Sec 3097 Civ C) SIDE PL Lenders Nome � LDMA Ref # PC Fee$ Permit Fee Lender s Address o I certify that I have read this application and state that the Issuance Fee O LDMA P/C# 8 above information is correct I Ogre to comply with all County Investigation Fee Q R ordinances and State law elahn to building construction Total Fe i U LDMA Perm # and here y au on a ental es of his County to enter upon th Dov -m do pro f mspe io o es o �l SEE REVERSE FOR EXPLANATORY LANGUAGE Signatu oT Applic nt or Agent F Date