HomeMy Public PortalAbout9123 OLEMA ST_Building__ f WORKERS' COMPENSATION DECLARATION
,I her , 1 affirm that I haver certificate of consent to self APPLICATION F®R BUILDING P E RM I T
i ,ire, QC a certificate of Workers' Compensation Insurance,
or atertified copy thereof (Sec. 3800, Lab. C.)
/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Polic Z50 Company 's ASE �y0
L7 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN .A DRESS q't 3EMA
Avc-
❑ Certified copy is filed with the county building inspec- BUILDING
do d9ep rtment. L �// ADDRESS Z /Z 46-vv dky r�
Date AZ Applicant 5/ 'S CITY P44 C/� ZIP 7&0 LOCALITY
NO.OF BLDGS. NEAREST
ERTIFICATE OF EXEMPTION FROM ORKERS' SIZE OF LOT NOW ON LOT CROSS ST. CEJ JU1 r
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. ;; MAP BOOK PAGE PARCEL
hundred dollars ($100)or less.) �, ��L�,5� /9� �0.����00� USE ZONE MA
OWNER Ptl NO.
I certify that in the performance of the work for which this �' SPECIAL �-
permit is issued, I shall not employ any person in any manner ADDRESS G Obi Z�� 49A CONDITIONS CL
so as to become subject to the Workers'Compensation Laws.
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CITY A'GJC C/ ZIP �V ;
cle
Date Applicant ARCHITECT OR Jor TEL DISTRICT GROUP TYPE FIRE ROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE ~-
Exemption, you should become subject to the Workers' Q13 w
Compensation provisions of the Labor Code, you must forth- ADDRESS a IN0K __.1 11T_ a
with comply with such N
p y provisions or this permit shall be TEL. Q a� 'STATISTICAL CLASSIFICATION APT. CONDO. Z
deemed revoked. CONTRACTOR .�j NO. �J ? _
LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .5 OO CZf46 rA14W NO.J"Sv
(commencing with Section 7000)of Division 3 of the BusinessLIC. SEWER MAP
and Professions Code,and my license is in full force and effect. CITY v V z-;r CLASS 6--3-7 BK VALIDATION
SQ. FT. NO. OF NO.OF C CK
License Number �Lic. Class C SIZE I STORIES ICAMILIES ONE VALUATION ®G
Date /� DESCRI O OFVCORK �00I� .704. NEW NEW ❑ $ / /-7�
Contractor (/
❑I am exempt under Sec. p�ay o ✓�/,//V&LIC � � ADD ❑
/� ALTER 0]BAP.C. for this reason t cav (r e/N7*t .SjS/1Q�"f REPAIR ❑ $
D e USE OF
L EXISTING BLDG. � DEMOL ❑ '
Signature- 5 APPLICANT TEL
OWNER- UILDER DECLARATION (PRINT)/961/M /dWo1 d��d.CO NO��`�-9. �8 FINAL _ �!�
+ DATE r
I hereby affirm that I am exempt from the Contractor's License ADDRESS ��O CBr<�sTi�iO �J/e. li�+N.e
Law for the following reason (Section 7031.5, Business and FINAL j��� $70
Professions Code): PRESENT By �'/�
❑ I as owner of the property, or m employees with BUILDING 1 ITEM
P P Y� YADDRESS
wages as their sole compensation,will do the work and LOCALITY TOTAL a o �
the structure is not intended or offered for sale(Section CHECK 7044, Business and Professions Code.) 87.38,❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO. lrft� f`t�_
with licensed contractors to construct the project (Sec- ADDRESS CHANGE .00
tion 7044, Business and Professions Code.)
REQUIRED TOTAL SETBACK FROM EXIST.
CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH
I hereby affirm that there is a construction lending agency for FRONT 0000-0001 9/12/889
the performance of the work for which this permit is issued P.L.
(Sec. 3097, Civ. C.). SIDE 5651 1 Al 9 93
P.L.
Lender's Name
P.C. Fee$ Permit Fee , LDMA Ref.#
Lender's Address
o I certify that I have read this application and state that theIssuance Fee /L r_ ( LDMA P/C#
8 above information is correct. I agree to comply with all County Investigation Fee /�
ordinances and State laws relating to building construction, Total Fee •._) LDMA Perm. #
and hereby authorize representatives of this County to enter
u on th�bovtio ed pr per y for inspection urp C I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of Applicant or Agent Dat