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Home My Public Portal About10227 OLIVE ST_Building__ iv WORKERS'COMPENSATION DECLARATION i insure,oraffirm that te of Workers'Compensation elnsura cef APPLICATION FOR BUILDING PERMIT or a certified copy thereof(Sec. 3800, Lab. C.) , COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING F] S ADDRESS/OWt e�-1 11,�5 ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS /��-Z QL///� JLI �� lf-317CA /7-P-0 Date Applicant CITY 1.Z-7 eg ZIP / &o LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST i1_��-r�J COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. A (This section need not be completed if the permit is for one TRACT BLOCK LOT OASSESSOR . hundred dollars($100)or less.) MAP BOOK PAGE PARCEL W10-01V .Sat N - /44 TEL. USE ZONE MAP —,Z I certify that in the performance of thei work for which this OWNER W10- NO. permit is issued, I shall not employ any person in any manner ADDRESS/dam aL/(/� S x SPECIAL so as to become subject to the Workers'Compensation Laws, nom, CONDITIONS 0 • ..Z "dly S41k- _=4 CITY L� ZIP / �V U Date Applicant 0' NOTICE O APPLICANT: If, after making•this Certificate of ARCHITECT O TEL. DISTRICT ROUP TYPE FIRE I P SSED BY 0 Exemption, you should become subject to the Workers' ENGINEER NO. CONST Z NE U Compensation provisions of the Labor Code, you must forth- ADDRESS with comply with such provisions or this permit shall be D.? deemed revoked. CONTRACTOR NO.TEL. STATISTICAL CLASSIFICATION APT, NDO. N � 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 and LIC. Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. .� NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE qq VALUATION Contractor pate DESCRIPTION,/�� v OF WORK - L NEW F]7T ADD � 9 ❑I am exempt under Sec. ALTER ❑ Pool 2 9 5 9.6 A B.&P.C. for this reason REPAIR ❑ $ # 0 0 0 0 0 1 Date: USE OF ❑ EXISTING BLDG. DEMOL r� ° ° 4 Q 5 0 Signature APPLICANT TEL 0 FINAL OWNER-BUILDER DECLARATION PRINT wo4N S'elk �, NO�p 3 I hereby affirm that I am exempt from the Contractor's License DAT ° ° ° 4 Q 5 0 5 Law for the following reason (Section 7031.5, Business and ADDRESS/D— /-�U�s', f�tel% FI Professions Code): PRE EN B cal 2-.°88 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. ❑ 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). REQUIRED TOTAL SETBACK F CONSTRUCTION LENDING AGENCY 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 P.L. Lender's Name LDMA Ref. # I P.C.Fee$ Permit Fee J L Lender's Address //g J� I certify that I have read this application and state that the Issuance Fee `V L�t/ LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee �] i ordinances and State laws relating to building construction, Total Fee yV[� LDMA Perm. # and hereby authorize representatives of this County to enter ( upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App,cant or Agent Date ' S WORKERS'COMPENSATION DECLARATION h6eby affirm that I have a certificate of consent to self APPLICATION F R BUILDING PERMIT r insure,'jAr cf certificate of Workers'Compensation Insurance, o or-a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Rit ❑ PY Y FOR APPLICANT TO FILL IN BUILDING Certified co is hereby furnished. ❑ ADDRESS Certified copy is filed with the county building inspec- BUILDING -y �1 /� tion department. ADDRESS �1O -=F. 01-1. Q /II/� S/ T�� z—Y t2// `,4 /7� Date Applicant CIT /vr L� G/'T ZIP 91 LNEARESTOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. /�"J�✓ �� 25— COMPENSATION INSURANCE (This .section need not be completed if the permit is for one TRACT BLOCK LOT NOASSESSOR hundred dollars($100)or less.) MAP BOOK PAGE PARCEL OWNER T •'�'�EL. USE ZONE MAP I certify that'in the performance of the work for which this � NOD NO. permit is issued, I shall not employ any person in any manner ADDRESS ZZ H. " S'"r &% SPECIAL • so as fo become subject to the Workers'Compensation Laws. ® CONDITIONS CITY Z:j L� /T ZIP 917A9 U Date // Applicant /�VDO/N �S'U� l/`� p; ARCHITECT OR TEL. NOTICE TO APPL CANT: If, after making this Certificate of DISTRICT G&OUP NST. 1 ZONE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. ` I(L,Y�) `V/ Compensation provisions of the Labor Code, you must forth- ADDRESS V U0 U with comply with such provisions or this permit shall be d; deemed revoked. TEL' STATISTICAL CLASSIFICATION APT. CONDO. Cl)CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (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 U STORIES FAMILIES ONE DESCRIPTION OF WORK NEW ❑ VALUATION Contractor Date ; zU b r•-- ' ❑ I am exempt under Sec. d,/0 c �i�/VO ADD t �8 31.9 A ALTER ❑ o 0 o b c-1 B.BP.C. for this reason S REPAIR ❑. $ Date: USE OF EXISTING BLDG. DEMOL ❑ o o '� 5•� Signature APPLICANT TEL. �`'`� 0 0 0 = g OWNER-BUILDER DECLARATION PRINT WOON -VICAf' z; NO.�'4� of 2 a 5 0 v I hereby affirm that I am exempt from the Contractor's LicenseADDRESS /01� �Q�/�� cS�T�1� /�� 4 1. o9-87 Law for the following reason (Section 7031.5, Business and F Professions Code): PRE EN /V�"CCIt 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. ❑ 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). REQUIRED TOTAL SETBACK FRRAFM CONSTRUCTION LENDING AGENCY 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 P.L. Lender's Name LDMA Ref. # Lender's Address P.C. Fee$ Permit Fee I certify that I have read this application and state that the Issuance Fee U�J� LDMA 0C# oil, above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter LDMA Perm. # MEN upon the above-mentione pro rty for inspection purposes. D C // � SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date e JWORKERS"ZIGMPENSATION DECLARATION i; I l4reb of%rn that I'have a certificate of consent to self inure, ora cert ficat of.Workers'atmpensation Insurance, APPLICATION FOR BUILDING PERMIT u or a certified copy treof(Se4 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING � OLI Or, ADDRESS �O` Certified copy is filed with the county building inspec- BUILDING I �t --1 tion department. ADDRESS I y� S _ _ G cA I S a Date Applicant CITY LZ JITT ZIP fl I 1g 0 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. /� 'i P9 (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 ONE MAP n ' I certify that'in the performance of the work for which this OWNER db TN .SD ) � NO. / -permit is issued, 1'sholl not employ any person in any manner r SPECIAL so as to bec me s bject to the Workers'Compensation Laws. ADDRESS 02Z t� s CONDITIONS O Date .� Applicant liLJ�� CITY C ZIP d NOTI TO APPLI NT: If, after makin 'this Certificate Of ARCHI ECT O TEL. DgRICT G OUP TYPE FIRE PROCESS VED BY O Exemption, you should become subject to the Workers' ENGINEER W CFI( C ld NO. L CONST. Z E U Compensation provisions bf the Labor Code, you must forth- ADDRE uG2.} V— —( C7 ,�f O f W with comply with such provisions or this permit shall be A.' deemed revoked. TEL. STATISTICAL CLASSIFICATION APT. CONDO. N CONTRACTOR 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 and LIC. Professions Code, and my license is in'full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO.OF I NO.OF CHECK License Number Lir.Class SIZE STORIES FAMILIES ONE VALUATION Contractor • Date DESCRIPTION OF WORK NEW ❑ .@.P./1 7 . r I $ (J(T(f I am exempt under Sec. � Abp � I I ALDTER ❑ B.BP.C. for this reason �A Z REPAIR ❑ $ Date: Uk OF EXISTING BLDG. DEMOL ❑ # Signature APPLICANT TEL. _ FINA PRINT G G dd0. OWNER-BUILDER DECLARATION DATE' ° I hereby affirm that I am exempt from the Contractor's License � $ $ULaw for the following reason (Section 7031.5, Business and ADDRESS I(s� A A& 12 � �. Professions Code): ill BUILDING ,r� (� r I, as owner of the property, or myemployees with ADDRESS wages as their sole compensation,will do the work and the structure is not Intended or offered for sale(Section LOCALITY 7044;,Business and Professions Code).' MOVING TEL.- 1, EL.- I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name SO LDMA Ref. # P.C.Fee$ Permit Fee Lender's Address ,�}} I certify that I have read this application and state that the Issuance Fee s CJ LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ZOO— ��. ordinances and State laws relating to building construction, Total Fee LDMA Perm.# and hereby authorize representatives of this County to enter $ upo above me on prop ty for inspectiopure ses. m SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App,cant or Agent Date