HomeMy Public PortalAbout10401 OLIVE ST_Building__ 0 '-.WORKERS'-COMPENSATI.ON DECLARATION. �
.I hereto affirm that I have a certificate of consent to,self (�
insure, SF a certificate of Workers' Compensation Insurance,• 1/ APPLICATION F O•R BUILDING PERMIT .
a ��a s ffified copy thereof(Sec. 3800 La¢. C.) ;3� �� COUNTY OF LOS ANGELES BUILDING'AND SAFETY '
P rrcy o1107QG3�,�Company • {p '�
❑ rfified copy is hereby furni hed. FOR APPLICANT TO FILL IN • BUILDING
d �/
rtified copy is#filed with t co Id'ng in ec BUILDING ` ;
tiOn�drepartment. ADDRESS v_
Date "'"•�' Applic6nt' CITY'• C ZIP �� LOCALITY I L G T 1
NO.OF BLDGS. NEAREST
CERTIFICATE OF.EXE I N'FROM. ORKERS'' SIZE OF LOT NOW ON LOT CROSS ST. ,
r• COMPEN O INSURANCE ASSESSOR
(This section need 'not'be o leted if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred°dollats ($100)o le .) t �L [�
OWNER �� \ �.� NO. -T r e� USE ZONE MAP '
NO. }
I certify that in.the.perf mance of the work for which this % SPECIAL
permit is issued,'l shall not employ any person in any manner r ADDRESS Q` rJ 5-i-`' I CONDITIONS
sd as to becorrie subject to the Workers'Compensation Laws. V.
.%-,I CITY': /��.. C - ZIP•
Date Applicant. : ARCHITECT OR' f TEL. DISTRICTGROUP I TYPE FIRE PROCESSED BY
NOTICE TO APPLICANT: -If; after.making this,Ceftificcte of ENGINEER NO. J CONST. ZONE
Exemption, you should become .subject.to the'. Workers' i ^�. w .
Compensation provisions-of the Labor Code, you must•forth- ADDRESS o �l N
,with comply with. such••provisions or this. permit shall•be ,' TEL.)/ STATISTICAL•.CLASSIFICATION :APT. .CONDO: Z
deemed revoked. CONTRACTORo&V NO. 7 O. v —
LICENSED CONTRACTOR$'DECLARATION ICLASS tJO:�DWELL. UNITS
f reby affirm fhat•I am licensed under provisions of Chopter 9 ADDRESS 6 Al N7 36%1 `
' (commencing.with Section 7000)of Division 3 of the Business LIC. SEWER MAP "
CIT`('.�NGS K � CLASS
and Professions Code,and my license is in full force and effect. ' .. BK, PG. .' VALIDATION
' SQ. FT.- 0.OF NO.OF CHECK.
License Numb ?3.0 �' .,Lic. Class N SIZE STORIES FAMILIES ONE
�( VALUATION �_ +'
Contractor ��a ` Date l `�6'ki D CRIPTION OF WORK I/,1^ NEW ❑ $
/� O a_ :i_r M _
❑ ,' - - •!_ _
'ADD I�• r_ .. .. _" ^'a..oi.r
I am exempt under Sec. Ae r!! ALTER ❑ ►. =!(�_ ,
B.&P.C. for„this reason $
USE.OF �] REPAIR ❑ rr..:
Date: /Ce :: .. i
EXISTING BLDG.-' DEMOL ❑ r r , t -;•�
a-'..I Y'.. s,-a=r.a.'.
•Signature"� •- APPLICANT.. `1 ., TEL.- 'J/ FINAL .
(PRINT) JQ -7 A/ �! � NO. "7 Qt G P'.LA.r;
OWNER-BUILDER DECLARATION DATE_ "' - z ” '
I hereby affirm that.I am exempt from the Contracior's:Lieense ADDRESS !e�^a"�� FIN
Law for'the following reason (Section'7031.5, Business and :.
Professions Code): . ...:" l '
PRESENT B ;"r ,"' ..i`1 i,l.I I,, ?�'7
❑ I, as owner of the property,-or-m em to ees with BUILDING
. P P Y Y P Y � + ADDRESS y..-,
i wages as'their sole compensation,will'do the work and - _ ! H Li s`t s
the structure is not intended or,offered for sale(Section LOCALITY
•7044, Business and Professioris.Code.)• MOVING TEL: '
El
CONTRACTOR NO.:
w
I,as owner of the property,am exclusively contracting ,
With licerised contractors to construct the project (Sec- ADDRESS
tion 7044,•,Busiriess and Professions Code.) • 'sy,�., _r
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
the performance of.the work for which this permit is.issued R.L:• "' - -: a•
(Sec, 3097, Civ. C.). SIDE
r i P.L. r �•:r ri f�
Lender's 3•`�=r•.r
Name LDMA Ref.# +
' P.C. Fee$ -� � Permit Fee
Lender's Address
1,.ceitify that I have read this application and state that the Issuance Fee r LDMA P/C#
'- above information.is correct. I agree to com ly with all Count Inve§ti atibn.Fee
ordinances and State laws relating to building construction, Total,Fee LDMA Perm.* `
a here authorize representatives of this County'to•enter "' '^ + =C! •
n t a1 d property for.inspection purposes. '
o "�' ?•i, SEE REVERSE.FOR EXPLANATORY LANGUAGE.
Signature of Applicant or Agent' Date