HomeMy Public PortalAbout10521 OLIVE ST_Building__ WORKERS' COMPENSATION DECLCARATION
hereby o4irm'that have a cdrtificate e{**consent to self ' APPLICATION FOR BUILDING PERMIT
' ins' e, or a certificate of Workers' Compensation Insurance,
or"a certified copy t/hof(Sec. 3800 b. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy�I - � Y Compbny �[^^_• a
❑ BUILDING
Certified copy is hereby furnished. FOR APPLICANT T FILL IN ADDRESS10
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Certified copy is filed with the county building inspec- BUILDING
tion department. ADDRESS
Datef I " Applicant CITY ` �'- ZIP LOCALITY c +
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST
i SIZE OF LOT NOW ON LOT CROSS ST.
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.) OWNER �0� ���� NO. �( USE ZO MAP _ 7
I certify that in the performance of the work for which this NO.
permit is issued, I shall not employ any person in any manner ADDRESS — K� — SPECNL a
so as to become subject to the Workers'Compensation Laws. CONDITIONS 0
CITY i ZIP Q U
Date ApplicantARCHITECT R TEL. DISTRICT G TYPE FIRE PROCESSED BY O
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST ZONE
Exemption, you should become subject to the Workers' �(�d/�
Compensation provisions of the Labor Code, you must forth- ADDRESS r a
with comply with such provisions or this permit shall be TEL. ST STICAL CLASSIFICATION APT. CONDZ
LIC. CLASS NO.
deemed revoked. CONTRACTOR NO. ,,--�� O. _
�—
LICENSED CONTRACTORS DECLARATION DWELL. UNITg
ADDRESS NO.
I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP
(commencing with Section 7000)of Division 3 of the Business LIC.
and Professions Code,and y lic se' in full force effect. CITY O y ,. CLASS BK � � VALIDATION
SQ. FT; ,r,�y NO. OF NO. OF CHECK
License Num Lic. Class SIZE V STORIES FAMILIES ONE
VALUATION
Contractor Dater `� DESCRIPTION OF WORKAha ` NEW
ElI am exempt under Sec. �/'G ADD ❑ $ poll.ALTER ❑
B.BP.C. for this reason cZ REPAIR ❑ $
Date: USE OF
EXISTING BLDG. DEMOL ❑
Signature APP(ICAN; C�TEL. (/ FINAL
OWNER-BUILDER DECLARATION PRINT
I hereby affirm that I am exempt from the Contractor's License DATE
Law for the following reason (Section 7031.5, Business and ADDRESS FINAL
Professions Code): 'PRESENT By
❑ BUILDINGI, 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 q'CONTRACTOR NO. 1
with licensed contractors to construct the project (Sec- " ADDRESSI ACCT.tion 7044, Business and Professions Code.) o
r REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. I '�'I:) 1079.25
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH v',�
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. 1 ITEMS.
(Sec. 3097, Civ. C.). SIDE TO-1 AL 1079.25
Lender's Name 0CHECK �s
d LDNIA Ref. # CHEC• 107?.''
P.C. Fee$ Permit Fee relr0
Lender's Address /� CHANGE
I certify t 9 I have read this application and state that the Issuance Fee m .5 �1 LDMA P/C# ,
3 above i otm�fa is orrect. I agree to comply with all County Investigation Fee ry
ordina ce and St la relating to building construction, Total Fee A ✓ LD perm. # Oti•
= and r y autho ze r resentatives of this County to enter ���
upo t e above- en�edproperty for inspection pur Jses. JC��f�L-�� _ �. j+� fi /��J/ <) U i1 r5P4K J1 1 AM 11X27
SEE REVERSE FOR EXPLANATORY LAN UAGE 8 Ti
Sign r of Applicant or Agent Date