HomeMy Public PortalAbout10648 OLIVE ST_Building__ WORKERS`COMPENSATION DECLARATION 4!, Lr
` I herey..lq~affirm that I hdve ra certificate.of FonSent to self
Nisure,•os.a certificate of Workers' Compensation Insurance, ; APPLICATION FOR BUILDING P E ISM I T
u .ora certified co y ther of(Sec. 3800 C•)
�• or` . • COUNTY OF LOS ANGELES �• BUILDING AND SAFETY
Policyift� Company
Certified copy is hereby furnished. FOR AP LI ANT TO FILL IN ADDRENSs Q LL
Certified copy is filed with a county building inspec- BUILDING
tion department. ADDRESS l j;
DatilL - Applicant CITY C C ZIP �� LOCALITY
NO.OF BLD T / CROSSSST .
CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOi , NOW ON LOT
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the permit is for one T BLOCK LOT NO. MAP BOOK PAGE PARCEL
hundred dollars ($100)or leas.) TEL. A/, US ZONE MAP `
• � OWNER s NO. GGII NO.
I certify that in the performance-of the work for which this
permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL
CONDITIONS IL
so as to become subject to the Workers'Compensation Laws. D�� OO
CITY "AA • zle i
Date Applicant i ARCHITECT O TEL. cy
NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. fJ6,d DISTRICT OUP TYPE FIRE PROCESSED BY Q
CONST.V ZONE
Exemption, you should become -subject to the Workers' FJ
Compensation provisions of the Labor Code, you must forth- ADDRESS9414&4 � �. �� w
06a - CL
with comply with such provisions or this permit shall be
TEL. STATISTICAL CLA IFICATION APT. CONDO. N
Z
• deemed revoked. CONTRALTO NO. CLASS NO.�DWELL.-UNITS
LICENSED CONTRACTORS DECLARATION. ADDRESS NO
I hereby affirm that I am licensed under provisions of.Chapter .hapter 9 SEWER P
(commencing with-Section 7000)of Division 3 of the Business LIC. 2
and Professions Code,and my lice is'n full f nd effect. CIN CLASS L7 BK ,VALIDATION
SQ. F O. OF NO.OF CHECK
License Num Lic. Class SIZE STORIES FAMILIES ONE23
VALUATION
Contractor Date (� DESCRIPTION OF WORK NEW $ odd.r ACCs'°V
ADD ❑ V ► G7 �TO 7G
❑1 am exempt under Sec. .03; N ALTER ❑ t ITEMS CMe °
B•BP.C. for this reason W. REPAIR ❑ - $ 1 ITEMS
Date: USE OF EXISTING BLDG. DEMOL ❑ TO 'S -46 o -'b
Signature APPLICANT
(PRINT) ' p,y� �� FINALEri 946o70
OWNER-BUILDER DECLARATION l DATE CHANGE
I hereby affirm that I arri exempt from the Contractor's License � �/� � °GLI
Law for the following reason (Section 7031.5, Business and ADDRESS ` • FINAL
Professions Code): PRESENT r By GGGn_GGG1
❑ I,•as owner of the property, or m employees with BUILDING V
P P Y• YADDRESS 7/12/E9
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section LocALIrY , 14443 1 AM10..�3
7044, Business and Professions Code.) MOVING TEL. ; A
❑ I,.as owner of the property,am exclusively contracting CONTRACTOR NO. °s
with licensed contractors to construct the project (Sec- ADDRESS 3307 . 1124-29,
tion 7044, Business and Professions Code.) i
REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. 1 ITEMS
CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH I
I hereby affirm that there is a construction lending agency for FRONT 117y°?
the performance of the work for which this permit is issued P.L. T�TAl.
(Sec. 3097, Civ..C.). SIDE
HE {/i 1124-225
P.L.
Lender's Name 5 I CHANGELDMA
,GG
P.C. Fee$ Permit Fe0:5 p Ref. q
Lender's dress �j
° 1 certify t t I have-, d this application and state that the Issuance Fee e ✓ ? LDMA P/C N ► I�(�(:!G_(�GG1 11 1ttifuC�
B
above' f rmatt is c rect. I gree to complywith al I County i Investigation Fee
ordin s a Stat laws ting to building construction, Total Fee / S LDMA'perm. q 6847 1 AM11:27
an by ithorl repr ntatives of this County to enter
U a ove-m ntion roperty for inspection urposes.
--- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature f Applicant or Agent Date