The URL can be used to link to this page

Home My Public Portal About9417 OLIVE ST_Building__ yc1"]IKERS'COMPENSATION DECLARATION Vd , � e'n't to seW 01N FOR I ®�NG PERMIT tifcafe of Workers'Compensaton Insurace, APPLICAT. eoy thereof (See" 3800, Lab. C.) rk + COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company "Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDR SS q 14! , ❑ Certified copy is filed with the county building Inspec- BUILDING C n tion department. ADDRESS 1/Qi yy�� a vn 1 Date Applicant CITY ZIP 0 M ,�LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT X NOW ON LOT r1 CROSS ST. (This section need not be completed if the permit is for one �b'� S�U11 ieKi Q(�( ASSESSOR hundred dollars($100)or less.) TR/�CT BLOCK Q(3 Who'* MAP BOOK PAGE PARCEL TEL a J USE NE MAP I certify that in the performance of the work for which this OWNER G� '1 V NO. NO. olive— r SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS V ll ve- A CONDITIONS so as to become subject to the Worke s'Compensat'on Laws. U �( CITY C ZIP C?17W Date ✓� lr' Applicant � ARCHITECT ON TEL. X NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GR UP TYPE FIRE PROCESSED B O Exemption, you should become subject to the Workers' �j /) CONST. ZONE I•" Compensation provisions of the Labor Code, you must forth- ADDRESS ✓� " a Ea with comply with such provisions or this permit shall be EL. `STATISTICAL CLASSIFICATION APT. rNDO. N deemed revoked. 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. 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 0 PGVALIDATION HECK -7 License Number Lic.Class S ZE� �� S ORIES' FAMILIES CONE Contractor Date VALUATI DESCRIPTION OF WORK NEW 016) f ADD ❑ $ : 9/04.EA I am exempt under Sec. I{1 l I AL7ER ❑ B.BP.C. for this reasonloo, r i o U o o ? i _'e REPAIR ❑ $ Date: USE OF I o r;3 G EXISTING BLDG. DEMOL ❑ Signature APPLICANT D . 11� TEL. q FJNAL o - /93, r 0?. (PRINT) o C V, NO. If/ OWNER-BUILDER DECLARATION [� DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS -(�i7 7 0 1 FIPIAL G G.7"{ Law for the following reason (Section 7031.5, Business and Profe ions Code): PRE EN By BUILDING ZM I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and a the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. ❑ 1, 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). FROM CONSTRUCTION LENDING AGENCY SETT BACK YARD HWY TOTAL SETBACK L NE 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. (Set. 3097, Civ. C.). SIDE C)aa A P.L. Lender's Name LDMA Ref. fi # o 0 0 0 0 1 S P.C. Fee$ Permit Fee I o �> 1 9. 7 Lender's Address I certify that I have read this application and state that the Issuance Fee / ` LDMA P/C R R above Information is correct. I agree to comply with all County Investigation Fee wr 0 %o, o o 0 1 9,r 7 35 ordinances and State laws relating to building construction, Total Fee LDMA Perm.N R andXtbacov. authorize representatives of this County to enter upomentiongd property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Slgnatur of Applicant or Agent Date WORKERS'COMPENSATION DECLARATION �yy� hereby affirm that I have certificate of consent to self APPLICATION F 'BUILDING ®E �v%N P T ,.insure, or a certificate of Workers'Compensation Insurance, or a ce44ified 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 /� Eltion copy is filed with the county building inspec- BUILDING ADDRESS tion department. ADDRESS 1 (tiq, Date Applicant CITY ZIP 71!�,..LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. y NEAREST COMPENSATION INSURANCE SIZE OF LOT S X NOW ON LOT I CROSS ST. R 10A/0 (This section need not be completed if the permit is for one �S�luv% )= ASSESSOR W O hundred dollars ($100)or less.) CT- BLOCK • O MAP BOOK AGE PARCEL TEL. I certify that in the performance of the work for which this OWNER � Vu T �) USPIN� NOP permit is issued, I shall not employ any person in any manner ADDRESS SPECIAL so as to become subject to the Workers'Compensation Laws. �+ CONDITIONS Dat Applicant CITY CI' -(U ZIP M NOTICE TO APPLICANT: If, after making is Certificate of ARCHITECT R TEL. DISTRICT G UP TYPE FIRE PR ESSED BY O ENGINEER W NO. CONST. ZONE (-- Exemption, you should become subject to the Workers' j ��//(� r/ Z W Compensation provisions of the Labor Code, you must forth- ADDRESS f O V with comply with such provisions or this permit shall be 0- deemed revoked. TEL. STATISTICAL CLLAAR�IFICATION APT. NDO. U)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. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC, ryry Professions Code,and my license is in full force and effect. CITY CLASS BK. PG.1 d�� VALIDATION SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ $ ❑ a UJ I ADD ❑ I am exempt under Sec. ALTER ❑. B.BP.C. for this reason REPAIR ❑,. $ DUSE OF Date: DEMOL EXISTING BLDG. . Qi 1 Signature APPLICANT W '•� FINAL OWNER-BUILDER DECLARATIONTJ W NO.dL156 DATE 7`�0 I hereby affirm that I am exempt from the Contractor's LicenseG p, yl ' Low for the following reason (Section 7031.5, Business and ADDRESS 1 ILA.' Tc- I -7M FI :92 8 9 7.4 A Professions Code): FRESENT / - BUILDING 0 0 0 0 0 I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and LOCALITY o ° 6 Q 5 0 the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING TEL. EJI, as owner of the property,am exclusively contracting CONTRACTOR NO. o o60 6 p j 0 c'_ with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 0 2, 1 7`8 8 REQUIRED YARD HWY TOTAL SETBACK PRIN CONSTRUCTION LENDING AGENCY SET BACK 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. # P.C.Fee$ Permit fee ( L Lender's Address 1 certify that I have read this application and state that the Issuance Fee LDMA P/C# 2 above information is correct. I agree to comply with all County Investigation Fee i ordinances and State lows relating to building construction, Total Fee r * LDMA Perm.# and hereby authorize representatives of this County to enter upon h above-mention d property for inspection purposes. g " -I-24 SEE REVERSE FOR EXPLANATORY LANGUAGE p+ /� Signatu of Applicant or Agent Date � i arulr✓L i�l WORKERS'COMPENSATION DECLARATION I' hereby,affirm that I have certificate of consent to self ' APPLICATION FOR BUILDING P E RM I T 'Insures or a certificate of Workers' Compensation Insurance, i;r cl certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Poficy No. Company ING ElCertifiedcopy is hereby furnished. FOR APPLICANT TO FILL IN ADDRE El [OWNER DING Ci Certified copy is filed with the county building inspec- L tion department. RESS �U S Date Applicant ziP t•!i LOCALITY NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' OF LOT NOW ON LOT �. CROSS ST.COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one CT BLOCK LOT NO. tc MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL' USEZZZONE MAP n NO. �O E NO. c�S I certify that in the performance of the work for which this S I/ SPECIAL � permit is issued, I shall not employ any person in any manner ADDRESS CONDITIONS a so as to become subject to the Workers'Compensation Laws. O p � , CITY zlp Date _�-o Applicant "c ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY 0 NOTICE TO APPLICANT: If, after making t s Certificate of ENGINEER Ca W melicNO. CONST.�p E N Exemption, you should become subject t the Workers j/ J UJI Compensation provisions of the Labor Code, you must forth- ADDRESS l �fr� (r'e — IL with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFI TION APT. CONDO. Z deemed revoked. 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 LIC. �: and 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 STORIES FAMILIES ONE VALUATIO Contractor Date DESCRIPTION OF WORK NEW $:2)0 0 &1 0 Elam exempt under Sec. k ADD LJ ALTER ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL �� n OWNER-BUILDER DECLARATION (PRINT) V NO. �/� 7 I herebyaffirm that I am exempt from the Contractor's License p� DATE Law fothe following reason(Section 7031.5, Business and ADDRESS { t' ��M7 �, FINAL\J/Q ACCT gs�air PRESENT I LJCiACClof the ro ert , or m em to ees with BUILDINGP P Y Y P Y ADDRESS -�-+ 306.75 sole compensation,will do the work and 3307 the structure is not intended or offered for sale(Section LOCALITY ® 1 ITEMS7044, Business and Professions Code.) MOVING TEL. I, as owner of the property,am exclusively contracting CONTRACTOR NO. TOTALTOTAL306.75 with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code.) ADDRESS HECK C 306.75 REQUIRED TOTAL SETBACK FROM EXIST. CHECK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP.LINE WIDTH � � ,I]Il 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. O OD-0001 9f 8/89 Lender's Name 8 P.C. Fee$ permit Fee ,, C7 LDM`Ref. # 5583 1 Ali 90-213 Lender's Address I certify that I have read this application and state that the Issuance Fee O 3� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee �y �` 3 ordinances and State laws relating to building construction, Total Fee • ✓ LDMA Perm. # x and hereby authorize representatives of this County to enter :41gnaturKe � binspection purposes. E SEE REVERSE FOR EXPLANATORY LANGUAGE Date