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HomeMy Public PortalAbout9556 OLIVE ST_Building__ WORKERS'COMPENSATION DECLARATION • J, C 'I hereby affirm that I have a certificate of consent to self APPLICATION FORBUILDING PERMIT insure, or a certificate of Workers'Compenstion Insurance,or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING D Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS �c •��r L , Certified copy is filed with the county building inspec- BUILDING 1i SS tion department. ADDRESS ` �I I U LOCALITY / Date Applicant » CITY J2 C�` ZIP R I 8 - �+ CROSSNEAREST.T. �Zi CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT ,SS X ; O NO.O.BLDGS. �'1 Mqp BOOK PAGE PARCEL OR COMPENSATION INSURANCE NOW ON LOT c1 (This section need not be completed if the permit is for one { USE ZONE MAP TRACT BLOCK LOT NO. NO. hundred dollars ($100)or less.) � -�+ TEL. / py SPECIAL D. I certify that in the performance of the work for which this OWNER tUl � U5�'1 �/r NO�10'1 / CONDITIONS 0 permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY U so as to become subject to the Workers'Compensation Laws. ADDRESS � � �� NS CO . ZONE Date Applicant CITY ZIP ' STATISTICAL CLASSIFICATION APT. CONDO. U NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. ��qq,,�� Lu Exemption, you should become subject to the Workers' ENGINEER NO 'i/Tr/ CLASS NO. DWELL. UNITS Compensation provisions of the Labor Code, you must forth- ADDRESS �-� 1644 1 SEWER MAP with comply with such provisions or this permit shall be TEL. CONTRACTOR NO. A deemed revoked. i gK•v PG /Z(O VALIDATION LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALVA ION (commencing with Section 7000)of Division 3 of the Business and LIC. �� ooO Professions Code, and my license is in full force and effect. CITY CLASS $ 00 SQ. FT. NO.OF NO.OF CHECK License Number Lic.Class SIZE t-'OQ STORIES FAMILIES ONE L Contractor Date DESCRIPTION OF WORK NEW $ ❑ n ADD I am exempt from the licensing requirements as I am a + I ti"�S f� ro licensed architect or a registered professional engineerALTER FINAL acting in my professional capacity (Section 7051, REPAIR DATE Business and Professions Code). USE OF DEMOL FINAL EXISTING BLDG. By Lic.or Reg.No. _Date APPLICANTTEL. OWNER-BUILDER DECLARATION PRINT) t��l E VS �,I- NO. Alf,? I hereby affirm that I am exempt from the Contractor's License \ , Law for the following reason (Section 7031.5, Business and " ADDRESS Professions Code): PRESENT �"� �-3 F-1BUILDING I, as owner of the property, or my employees with ADDRESS / wages as their sole compensation,will do the work and JT'J9 {r e) 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- ,• , 7 4 I tion 7044, Business and Professions Code). ADDRESS REI fr/ QUIRED TOTAL SETBACK FROM EXIST. e 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 f P.L. I` Lender's Name ' Lender's Address P.C. Fee$ (p Permit Fee ' I certify that I have read this application and state that the p Y PP Issuance Fee c 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 I upon the above-mentioned property for inspection purposes. [. SEE REVERSE FOR EXPLANATORY LANGUAGE 0 Signature of Applicant or Agent Date es WORKERS'COMPENSATION DECLARATION . • • - ` - I hereby affirm that I have certificate of consent to selfP®LICATI ®R KBUI� ING PERMIT insure, or a certificate of Workers'Compensation Insurance, I �® N 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 ADDRESS ! . i Certified copy is filed with the county building inspec- BUILDING ` }ion department. ADDRESS 5s LOCALITY or�� N REST Date Applicant CITY ZIP CROSS ST. �i CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 55 i� 21eq NOW ON OTS NWPSBOOK PAGE SOR PARCEL COMPENSATION INSURANCE i (This section need not be completed if the permit is for one USE ZONE MAP / hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. 41 TEL. / SPECIAL �- I certify that in the performance of the work for which this OWNER �/ NO. CONDITIONS permit is issued,I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY O so as to becomes biect to the Workers'Compensation Laws. I ADDRESS CONST. ZO E U L/V © �, Date Applicant + C i IX CITY ZIP STATISTICAL C SIFICATION APT. CONDO. NOTICE O PLICANT: If, after making this Certificat of ARCHITECT OR TEL. UNITS DWELL CLASS NO. . Exemption, you should become subject to the Workers' ENGINEER NO. CL Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be n TEL. VALIDATION deemed revoked. `;CONTRACTOR ` NO. BK. PG, LICENSED CONTRACTORS DECLARATIONf%�� LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS <�3P DkV A NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY �U�� I /�✓ �2 CLASS $ SQ.FT. NO.OF' NO. F CHECK - License Number Z S C1 / 0 6 Lic.Class 13 SIZE STORIES FAMILIES ONE f r S Contractor F `( Date C L DESCRIPTION OF WORK NEW ❑ am exempt un er Sec. O� ADD n,•.;- ALTER ❑ FINAL B.BP.C. for this reason DATE 2 REPAIR USE OF FINAL a �" � Da j EXISTING BLDG. DEMOL By Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT NO. . 3 6 7.2 A I hereby affirm that I am exempt from the Contrac or's License r , Law for the following reason (Section 7031.5, Business and ADDRESS K ? C. 0 0 0 0 Professions Code): PRESENT „ 0 C ❑ 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 c ° 6 Q, (� 7044, Business and Professions Code). MOVING TEL. I,as owner of the property,am exclusively contracting CONTRACTOR NO. C 71 11 -83 with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). 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 P.L. tSec. 3097, Civ. C.). SI.DE P.L. M 'rLender's Name P.C.Fee$ Permit Fee Lender's Address I certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee p r rs I and hereby authorize representatives of this County to enter --------------- upon the b ve-me finned r party for'nspection purposes. / ( 7 / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent i WORKERS'COMPENSATION DECLARATION !' 'a r L: hereby affirm'that I have a certificate of consent t self_, it El �I T I N �O R AlUIDING Y LJt1 E��=�insure, or a certificate of Workers'Compensation Irisurar ce, j' RMIT "'or a certified copy thereof(Sec. 3800, Lab. C.)' Policy No. CompanyCOUNTY OF LOS ANGELES BOILDING AND SAFETY. , - BUILDING Certified copy is hereby furnished.` •FOR APPLICANTIO FILL•IN' j, ADDRESS .. t Certified copy is filed with the county building inspec- BUILDING L + tion department. ` ADDRESS'. J 0'�V _3j .7&0 -QIP✓ 'I LOCALITY I 1 em le cl"� ZIP tea. ? O CROSS ST. Date •• '• ' NEAREST. 00 Applicant ' ' '.CITY - � • CERTIFICATE OF EXEMPTION FROM WORKERS', aa NO.OF.BLDGS.: •ASSESSOR COMPENSATION INSURANCE ' SIZE OF LOTX o�-Y•® NOW ON LOT NyCP BOOK PAGE PARCEL ' USE.ZONE MAP :(This section need not be completed if the permit.is for one ',, ,�� BLOCK LOT NO. ,' NO. • hundred 'dollars($.1.00)or.less.) ) I +�' TEL. a ,,/� 'i SPECIAL �- ! OWNER. A V (/ J r NO.2 ( a CONDITIONS !- D. I certify that in the performance of the work for which this + DISTRICT GROUP TYPE FIRE, 5 PR ED BY permit is issued,I shall not employ any person in any manner S /� - S �� CONST. ZONE ,,,permit so as to becom subject to the Workers'Compensation Laws. ADDRESS --fill Date b f '•Ap licant ' r` `. CITY.. (.1, ZIP ST•ATISTICAL.CLASSIFICATION Pi. 1CONDO. �. i ARCHITECT OR�` TEL. NOTICE TO PPLICANT: I , after 'making this Certificate f {. ENGINEER ,J CSS TN CLASS NO. 10 UNITS ;'Exemption, you- should become subject to the Workers' IL Compensation.provisions of the Labor Code, you must forth- ADDRESS• SEWER MAP _ 0 with comply with such provisions or this PeFmit,shall be i deemed revoked. 'i r TEL'// p BK. PG, • VALIDATION + CONTRACTOR $f ire NO.L7 1.�� /` I LICENSED CONTRACTORS DECLARATION' $ LIC, !. I hereby affirm that I am licensed under pro'visions:of Chapter 9 ADDRESS /� �- 10I NO. V LUATIOId' (commencing-with Section 7000)of DivisibiY3 of the:Business andp LIC. °� Professions Code, and my license is in full force and effect. •CITY 11� 9C'_-r CLASS $ i®., 000 SQ.'FT; Q NO.OF NO.OF CHECK .License Number 'Lic.Class �:) I•' SIZE ( STORIES FAMILIES ONE �t $ Date !f DESCRIPTION OF WORK NEW O Contractor ' I I am exempt un er Sec. IJP •��x/YJ • - ALTER ' 4"a ` P ( FIMAL e B.&P.C. for this reason REPAIR DATE` C !'e- J 1.f A USE OFFINi4L `+ L „ sul � • Date: EXISTING BLDG.- DEMOL BY .: .' e `' • APPLICANT `. �p L �^ TEL. C f 4 ` Signature PRINT AJI 9�,U0 tl r NO.Gf4 _l b li•6 Q'2 OWNER:—BUILDER—DECLARATION I herebyaffirm that lam exempt from the Contractor's License ee P i ADDRESS 6 /� ® Jt�-4+ 2 8C6 Law for the following reason (Section 7031.5, Business and ' Professions Codd):. PRESENT. BUILDING 0 S."71 1 •-'8 3 I, as owner of the property, or,my employees with ADDRESS wages as their sole compensation,will do the work and t the structure is.not intended or offered for sale(Section LOCALITY •• •� +•• �,`', S 7044, Business and Professions.Code), MOVING TEL. C/ CONTRACTOR NO, r- 0 I,as owner of'the property,am exclusively contracting .! with licensed contractors to construct the project•(Sec- tion 7044, Business and Professions Code). ADDRESS REQUIRED TOTAL SETBACK.FROM EXIST.. CONSTRUCTION LENDING AGENCY' SET BACK YARD HWY PROP.LINE WE I hereby affirm that,there is a construction lending agency for FRONT 3•`w ��r the performance of The work for which this permit is issued P.L. '- tSec. 3097; Civ. C.). SIDE - Q Lender's Name �t. i, 3 -1r 1 C r Lender's Address P.C.'Fee$ Permit Fee 'd ° r' C. 1 1 r' I certify that I have read this application and state that the �i , : Issuance Fee �r ` •'7� r':� r� 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 upon thea above-mentioned property for Inspection purpo es. rL1 wk SECREVERSE FOR EXPLANATORY LANGUAGE 0 1 J Signature of Applicant or Agent' Dat ` ®s