HomeMy Public PortalAbout9830 OLIVE ST_Building__ j tieORKER$'COMPENSATION DECLARATION
r I hereby offirct that I (raver certificate of consent to self �� FGR "WILDING PERMIT
insure, or a certificate of Workers'Compensation Insurance,
or a cerfified copy thereof(Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company BUILDING
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ��1 (3 0 LI -{ ST
-
ADDRESS
copy is filed with the county building inspec- BUILDINGc /
tion department. ADDRESS q�310 061 '✓e- JJ
Date Applicant CITY Y+-+ t ZIP LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' , N EA
OF BLDGS. NEAREST
ST
INSURANCE SIZE OF LOT W ON LOT CROSS ST. a
(This section need not be completed if the permit is for one �o�� I53 ASSESSOR
hundred dollars($100)or less.) TRACT S BL . LOT NO. MAP BOOK S PAGE �/ PARCEL
TEL' USE ZONE MAP
I certify that in the performance of the work for which this OWNER r r NO. NO.
permit is issued, I shall not em loy any person in any manner SPECIAL
so b ome su ject to the]Workers'Compensation Laws. ' ADDRESS v �7 (; CONDITIONS V
CITY --re/rt L �� ZIP / f
Date pp is nt ARCHITECT OR TEL. — DIS RIOT GROUP TYPE FIRE PROCESSED BY
NOTI E D' PP (CANT: If, a r making this Certificate of CONST. ZONE
ENGINEER NO.
Exe�ptio ou should become subject to the Workers' Q ggg
Com ens•Ti n provisions of the Labor Code, you must forth- ADDRESS 0IL
with,com I with such provisions or this permit shall be
dee ed ked. /1 TEL. Q•. .STATISTICAL CLASSIFICATION APT.
CONTRACTOR C S h v( G NO.
LICENSED CONTRACTORS DECLARATION }IC, CLASS NO. DWELL. UNITS
I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,S(J Gro IA� atm+• SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and /1 LIC.
Professions Code, and my license is in full force and effect. CITY 2 A, - (, f CLASS I BK VALIDATION
SQ. FT./ NO.OF NO.OF CHECK
License Nu ber Lic.Class C SIZE {(/3 STORIES FAMILIES ' ONE
V TION
Contracto 5 1 CO Date DESCRIPTION OF WORK T u ,ti NEW ❑ : $
ADD
❑ I am exempt under Sec. $ "�
ALTER ❑ pill
B.&P.C. for this reason REPAIR ❑( $
USE OF
Date: EXISTING BLDG. DEMOL ❑,..
Signature APPLICANTTEL. FINAL
OWNER-BUILDER DECLARATION PRINT) NO. DATEG7_
I hereby affirm that I am exempt from the Contractor's License -2 4 0 7.4 A
Law for the following reason (Section 7031.5, Business and ADDRESS FIN
Professions Code): PRESENT By 0 0 0 0 0 1
❑ BUILDING
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ( o o59,25
the structure is not intended or offered for sale(Section LOCALITY
7044, Business and Professions Code). MOVING TEL. 0 0 0 5 9,2 5
❑ I,as owner of the property,am exclusively contracting CONTRACTOR NO.
with licensed contractors to construct the project (Sec- ADDRESS 0220-86
tion 7044, Business and Professions Code).
IRED'see YARD HWY TOTAL SETBACK FR M
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.
o -
�.
Lender's Name LDMA Ref. #
P.C. Fee$ Permit Fee J
Lender's Address ��))
r I certify that I have read this ap li ation and state that the Issuance FeeID
SV LDMA P/C#
r above information is correct. I a ee to comply with all County Investigation Fee ��-r
ordinances and State laws rel ing tb building construction, g Total Fee v' S LDMA Perm. #
nd hereby aut rize rep
re er4ativeplof this County,to enter ._,,.K...... ...
I u o ob ve entioned r perty or inspection urposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
igatu a of Applicant or Agen Date /— (