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Home My Public Portal About9950 OLIVE ST_Building__ 1,� RKERS'COMPENSATION DECLARATION affirm that I have certificate of consent to self APPLICATION FOR BUILDING PERMIT insuresure,, or Y!Lertificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company un Certified copy is hereby furnished. BUILDING </q, FOR APPLICANT TO FILL IN ADDRESS •�j )��V !� Certified copy is filed with the county building inspec- BUILDING ,,�• tion department. ADDRESS W50 (91111LE Date Applicant CITY ;�'� �G(� ZIP91 LOCALITY C CERTIFICATE OF EXEMPTION FROM WORKERS' r NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT �j"j NOW ON LOT CROSS ST. mw (This section need not be completed if the permit is for one ASSESSOR hundred dollars($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. I certify that in the performance of the work for which this OWNER 1NO. �. USE ZONE O � ^ '=L . permit is issued, I shall not employ any person in any manner � DP �� SPECIAL 8fv so as to become subject to the Workers'Compensation Laws. ADDRESS i i7 � CONDITIONS U Date L Applicant '"J� `t 'e-'79 CITY V [i Zi�� ZIP �` NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL• DISTRICT GROUP TYPE FIRE PROCESSED BY O ENGINEER NO. ►.-. CONST. ZE V Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS ✓t a with comply with such provisions or this permit shall be L. STATISTICAL ClA$$IFICATION APT. NDO. N deemed revoked. CONTRACTOR NO. '1 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 PG VALIDATION SQ. FT STORIES F NO,OF 7 CHECK ONE License Number Lic.ClassVALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ � .` � � ADD $ , ❑ I am exempt under Sec. J' ❑ ALTER B.BP.C. for this reason USE OF REPAIR ❑❑ $ z 1 132 A Date: EXISTING BLDG. � �-I j^ L ! DEMOL � o 'Z 9 6050, ,5•� APPLICANT —ry TEL FINA /� Signature OWNER-BUILDER DECLARATION PRINT ? 1 • ' JO NO. �E ' DAT� �T o .29a500 I hereby affirm that I am exempt from the Contractor's License 55 �� Law for the following reason(Section 7031.5, Business and ADDRESS FIN 1,15-88 Pro scions Code): PR By. 1, as owner of the property, or my employees with &Lr 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 CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). wwrm CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAL SETBACK 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 m P.C. Fee$ Permit Fee vDMA Ref.,q Lender's Address r ' I certify that I have read this application and state that the Issuance Fee 0"S� LDMA P/C N g above information is correct. I agree to comply with all County Investigation Fee 0 ordinances nd tate laws relating to building construction, ` 1 Total Fee S LDMA Perm. # N and here' out a 'z repr entatives of this County to enter $ upon th bov ione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Applicant ar'Agent Date ! ORKERS'COMPENSATION DECLARATION v r` hereby;affirm that I have certificate of consent to self � L� APPLICATION FOR BUILDING P E RM I T insure, or a certificate of Workers' Compensation Insurance, or a certified copy theretospany c. 3800 Yb. C.) r .] lL � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy t 119�Sa" ' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy is filed wHhn 'ng' p c- BUILDING /t�io�n��d(e�paart�ment. ADDRESS Dated�' Applic CITY Calf LG= /'IV– ZIP Q LOCALITY OF BLDGS- NEAREST CERTIFICATE OF EX S' SIZE OF LOT OW ON LOT CROSS ST. AlCOMPEN TIOASSESSOR (Thissection need not b com is for one TRACT BLOCK LOT NO. �/ MAP BOOK PAGE PARCEL hundred dollars ($100) le TEL'�'� c USE ZONE MAP r OWNER No-57a NO ! 1 certify that in the performance of the work for which this SPECIAL permit is issued, I shall not a loy any person in an ma r ADDRESS �� j CONDITIONS a_ so as to become subject to th Workers'Compens i O _ CITY ZIP91' V Dat ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY •NOTICE TO APPLI ANT: aft r mokin6 this Certi icate of ENGINEER NO. CONST. ZONE Compensation oExemption,pesayou shout beth a subject to the Workers- 'Oq p CL Com ensation rovisio s of the bar Code, you must forth- ADDRESS /� with comply with suc provisi ns or this permit shall beTEL• / STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR NO. (p _ LICENSED CONTRACTORS DECLARATIONLIC. �� CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter9l ADDRESS dr1V0. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY L r CLASS — BK PG VALIDATION SQ. rr. NO.OF NO.OF CHECK License Number Lic. Class SIZE 7 STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ $ O• r� ❑I am exempt under Sec. ADD � v I �. ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. C CGS DEMOL ❑ Signature APPLICANT TEL• FINAL OWNER-BUILDER DECLARATION (PRINT) a -r NO. DATE/'`�L �( I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS' , �� ;FIN t. f ) 1 Professions Code): PRESENT By !/ ❑ I, as owner of the property, or m employees m to ees with BUILDING A nr P P Y� Y P Y ADDRESS 11i�41 e v wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY , 3M7 6$063 7044, Business and Professions Code.) MOVING TEL. 9 T ❑ I, as owner of the property,am exclusively contracting CONTRACTOR NO. 1 1 TM with licensed contractors to construct the project (Sec- ADDRESS T �I�. m tion 7044, Business and Professions Code.) t REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. CASH 68 63 63 CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH = I hereby affirm that There is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. � ' ou� (Sec. 3097, Civ. C.). SIDE "k P.L. , Lender's Name /6�7�8? 8 P.C. Fee$ Permit Fee LDMA Ref. # A71 ae 16 Lender's Address �1 4115 1 0 I certify that I have read this application and state that the Issuance Fee v LDMA P/C# 3 above information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, I Total Fee t10 LDMA Perm. # Jnd hereby authorize representatives of this County to enter pon the above-me i n I p)operty for inspection purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date