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HomeMy Public PortalAbout5710 PRIMROSE AVE_Building__ WORKERS'COMPENSATION DECLARATION hereby affirm that I have certificate of consent self APPLICATION F OR BUILDING P E RM I T insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Q fi� I—(.d 14, d r ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING P ADDRESS V� ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS . ZuUA ` LL Date Applica CITY ZIP LOCALITY ' a JV NO.OF BLDGS. NEAREST CERTIFICATE OF EXEMPTIO WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCEASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100)or less.) TEL. OWNER NO. USE ZONE INO MAP I certify that in the performance of the work for which this SPECIAL permit is issued, I shall not employ any person in any manner ADDRESSCONDITIONS D_so as to become subject to the Workers'Compensation Laws. OV CITY zip b Date Applicant ARCHITECT OR f TEL. DISTRICT GROUP TYPE �� FIRE 5PROCESAD BY O NOTICE TO PPLICANT: If, after making this Certificate of ENGINEER NO. j ?1� V CONST5' / E w Exemption, you should become subject to the Workers' U �Vf Compensation provisions of the Labor Code, you must forth- ADDRESS e C a with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APf. CO O. z Z deemed revoked. CONTRALTO LICENSED CONTRACTORS DECLARATION0 C. ': CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC49 ly SEWER MAP and Professions Code,and my license is in full force and effect. CITY p CLASS BK. PG. VALIDATION SQ. . NO.OF NO.OF ECK License Number Lic. Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK ,G NEW ❑ $ r� ❑1 am exempt under Sec. `74 V 14 , ADD ❑ p( ► ALTER ❑ B.BP.C. for this reason IMPAIR ❑ $ Date: USE OF EXISTING BLDG. — OL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE ¢f I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINA 1 Professions Code): PRESENT By ❑ I, as owner of theproperty, or mBUILDING F�ifTe4 Y employees with ADDRESS wages as their sole compensation,will do the work and 82,1313 the structure is not intended or offered for sale(Section LOCALITYPoo 7044, Business and Professions Code.) MOVING TEL. 1 ITE11- ❑ I,as owner of the property,am exclusive) contractingCONTRACTOR NO. _ with licensed contractors fo construct the project (SeADDRESS TOTAL RL 18�' .01131 tion 7044, Business and Professions Code.) CHECK 82.011 CONSTRUCTION LENDING AGENCY SETQBACK YARD HWY TOTAL SSEETPB LCIKE ROM XI Fi i I hereby affirm that there is a construction lending agency for FRONT CHANGE the performance of the work for which this permit is issued P L• (Sec. 3097, Civ. C.). SIDE +� P.L. QtJCILI-CICI 1 2/1.,.!� I Lender's Name , s P.C. Fee$ Permit Fee 0 LDMA Ref.# LtOrV 1 1 AN 9°13 / Lender's Address I certify that I have read this application and state that the Issuance Fee 2 r O LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 3 ordinances and State laws relating to building construction, Total Fee LDMA Perm. # c and hereby authorize representatives of this County to enter upon t e ab a-rqa tinned property for inspection purposes. — SEE REVERSE FOR EXPLANATORY LANGUAGE i t Applicant or Agent Date WORKERS'COMPENSATION DECLARATION u ,/7 her affirm that I have certificate of consent to self APPLICATION F®R BUILDING PERMIT ' insure, or q certificate of Workers'Compensation Insurance, or a certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING O � ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING �7 tion department. ADDRESS• ;7 Date Applicant CITY ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS. 'NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT ;CROSS ST. (This section need not be completed if the permit is for one TRACT BLOCK LOT NOr / 'MAP BOOK PAGE PARCEL ASSESSOR -hundred dollars($100)or less.) TEL. OWNER ,r"T'� 6 G'K I_� NO. a USE ZO,LVE MAP �jj�7 _ I certify that in the performance of the work for which this /j`.J NO. permit is issued, I shall not employ any person in any mann ri �l SPECIAL �. so as to be me ubject to the Wor)cers' om nsation La s.. ADDRESS :J ��G 1�� CONDITIONS Date Applicant CITY 7: ' /,C- C—»Y ZIPad TEL. NOTICE'TO PPLICANT: If, after making this Certificat ARCHITECT OR of � DISTRICT GRqUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. /J CONST. ZONE / Compensation provisions of the Labor Code, you must forth- ADDRESSIL ems} ,� with comply with such provisions or this permit shall be- 4n deemed revoked. CONTRACTOTEL STATISTICAL CLASSkICATION APT. C DO. g R �' �+j,� 7v�/i LICENSED CONTRACTORS DECLARATION LIC, CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �1lJe7T� �T ti NO.x,33Milli (commencing with Section 7000)of Division 3 of the Business and ' LIC q� SEWER MAP Professions Code, and my license is in full force and effect. CITY, S1Ti?!� �/�.1�1s CLASS BK PGVALIDATION % SQ'Fr' NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES FAMILIES ONE VALU TION Contractor G� Date DESCRIPTION OF WORK 052, A D O t $ CSDQ v ❑ I am exempt under Sec. Jt'� `J , ALTER ❑• B.&P.C. for this reason REPAIR ❑ $ ;2 68 4 8 A Date: USE OF EXISTING BLDG. DEMOL ❑•, # 0 0 0 0 0 Signature O/i . APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE�,/ ) ° 1 2 1L 8 8 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIProfessions Code): PRESENT ByN BUILDING 1 2[(,8 8� ��LL� � ❑ I, as owner of the property, or my employees with ADDRESS Q 4, 13-8 7 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). CONSTRUCTION LENDING AGENCY SETBACK YARD HWY TOTAL SETBACK NEER WIOM DTH 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 f LDMA Ref:# � P.C. Fee$ Permit Fee ' Lender's Address F, I certify that I have read this application and state that the Issuance Fee ©rJ� LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee $ ordinances and State laws relating to building construction, rl u Total Fee LDMA Perm. # and hereby authorize representatives _f this County to enter up n the above-me coned property or nspection urposes. a / , 1 3 -' SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature f t 9 o Applicant o Agen I