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HomeMy Public PortalAbout6445 TRELAWNEY AVE_Building__ WOWRS' COMPENSATION DECLARATION hereby d cer that I*f W r certificate of consent to self APPLICATION F. R. BUILDING PERMIT ir(sure, or a certificate of Workers Compensation Insurance, ora certified copy thereof (Sec 3800, Lab C ) iiR COUNTY OF LOS ANQELESl BUILDING AND SAFETY s ' Policy No Company BUILDING L 14 � ❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS IJ Certified copy is filed with the county building inspec- BUILDING- non department ADDRESS CITY ZIP / 7 O LOCALITY Date Applicant NO OF BLDGS CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT iC/ NOW ON LOT CROSS CRO55 ST Vnin! in, ink COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for ossa TRACE MOCK LOT NO MAP BOOK PAGE PARCEL hundred dollars ($100)or len ) TEL USE ZONE MAP OWNER !�- A /�10 �-lecAdV I certify that in the performance of the work for which this SPECIAL y Permit is issued I shall not employ any person in any manner ADDRESS ..S T /V I CONDITIONS M so os to become subject to the Worke Compensatio Laws O CITY ZIP U /SAO-q0 Date Applican AEff OR TEL DISTRICT GROUP TYPE FIRE PROCESSED BY W NOTICE TO you SANT If er mabjec tto ficok of ENGINEER D /c/ _'CW 140 �`=C O(L 'J ODNST ZONE Exemption, you should become subject to the Workers' 4U, 3 Compensation provisions of the Labor Code, you must forth- ADDRESS l011 AA:�.lN/TaS with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT CONDO Z deemed revoked CONTRACTOR NO LICENSED CONTRACTORS DECLARATION UC CLASS NO LL UNITS— LICENSED hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEWER (commencing with Section 7000)of Division 3 of the BusmenUC and Professions Code,and my license n in full force and effect CITY i G'r Mv.SS BK A (DATION SO IT NO OF NO OF CHECK- License License Number LIC Clan SIZE STORIES FAMILIES ONE VALU TION 3307 342.93 Contractor Date DESCRIPnON $ G 1 ILGILJ ❑I am exempt under SecALTER ❑ pool 342. 9$ B 8P C for this reason REPAIR ❑ $ /�E�A�LM 342.r9�8, Date D EXISTING BLDG 7E DEALOL ❑ CFIAF" .OU Signature A�(PR NANT (� [// Q1(-l..qp FINAL OWNER-BUILDER DECLARATION DATE rvyyL�M I hereby affirm that I am exempt from the Contractor's License ..S T��L+4 N�- FINAI 00 1 8/ 229 Law for the following reason (Section 7031 5, Business and ADDRESS Professions Code) ONMON By 4W 1 Air 9:41 ❑ j, as owner of the property or my employees with ,ppDIu ��/))) 1 wages as their sole compensation will do the work and Poo the structure is not Intended or offered for sole(Section LOCALITY 7044, Busmen and Professions Code ) MOVING TEL ❑ j, as owner of the property,am exclusively contracting CONTRACTOR NO with licensed contractor to construct the project (Sec- ADDRESS tion 7044 Business and Professions Code ) 5 c EX CONSTRUCTION LENDING AGENCY SET REQUIRED YARD FIW1' TOTAp P LIINNEE A I hereby affirm that there is a construction lending agency for FRONT C the performance of the work for which this permit is Issued P L :^� I-'L 4 C� �+ r-• (Sea 3097, Civ C ) SIDE C I Lenders Name ' P C Fee S Perms Fee 1 LDM"ef e Lenders Address /'571-7 `��UGR� S� � R , o I certify that I have read this application and state that the in nce Fee t'" LDMA PTC F above information is correct I agree to comply with all County Investigation Fee n ordinances and State jaws relating to building construction, TotalF. LDMA Perm Y 4' and hereby authorize representatives of this County to enter �/�t ' upon t e above-ment on property Inspection purposes Cc, ^n ���'O^'9D SH F"EM FOR EXPLANATORY LANGUAGE r^I �O 'C' n Sgnoture of Applicant or Agent Date O — U - T e WORKERS COMPENSATION DECLARATION ',Pkffoirm that I have a certificate of consent to selfAPPLICATION - FOR BUILDING PERMITsure a}%cendicotgtof Workers Compensation Insurance or a certified copy thereof jSec 38DO Lob C•) - d COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company - BUILDING El Certified copy is hereby furnished FOR APPLICANT TO FILL IN AUILUII El Certified copy is filed with the county building inspec- BUILDING DDRESS tion deportment i ADORES$ / Date Appbcont , _ CITY - - -ZIP / - -- LOCALITY =z Ixt CERTIFICATE OF EXEMPTION FROM WORKERS - - - NO OF BLDGS - NEAREST COMPENSATION INSURANCE SIZE OF LOT O/G$ NOW ON LOT Z GLOSS Si (This section need not be completed if the permit is for one TRACT BLOCK LOT NO ASSESSOR hundred dollars($100)or leu) MAP BOOK PAGE PARCEL TEL 77$pppNNN - I certify that in the performance of the work for which this OWNER / '��"�"d NO K4' ,/ / NO > IL permit a issued I shall not employ any person m any manner _ _ _ 'K`r SPECIAL IL b as to become subject to the Workers mpensation L s 's'DORE55 - CONDITIONS Date !17'67 Apphc Cm 6L ZIP / 7 O - m NOTICE TO APPLICANT If making this C, i scare of '�'rEER� TEL DISTRICT GROUP TYPE FIRE BV Exemption you should ome subject to the Workers - CONST, / Z tJ Compensation provisions of the Labor Code, you must forth ADDRESS S �/ _ _ d with comply with such provisions or this permit shall be - - TEL STATISTICAL CLAS$LFICATION APT ONDO deemed revoked CONTRACTOR L[.iNC2 NO 76 O/C/ LICENSED CONTRACTORS DECLARATION - - - -- LIC CLASS.- DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO SEAR MAP (commencingry with Section 7OD0)of Dewn 3 of the Business and _ _ _ _ __ LIC Professions Code and my license is in full force and effect CITY CLASS 1 PG VALIDATION SO FTS /JYs NO OF _ NO OF _ CHECK License Number L¢ Cloys SIZE / 7 �- STORIES FAMILIES ONE NEW VALUATION Contractor Date DESCRIPTION OF WORK - --- - : - �s L am exempt under Sec ALTER B 8P C for this reason REPAIR 6 i Duro USE OF EXISTING BLDG DEMOL -f 61 4,5 A Signature APPLICANTTEL RNAL nn n e . . e OWNER-BUILDER DECLARATION (PRINT) PRINT O U I 'elft_A No DAh W ,/ #_ * 23 I hereby off irm that I am exempt from the Contractors license Low for the following reason Section 7031 5 Business and ADDRESS FINAL to—ions Code) BUILD! BY 12- 19-86 I, as owner of the property, or my employees with ADDRESS wages m their sole compensation,will do the work and LOCALITY ; the structure is not intended or offered for sale(Section ' 7041 Business and Professions Code) - - MOVING - _- TEL - I as owner of the property am exclusively contracting CONTRACTOR NO with licensed contncrors to construct the project (Sec- non 7044 Buane ,and Professions Code) AD ,N \•`' ' i CONSTRUCTION LENDING AGENCYIX I D YARD ,y _TOT t SETB •_ ` : __ _ _ APROP LINE WIDTH i I hereby affirm that there is o construction lending agency for FRONT 2 6 7 9 A the performance of the work for which this permit is issued PL - - - — - -- (Sec 3097, C,v C ) SIDE # • • • e 1 7 Lender's Nome P L I - 27375 $ /] LDMA Ref Y lender s Address C Fee i Permit Fee / 3. ' • • 2 7 3 7 5 FL I certify that I have rend this application and state that the _ - Ivuonce Fee / N V LDMA P/C Y # 3 8'� above information is correct 1 agree to comply with all County Investigation Fee - ordinances and State jaws reloting to building construction Tour Fee- LDMA Perm E d and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ' Sigigture of Applies or Agent - Date-