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HomeMy Public PortalAbout4839 ARDEN DR_Building__ -�- - -� APPLICATION FOR BUMDING PERMIT �l COUNTY OF LOS ANGELES . BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, 3 , h r` ` Vim_ or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP l! li/1 copy thereof(Sec.3800,Lab.C.) _ ,-- LocnuTv _ ,P�OII/ryrv`0.��_�C�} _5n TI C,Ompany n1511 I!M f;CP� SIZE O L T NO.OF BLDGS.NOW ON LOT Ltl Gertlfied Copy is hereby furnished. 'L '# NEAREST CROSS ST. �1 ❑ Certified copy is filed with the county building inspection TR CT BLOCK LOT NO. �0�� i department. 111(((''����..Q � USE ZONE MAP NO. Date W \.) A licant •-=`��- �\-� AS ESS- AP BOOK PAGE PARCEL r NilPP SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL.NO. �, v 2 W 14 COMPENSATION INSURANCE ADDRESS �• 8 5%0 21014 10 `1 WITHIN 1000 Fr.OF SCHOOL? YES NO f� J (This section need not be completed if the permit is for one hundred 3M I. HVUW Tkla v1 W ' DISTRICT GROUP TYPE CONST,' FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP jj�� X-31 � � jjI certify that in the performance of the work for which this permit q % d'� � U� 1/ �Tis issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. ���!!! "`---i��� become subject t0 the Workers'Compensation Laws. -141 ,b88 STATISTICAL CLASSIFICATION I APT CONDO Date Applicant 1 ADDRESS 1 s•�S r CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after makingthis Certificate of 2 � (~v-t0a IV6 *300 REQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become subject to the Workers' CONTRACTOR L_. TEL.NO. l 1 i / SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith "L (0ON AXON ZiF�B$ FRONT comply with such provisions or this permit shall be deemed revoked. DDRESS .,NO P L X30 l � „G, Rte;") SIDE LICENSED CONTRACTORS DECLARATION CITE' ' LIC.CLASS PL a I hereby affirm that I am licensed under provisions of Chapter 9 S .FT SIZE OF STORES NO.OF FAMILIESI ' `z ER MAP (commencing with Section 7000)of Division 3 of the Business and C Professions Code,and my (cense is in full force and effect. r! Z► NEW BK /. PG � a S 2 DESCRIPTION OF WORK ADD ❑ VALUATI W License Number Lic.Class N Contractor ;plf/c�(r `Cdfvs�Date =1�'�•�� ALTER ❑ �ra J f� z ❑ I am exempt under Sec. REPAIR ❑ DOe• — B.BP.C.for this reason - DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PRINT) TEL.NO. LN LDMA Perm# El I;as owner of the property, or my employees with wages as s OZ A t-' °'F their sole compensation,will do the work and the structure is ADDRESS H 7t�I y-`"n 1I not intended or offered for sale (Section 7044, Business and 0 d FINAL DATE C Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ❑ I, as owner of theproperty, am exclusive) contracting with THE A MIXTUREAMOUNTS CONTAINING A HAZARDOUS MATERIAL EQUAL TO TI GREATER THAN ; )I AL 619 - 01 Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDES FINAL BY E ly E ' licensed contractors to construct the project.(Section 7044, Business and Professions Code.) �;ves❑ No : 1 i:€', L i Y e Oil i WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH ,U^ CONSTRUCTION LENDING AGENCY COAST GUIDEL NES ITV MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST / ��' � �� CHANGE NGE u!!I I hereby affirm that there is a construction lending agency for YES ElNO Z the performance of the work for which this permit is issued(Sec. _ _ I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 3097,CIV.C.). NG CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES I I Il'- il 1 /m'f i`z�i PERMITT �r�. j• COUNTYCODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING � �• Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. (� :(5 1 A 4 A-'55 Lender's Address • �i t �� lO. OWNER OR AGENT o' 1 certify that I have read,this application and state that the above/•�( information is correc )I agree to Comply with all county P•C.FEE PERMIT FEE / �� !J / ordinances and S�ree Liesntatives relating to building construction,and • 01 6� a. hereby authorize of this County to enter upon ISSUANCE FEE the above-mentiorty for inspection purposes /�• INVESTIGATION FEE TOTAL FEE n �( Sicn•tun of ApgMxnt« 64q _..�-� , (;1 SEE REVERSE FOR EXPLANATORY LANGUAGE r WORKERS' COMPENSATION DECLARATION ;. •1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or d certifi�e�d9copy thereof�ec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY PoI'I'c -No.�/G� �� CompanyBUILDINCi 'T�iB�cs.4l�i by1R-.e� LTJ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDLNG ADDRESS D c tion department. o C Date f Z b Applicant ;s +�� -�• CITY -ref-4 —. G17 ZIP (?138o LOCALITY NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE'OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL' USE ZONE MAP / OWNER NO. I certify that in the performance of the work for which this n permit is issued, I shall not employ any person in any manner ADDRESS p( 10 SPECIAL CONDITIONS O .so as to become subject to the Workers'Compensation Laws. U CITY ZIP Date Applicant ARCHITECT OR g' a!,VS�- E-4N1 TEL. qr���� DISTRICT GROUP TYPE FIRE PROCESSED BY Q NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER pG �T-S NO W*-71 �zcLY3' CONST. NE F- Exemption, you should become subject to the Workers' t / U Compensation provisions of the Labor Code, you must forth- ADDRESS 2/3 "0 UA)7_/ TvIJ `BIZ, 3c�v �� t/ a with comply with such provisions or this permit shall be TEL. � � STATISTICAL CLA IEICATION APT. CONDO. Z deemed revoked. CONTRACTOR i"'&&,UOV NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO DWE UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS _'b3o ••�� NO.$S- )jb'-3s (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP CITY �L /1i/O r3 C-A ! 33 CLASS and Professions Code,-and my license is in full force and effect. BK. PG. VALIDATION p SQ. FT.' O. OF NO.'OF CHECK License Number �%i 63S Lic. Class -Z SIZE. (p,� STORIES FAMILIES ONE �{� p VALUATION ' Contractor► / f/�Y o CO Date �Z�2"� / DESCRIPTION OF WORK NEW G] �� ADD El /2©` Elpop.I am exempt under Sec. f ALTER ❑ B.BP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL I OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL , Professions Code): PRESENT By ( °"t' ❑ I, as owner of theproperty, or m em to employees with BUILDING Y P Y ADDRESS � 3 _f'_si -�'r•�+a�+_ 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. �_„„ ❑ 1, as owner of the property, am,exclusively contracting CONTRACTOR NO. ;;,I i= S_j 6 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 H{T'•'�- -- 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. c.t�,i n �a LDMA Ref. # P.C. Fee$ (� Q Permit Fee 3 Lender's Address 0 1 certify that I have read this application and state that the Issuance Fee 76 LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee O / 6 ordinances and State laws relating to building construction, Total Fee Q (o LDMA Perm. # and hereby authorize representatives of this County to enter upo he above-mentioned property for inspection purposes. t�/Z= % SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date