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HomeMy Public PortalAbout4841 ARDEN DR_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS 1 hereby affirm that I have a certificate of consent to self insure, V� or a certificate of Workers'Compensation Insurance,or a certified CI ZIP COPY thereofI (Sec. ti Lab.C.) (� LOCALITY Policy No. i 11Ii1 rN ompany 1 �L C �/7- SIZE O OT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. I f NEAREST CROSS ST. ❑ TRACT BLOCK LOT NO.Certified copy is filed with the county building inspection USEZONE MAP NO. depa ment. ^ / , ASSESSOR MAP BOOK PAGE PARCEL 141-1 o/ r ;1 -_I Date ',, Applicant 1. Cc` fl SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TELNO. COMPENSATION INSURANCE `4 WITHIN 1000 FT.OF SCHOOL? YES No A DRESS (This section need not be completed if the permit is for one hundred Ca. &Iki !S11 ew DISTRICT GROUP TYPE CONST.' FIRE ZONE`PROCESSED BY dollars($100)or less.) CITY ZIP t.�r O� n 1 certify that in the performance of the work for which this permit (,� 01110 c�/1 K is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. become subject to the Workers'Compensation Laws. S $„ b STATISTICAL CLA IFICATION APT CONDO Date Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST CONTRACTOR �jJtf)- TEL.No., Exemption, you ShOUId become subject f0 the Workers' �' 1 SETBACK YARD HWY PROP LINE WIDTH (_r Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. APL DDRESS —�•�• w _ -' LIC.NO. / — FRONT LICENSED CONTRACTORS DECLARATION CITY �L - L LIC.CLASSPLc I hereby affirm that I am licensed under provisions of Chapter 9 & 2 � EWER MAP v (commencing with Section 7000)of Division 3 of the Business and S .FT SIZE N F STORE NO. FAMILIES �1 O Professions Code,and my license is in full force and effect. 9rb NEW BK L PG (/J U License Number_(���6�3 LiC.C18ssr 111 lZ DESCRIPTION OF WORK ADD ❑ vnwA ON � �� wa Contracto��l "� o� Date 1$i`�S'��1 ALTER ❑ $ r �/ 1"� y - - -- ❑ I am exempt under Sec. REPAIR ❑ $ ODD z' B.BP.C.for this reason DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM ❑ ,w Signature APPLICANT(PRI T) TEL.NO. LDMA Perm# Zw•i•6 °e ❑ I, as owner of the property, or my employees with wages as p their sole compensation,will do the work and the structure is ADISRESS 3307 614 JD not intended or offered for sale (Section 7044, Business and 2t-�q d14TW&TOd P014300 4110�,Q FINAL DATE Qi ITEMS ` Professions Code.) WILLTHEAPPLICANTORFUTUREBUILDINGOCCUPANTHANDLEAHAZARDOUSMATERIAL ❑ 1, as owner of theproperty, am exclusive) contracting With OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q TOTAL -19 & m n"4 Y 9 THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY -1 0 licensed contractors to construct the project.(Section 7044, Business and Professions Code.) YES❑ NO❑ JIM iCHECK 619.01 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH �E f•'�{'(�j�' l �I CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST p[-. Y' �� CHANGE °- FOR GUIDELINES. �/ I hereby affirm that there is a construction lending agency for VES 1:1 NO 117 apo• 7 a the performance of the Work for which this permit IS issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD Qyry� �t4F +f'i�jf 3097,CIV.C.). PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES v—/ — / ` 000-0001 '• �'��--1" 90 COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING 1 F M 1 1 yj. o Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 9'r7i (�y 1 Fes!s��' Lenders Address ��� OWNER OR AGENT o 1 certify that I have readthis pplication and state that the above PC.FEE Q information is Correct; agree to comply with all county Uzi ordinances and State la relating to building construction,and r O PERMIT FEE 70a hereby authorize repress tatives of this County to enter upon _ ISSUANCE FEE the above-mentionedp py arty for inspection purpos S. a _J � TOTAL FEE Sign ma Apar .,� '`j U - SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION I hereby .insure, oroafcertifhmirm te of Workers' Compensation Insuran eI have a certificate of consent to , APPLICATION FOR BUILDING PERMIT .•or cs certified copy ereof, ec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY r'S b Policy.No.UW Company TA4Af5/gf- tC,9 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDINGADDRESS ElCertified copy is filed with the county building inspec- BUILDING l7^ t tion department. ADDRESS , �ri.� DateL l A licant CITY' ' GjT ZIP LOCALITY PP 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 I LOT NO. MAPBOOK PAGE I PARCEL hundred dollars ($100) or less.) TEL. MAP USE ZONE OWNER NO. NO. 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 ADDRESS �� CONDITIONS 4: so as to become subject to.the Workers' Compensation Laws. 0 CITY ZIP Date Applicant ARCHITECT OR TEL. qq DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER C NO&S 7/X408 CONST. ZONE 0 Exemption, you should become -subject to the. Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS-MI-3-0 r/Lt T/ 7-1-/J with comply with such provisions or this permit shall be TEL. 6 STATISTICAL SIFICATI APT. CONDO. N deemed revoked. CONTRACTOR r�u G©NS .NOty�-57 -7117 Z LICENSED CONTRACTORS DECLARATION LIC. CLASS ELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS%v' ® �5.' i4l2tJ' NO.a� 1 SEWER MAP (commencing with Section 7000)of Division 3 of the Business 'LIC: and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO:OF NO. OF CHECK License Number 63-5 Lic. Class B—L SIZE 6,7� STORIES FAMILIES ONE 1�I VALUATION Contractor TIO p DESCRIPTION OF WORK NEW 4 [�--G'07�7Dote 1 Z /y_7 I a ADD El lI am exempt under Sec. �(2.� �� /eja�tGLh` / ►. ALTER ❑ B.&P.C.aforthis-reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL 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 ❑ I, as owner of theproperty, or m em to employees with BUILDING �'-:�'• e' Y P Y ADDRESS wages as their sole compensation,will do the work and LOCALITY a3 q the structure is not intended or offered for sale(Section .! -' 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. S.• , - with licensed contractors to construct the project (Sec- ADDRESS �� � , C ,HL �"J. 63 tion 7044, Business and Professions Code.) _HI;_CY - REQUIRED TOTAL SETBACK FROM EXIST. -»a CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT • )Hl the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE. P.L. - - Lender's Name d LDMARef. # :v,�si- m O p P.C. Fee$ � �O Permit Fee •O '»+•_=v_? id:..7 »; 's:� Lender's Address r , - o I certify that I have read this application and state that the Issuance Fee 7S LDHiA P/C# 0 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 J LDMA Perm. # a and hereby authorize representatives of this County to enter upon,{t�i\e above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date