The URL can be used to link to this page

Home My Public Portal About4845 ARDEN DR_Building__ _.WORKERS' COMPENSATION DECLARATION •insureboraaffirm certif cafe of Workers' Comtpensation Insuran of consnt to of APPLICATION FOR B U I L D I NG_PERMIT or d certified copy th reof (Sec. 3800, Lab. C.) � COUNTY OF LOS ANGELES - BUILDING AND SAFETY Policy No. Colhpan��NS'"2`� BUILDING • ❑ Certified copy is hereby.furnished. FOR APPLICANT TO FILL IN ADDRESS 7 !/� s+ /Z•///�� ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ( ADDRESS � .. Z fy `\` CITY `'T GT ZIP ! r> LOCALITY Date .Applicant P .+ NO. OF BLDGS. CERTIFICATE OF.EXEMPTION FROM WORKERS' SIZE.OF LOT NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE . ASSESSOR(This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE RCEL hundred dollars ($100)or-less.). - TEL. OWNER NO. USE ZONE MAP. I certify that in the.performance of the vaork for which this ® NO. SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS !t �� CONDITIONS d so as to become subject to the Workers'Compensation Laws. O CITY ZIP U Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT:.'If, after making This•Certificate of ENGINEER t.,�-o Gfi4?'ZS '�-6� DISTRICT GROUP TYPE FIRE, PROCESSED BY 5 NO�� CONS,T. NE 0 Exemption; you .should become" subject to the Workers' _� GSZ � w o Compensation provisions of the Labor Code, you must forth- ADDRESS /; /-f /� 0 1Q ��a a_ with comply with such provisions.or this permit shall be " STATISTICAL C-ASS ILATION APT. CONDO. Z deemed revoked. CONTRACTOR 1iJ rNJ{�L GBA,3.S ,N0.�3/ -ri7�� >7 LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. D ITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS Odd/ �- NO.S51.G3 (commencing with Section 7000)of Division 3 of the Business ,r.. LIC. ' SEWER MAP and Professions Code,and my license is in full force and effect. CITY d�drjn/T� CLASS BK PG VALIDATION Q.p Y SIZE 6• STORINOES MILLIF CHE IES ONEK License Number, // ��-� Lic. Class �— f� VALUATION Contracto7r ,"L A-A / Date Y''(> DESCRIPTION OF WORK NEW r $ n ADD ❑ ��a° .! pop I am exempt under Sec. t �� ALTER El B.BP.C. for,this,,reasonS — REPAIR ❑ Date: USE OF EXISTING BLDG. DEMOI ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT). NO. DATE ` 1 hereby affirm that I am exempt from the Contractor's License Law for the ADDRESS _ following,.reason (Section 7031.5, Business and FINAL Professions Code): PRESENT . By ❑ I, as owner of the property, or my employees with BUILDING ADDRESS wages as their sole compensation,will do the work and , j loy, the structure is not intended or offered for sale(Section LOCALITY 7044, Business.and Professions Code.) MOVING TEL. _1: L; "71F CONTRACTOR NO. h7 — ❑ I, as owner of the property, am exclusively contracting _ with licensed contractors to construct'the project (Sec- ADDRESS � '3°�""-.r. `-" J- tion 7044, Business and Professions Code.) _ REQUIRED YARD HWY TOTAL SETBACK FROM- EXIST. `;.)"(; ;'•i 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. (Sec. 3097, Civ. C.). SIDE. P.L.. Lender's Name 'y p o _ P.C. Fee$ �O Permit Fee ��p LDMA Ref. # y 3 Lender's Address 1 certify that I have read this application and state that the Issuance Fee � �`� LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee R ordinances and State laws relating to building construction, Total Fee 6� LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Q. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date a APPLICATION FOR BUILDING PERMIT _ COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS DING DRESS • I hereby affirm that I have a certificate of consent to self insure, BUIL `,J� or a certificate of Workers'Compensation Insurance,or a certified CITY ZIP e copy thereof(Sec.3800,Lab.C.) LOCALITY Po Policy NDtiW � _05a471D,Company ��-?gflUZ-ti('e�A) SIZE OF LOT � NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. -121)( NEAREST CROSS ST ❑ Certified copy is filed with the count building inspection TRACT BLOCK LOT NO. y fd USE ZONE MAP NO dopa men. f 7— Q I i b ` ) � �•` ��u` ASSESSOR MAP BOOK PAGE PARCEL _ �d Date t� Applicant SPECIAL CONDITIONS ER TEL.NO. CERTIFICATE OF.EXEMPTION FROM WORKERS' OWNER < YES NO COMPENSATION INSURANCE p WITHIN 1000 FT.OF SCHOOL? A125� y( (This section need not be completed if the permit is for one hundred DISTRICT GROUP TYPE CONST.' FIRE ZONE PROCESSED BY dollars($hat or less.) CITY ZIP 5,b v R3 Y- I certify that in the performance of the work for which this permit {�. - 1 ,q1101 0 is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINqER TEL.NO. become subject to the Workers'Compensation Laws. S� _ STATISTICAL CLASSIFICATION APT CONDO/ Date Applicant A D E S ICLASS NO. DWELL UNITS V NOTICE TO APPLICANT. If, after making this Certificate of qA Cm lk' , REQUIRED TOTAL SETBACK FROM EXIST C NTRACTOR TEL. O Q 1 Exemption, you should become Subject t0 the Workers' /�1 EL. - Cl i —SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith " � Zi C- —-t I (O 7 2`•1 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS � � LIC.NO. � PL 11 d"l. i r R. a'tS✓, ��nv�`3~ SIDE > LICENSED CONTRACTORS DECLARATION CITY hl''�,��pp� r uc.cLAss ~L �!�S•�.11xr PL I hereby affirm that I am licensed under provisions of Chapter 9 R 2L' SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT SIZEjj�, OF ST ES NO. F FAMILIES f b 2 O Professions Code,and my license is in full force and effect. ,I �' NEW BK J� PG /�.b �( U 1 l D CRIPTION OF WORK VALUATION `' W License Number�5��3 _ ��?Z' �r ADD ❑ 2 , ( Lic.Class DD n. Contractor1l�l� CBNSDate � �9-11 ALTER ❑ $ ° �_ ElI am exempt under Sea REPAIR ❑ �a� O.8-a B.BP.C.for this reason DEMOL ❑ LDMA PIC# USE OF EXI TING BLDG. Date: s[ URM. ❑ y Signature NPPLICANT(PRINT) TEL.NO. LDMA Perm# ❑ I, as owner of the property, or my employees with wages as O their sole compensation, will do the work and the structure is A DRES F 3_307 615r°`I1 not intended or offered for sale (Section 7044, Business and P � _ dg3 FINAL ATE cc G Professions Code.) ^ZG G .� f TENS WILL THE APPLICANT ORFUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J d .L ❑ I, as owner of theproperty, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Y g THE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BYTOTAL dam" licensed contractors to construct the project.(Section 7044, YES 19 . 01 Business and Professions Code. WILL 1:1 NO❑ CHECK �' O WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING �°i OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH n/� AA �{ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST ��, Y cCJv/� .;iy��(� FOR GUIDELINES. 1 hereby affirm that there is a construction lending agency for YES❑ NO❑ ` the performance of the work for which this permit is issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD /J J ((} }{ ( + 3097,CIV.C.). PERMITTING CHECKLIST.1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELESii£i i rfI..1 a. COUNTY CODE,TITLE 2.CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING _ � rr} Lender's Name HAZARDOUS MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 9-`2 i I I�i i 10 n C4 aLender's Address OR AaQ.. '/ C�• _ t i•_ o I certify that I hIreadis application and state that the aboveinformation is agree t0 Comply with ell CountyP.C.FEE PERMIT FEE ordinances anrelating to building construction,and y4. hereby authornta -70 tives of this County to enter upon y ISSUANCE FEEthe above-menarty for inspection puo__ 51 INVESTIGATION FEE TOTAL FE •'7 . r Slgn .°IApplim. DH.. SEE REVERSE FOR EXPLANATORY LANGUAGE