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Home My Public Portal About4868 ARDSLEY DR_Building__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent jo self ;.. insure, or a certificate of Workers' Compensation Insurarfce, - APPLICATION,� FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) �'�' ' � COUNTY OF LOS ANGEL•E!� BUILDING AND SAFETY Policy No.—Co.mpony BUILDING� V/ Certified copy is herey furnished. 'FOR'•APPLICANT'TO FILL IN ADDRESS a Certified copy is filed with.the county building inspec- BUILDING o tion department. ADDRESS �/ t LOCALITY , , /� NEAREST Date Applicant CITY ZIP: .O0 CROSS ST. � CERTIFICATE OF EXEMPTION FROM WORKERS' i NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars ($100)or less.) TRACT I BLOCK LOT NO. ( NO. o f0 TEL. 5' r SPECIAL I certify that in the performance of the work for which this OWNER — NO.Cl- ' CONDITIONS permit is issued, I shall not employ an per in an manner _ s/� [TISTRICT GROUP TYPE FIRE PR ESSED BY A C1 P P Y Y P Y rZ] CONST. ZONE V so as to become subject to the Worker 'Compe ation Laws. ADDRESS n- L ,v/► CITY (i /E W ZIP J /l o Date �� Applicant STATISTICAL CLASSIFICATION PT. CONDO. l NOTICE TO APPLICANT: If, after making this Certificate'of ARCHITECT OR TEL. � f ENGINEER NO. CLASS NO. DWELL. UNITS Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be z', deemed revoked. TEL' BK.CY—PG, VALIDATION CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS $ SQ. FT. NO.OF NO. OF / CHECK License Number Lic.Class �- SIZE STORIES FAMILIES ! ONE Contractor Date DESCRIPTION OF WORK NEW ADD I am exempt under Sec. FINAL ALTER B.&P.C. for this reason REPAIR ❑ DAT Date: USE F EXISTING BLDG. DEMOL BNA Signature APPLICANT TEL. �Gt:s�bf y OWNER-BUILDER DECLARATION PRINT NO.oma" 7!J I hereby affirm that I am exempt from the Contractor's License 496 p �1 � Law for the following reason (Section 7031.5, Business and ADDRESS 00 O r• ��l— 1` A � 25Z Professions Code): PRESENT BUILDING 0 0 0 0 0 I, as owner of the property, or.my employees with ADDRESS r wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section ! LOCALITY t 2 0 217 3 7 J 7044, Business and Professions Code): MOVING TEL. ' ❑ CONTRACTOR NO. 0 0 2 7 3,'7 G S I, as owner of the property, am exclusively'coniracting .�v with licensed contractors to construct the project (Sec- ADDRESS 'tion 7044, Business and Professions Code). 01 0 7—83 REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY 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 FD 'P.L. Lender's Name P.C. Fee$ Permit Fee O( J .1 Lender's Address I certify that I have read this application and state that the Issuance Fee s O above information is correct. I agree to comply with.all County Investigation Fee �� g ordinances and Sta laws relating to building construction, Total Fee b and h eby authori representatives of this County to enter upon a above-men ned property for inspection purposes. c SEE REVERSE FOR EXPLANATORY LANGUAG Signature of Applicant or Agent Date` ®s APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS e2—G V f��1E hereby affirm that I have a certificate of consent to self insure, ( 13 or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) j� ZIP ��f� LOCAL( Policy No. Company T/ NO.OF BLDGS.NOW ON LOT / G 4' 7 ❑ Certified copy is hereby furnished. NEAREST CROSS ST. ❑ Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAPNO. Date Applicant ASSE OBOOK PAGE/� PARCEL_ `,7/ S 2) ��/ SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' VIER 1'l TEL.NO. YES NO COMPENSATION INSURANCE V J WITHIN 1000 FT.OF SCHOOL? A RESS (This section need not be completed if the permit is for one hundrDISTRICT GROUP ITYPECONST' FIRE ZONE PROCESSED BY /dollars($100)or less.) CIN ZIP ✓ I certify that in the performance of the work for which this permit �/ 3 is issued, I shall not employ any person in any nner 30 as to ARCHITECT OR ENGINEER become isubject to the Workers'Co nsation Laws. STATISTICAL CLASSIFICATION APT CONDO Date pplicant ADDRESS CLASS NO.2/DWELL UNITS NOT( E TO APPLICANT. If, after making this Certificate of CONTRACTOR TEL.NO. REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' SETBACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you mustforthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P IL DE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PIIL I hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZE NO.OF STORES NO.OF FAMILIES Professions Code,and my license is in full force and effect. NEW BK PG , CD License Number Lic.Class DE; IPTIQN Qt W.QRK /11�� ADD ❑ Contractor Date C/f�v/` / ALTER ❑ $ uN' _z ❑ I am exempt under Sec. v , REPAIR ❑ $ BARC.for this reason /C �i DEMOL ❑ USE OF (STING BLDG. LDMA P/C# „g $ Date: �G_�dOF uRM ❑ '..'_;9� Signature APPLICANT(PRINT) TEL.NO. t g LDMA Perm It Z t1 t 93 c f I 1, as owner of the property, or my employees with wages as n elel- ��-I ZfZ O = i i-ML their sole compensation,will do the work and the structure is ADDRESS , not intended or offered for sale (Section 7044, Business and Gc FINAL DATE G o G TOT AI L 93= 63 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL {V� "HECK OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN Q '.t#Ct l --' El 1, as owner of the.property, am exclusively contracting withTHE AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B > licensed contractors to construct the project.(Section 7044, YES❑ NO❑ CHANGE Oil Business and Professions Code.) II'�f�GE n a_ WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROMTHESOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. ,. ("�I Il�ll�ljl'�I f ! ;;.7,U I hereby affirm that there is a construction lending agency for YES❑ NO❑ 3 '7/J �_.� ' 1 the performance of the work for which this permit is issued(Sec. i 3097,CIV.C. . 1 HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD i7 3 1 Lt M f JF PERMITTING CHECKLIST.I UNDERSTAND MV REQUIREMENTS UNDER THE LOS ANGELES - COUNTY CODE,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 SCAOMD. Lender's Address rnvNeRaRAGENT o° I certify that I have read this application and state that the above P.C. EE PERMIT FEE information is correct. I agree•to comply with all county . p / ordinances and State laws relating to building construction,and O b hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. 1 G INVESTIGATION FEE TOTAL FEE / sq,wun of Agke,n«Aq� om �. �+ SEE REVERSE FOR EXPLANATORY LANGUAGE