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HomeMy Public PortalAbout4910 ARDSLEY DR_Building__ APPLICATION FOR BUILDING PERMIT i1 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, 4 9 1 0 ArUsIV Dr. T h ` 1 7 . or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) CITY ZIP_ LOCALITY Policy No.I1 F 2 239-9 fi Company C 1'a t r- f 17 n d SIZE OF LOT t NO.OF BLDGS.NOW ON LOT Certified copy is hereby furnished. 7056 sqs . NEA EST C SS 7 TRACT BLOCK LOT NO. aW Hr V� ❑ Certified copy is filed with the county building inspection usEzoNE MAP No. P �- � + de artment. ASSESSOR MAP BOOK PAGE PARCEL ��/1/ � DaterrApplica vrs U L 1 SPECIAL CONDITIONS OWNER TEL.NO. CERTIFICATE OF EXEMPTION FROM WORKERS' David Lee, 2 8 6—7 4 4 5WITHIN 1000 FT OF SCHOOL? YES NO COMPENSATION INSURANCE ADDRESS (This section need not be completed if the permit is for one hundred Same above DISTRICT GROUP TYPE T.' FIRE ZONE RO ESSED BY dollars($100)or less.) CITY ZIP 02 I certify that in the performance of the work for which this permit 1 3 is,issued, I shall,not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. become subject to the Workers'Compensation Laws. STATISTICAL CLAF$IFICATION O Date Applicant ADDRESS CLASS NO. `-/ DWELL UNITS NOTICE TO APPLICANT: If, after making this Certificate ofCONTRACTOR 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 must forthwithADDRESS 9098 FRONT comply with such provisions or this permit shall be deemed revoked. L P L 154 .S.San gakbriel Bld 58854 SIDE a LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS p L O Sari gabriel 13 t4i 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. 171 NO.OF STORES NO.OF FAMILIES O Professions Code,and my license is in full force and effect. ' `! NEW ❑ BK PG 0 TI F R qpp VALUATION w License Number 5$�5 4 6 Lic.Class R 4f CO) Contractor Pp 391 ;on Date �'�9 ALTER ❑ $ � 900 z ❑ I am exempt under Sec. A-efc REPAIR ❑ B.BP.C.for this reason DEMOL 11LDMA P/C# Date: USE OF EXISTING BLDG. URM. C1Resit encial Signature APPLICANT(PAINT) TEL.NO. LDMA Perm#F ❑ 1, as owner of the property, or my employees with wages as Dendclion Devel . Inc. 285-909-8 Z their sole compensation,will do the work and the structure is ADDRESS r Q not intended or offered for sale (Section 7044, Business and Same a"boVe FINAL DATE Professions Code.) tel,/ WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL - ❑ 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 BYM., licensed contractors to construct the project.(Section 7044, (� I _ Business and Professions Code.) YES❑ NO{� " lyj c rij e� .. WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST ,H7y%i ILe/' FOR GUIDELINES. _ ^ I hereby affirm that there is a construction lending agency for ves El No❑{ ':- F•jl 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.J. PERMITTING CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES gg. COUNTY CODE,TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING a Lender's Name HAZARDOUS ATERIALS REPORTING AND FOR OBTAININW PERMIT FROM THE SCAQMD. 3 —I i 3 S'I I a !I_S,!!1 ,l l,� fir; .mss. o Lenders Address k—wa OR AGENT , i1t2 � sILI I ;= o 1 certify that I have read this application and state that the above P.C.FEE PERMIT FEE information is correct. I agree to comply with all county [� QZF ordinances and State laws relating to building construction,and J� 7 ¢- hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. INVESTIGATION FEE TOTAL FEE 2 SIgmWmof ApglicaMwAgent D.W SEE REVERSE FOR EXPLANATORY LANGUAGE. WORKERS'COMPENSATION DECLARAriON nsurebor afcertificatelof Workers Colmpenofonolnsuranoce,o'r ' ` APPLICATION . FOR BUILDING PERMIT certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 'olicy No"$J-IIAqVCompany WA045 TMI. A60K-/ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN AooRESS Q $ 6 Certified copy is filed with the county building inspec- BUILDING qTQ tion department. ADDRESS 6 LOCALITY LC NEAREST Date Applicant CITY (.E G ZIP CROSS ST. CA04C CIT All CERTIFICATE OF EXEMPTION FROM WORKERS" NO. OF BLDGS. j ASSESSOR COMPENSATION INSURANCE SIZE OF LOT X 11,ji NOW ON LOT I MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for orie TRACT BLOCK LOT NO. *� USE ZONE NO. {, O !� 6 hundred dollars ($100)or less.) � TEL. C SPECIAL certify that in the performance of the work for which this OWNER LCV NO CONDITIONS O permit is issued, I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY V ADDRESS / CONST ZONEIM so as to.become subject to the Workers'Compensation Laws. 3 /�% Date Applicant CITY ZIP STATISTICAL CLASSIFICATION I APT. ICONCO. V NOTICE TO APPLICANT:. If, after making this Certificate of ARCHITECT OR TEL. Ly Exemption, you should berkers'come subject to the Wo ENGINEER NO. CLASS N0._!��;—I�DWELL. UNITS -ompensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be 7 fle deemed revoked. CONTRACTOR D /Lf/ NO. -� BK.•G PG, 7 VALIDATION LICENSED CONTRACTORS DECLARATION i LIC. hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 13#f (if/. &Akt/ey NO. VALUATION (commencing with Section 7000)of Division 3 of the Business and or LIC. Professions Code, and (� lins my license is in full force and effect. CITY W w/Na CLASS `� $ S . INO OF NO. License Number.rL�w+ /✓ Lic.Class SIZEFT D� STORIES / MILLIIES CHECK �AA e�� e'..��ttD M ONE Contractor ALl>1M� WI�+Gy Date a„i�//� NEW $ DESCRIPTION OF WORK 1 am exempt from the licensing requirements as I am a I'10 ADD licensed architect or a registered professional engineer ALTER FINAL acting in my professional capacity '(Section.. 7051, 1 DATE 4 l 7- �3 Business and Professions Code). ' USE OF REPAIR EXISTING BLDG. E/MfCE' DE By AL Lic.or Reg.No. _Date APPLICANT TEL. B^ OWNER-BUILDER DECLARATION (PRINT) E7 NO. I hereby affirm that I am exempt from the Contractor's License ^' ��, r� / Law for the following reason (Section 7031.5, Business and ADDRESS E U/ Professions Code): PRESENT BUILDING I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(SectionLOCALITY. 7044, Business and Professions Code). MOVING TEL. I, as owner of the property, am exclusively contracting CONTRACTOR NO, '41 5'6 A with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. # 0,0 0 0 0 1 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT 2 0 1 5 1.0 the performance of the work for which this permit is issued P.1. ' (Sec. 3097, Civ. C.), SIDE 0 0 1 5 1. P.1. Lender's Name 05,28-82 Lender's Address P.C. Fee$ Permit Fee A ' I certify that I have read this application and state that the Issuance Fee above information is correct. I agree to comply with all County Investigation Fee �® ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter Total Fee upon thoYe-mer% n d property for inspection purposes. 2, 8Z SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Ap li ni or Agent - Date ©s