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Home My Public Portal About8930 BROADWAY_Building__ WORKERS' COMPENSATION DECLARATION �L I hereby affirm that I havea certificate of consent to self APPLICATION FOR BUILDING PERMIT LI IS insure, or a certificate of Workers'Compensation Insurance, or a certi�fised copy thereME of(Sec. 3800, L b. . ompany Q COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy NoF .�C Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN ADDRESS J'0 f'TY Certified copy is filed with the county building inspec- BUILDING ILI lion depart ent. ADDRESS LOCALITY �(//�� NEAREST Date L Applicant O I y f'� CITV K, 'N ZIP CROSS ST. CERT ATE OF EXEMPTIO ROM WORKERS' NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT MAP BOOK PAGE PARCEL o (This section need not be completed if the permit is for one USE ZONE MAP /90 �97 hundred dollars($100)or less.) TRACT BLOCK LOT NO. NO. Q TEL.i�p/ (y / SPECIAL } I certify that in the performance of the work for which this OWNER th NO.1�a7"'1 id `�I CONDITIONS Z- I S permit is issued,I shall not employ any person in any manner DISTRICT GROUP TYPE FIRE PR ESSED BY O so as to become subject to the Workers'Compenss/A9J�.on Lows ADDRESS lrC E/ •J�n CONST. ZQ E - U Dofe� Applican •(Y CITY ZIP STATISTICAL CLASSIFICATION APT. CONDO. O NOTItE 1O APPLICANT: If, after m king this Certificate of ARCHITECT OR TEL. V Exemption, you should become subject to the Workers' ENGINEER / NO. CLASS NO. DWELL. UNITS ^ S Compensation provisions of the Labor Code, you must forth- ADDRESS (% SEWER MAP With comply with such provisions or this permit shall be Q� _ LI 2 TEL. ) VALIDATION deemed revoked. y� CONTRACTORS NO. BK./- PG, LICENSED CONTRACTORS DECLARATION LIC, p I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. ` Z VALUATION (commencing with Section 7OOD)of Division 3 of the Business and ' LIC. ). C954 Professions Code, and my license is in full force and effect. CITYZ_ 6 - Q 7/ CLASS $ 1700 - A , SQ. FT. NO.160F NO.OF 'CHECK License Number l Lic.Class SIZE STORIES FAMILIES ONE Q Q DESCRIPTION OF WORK NEW ❑ $ Contractor Date / e � / I am exempt under Sec. 1 !o� A n ADD ❑ ALTER ❑ FINAL �ry 11 B.BP.C. for this reason REPAIR ❑ DATE -T Date: USE OF DEMOL FINAL By EXISTING BLDG. By Signature APPLICANT TEL. 24 OWNER-BUILDER DECLARATION PRINT NO. I hereby affirm that I am exempt from the Contractor's License , T/ Law for the following reason (Section 7031.5, Business and ADDRESS q1, Professions Code): R EN 7 ❑ BUILDING ./ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and G the structure is not intended or offered for sole(Section LOCALITY r 2 7 137 A 7044, Business and Professions Code). MOVING TEL. e! e o 0 o e I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS / / 2 ° ° 6 05 0 tion 7044, Business and Professions Code). \V(O ' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ° ° 6 0.5 0 trREQUIRED TOTAL SETBACK FROM EXIST. ° 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. 100. 0'6 1 4 -8 j (Sec. 3097, Civ. C.). SIDE P.I. Lender's Name P.C. Fea b cJ V. - Lender's Address Permit Fee f 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 Fea ordinances and State lows relating to building construction, Total Fee d and her authorize rep entalives of this County to enter po a ab e- e QII property for inspection p rpo/se/s/(�_yJ� _�'x/V.�GLnt ��p�C�Dcl SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent D DEPARTMENT OF BUILDING AND SAFETY APPLICATION FOR PERMIT I COUNTY OF LOS ANGELES BUILDING WM. J. FOX. CHIEF ENGINEER FOR/ APPLILCA�NT TO FILL IN / FOR OFFICE USE ONLY BUILDING 1/pl V// A / � `' DISTRICT NO. PLAN CK.NO. PERMIT NO. ADDRESS O/ �/ f/) YeS. ,A A '2 ' LOCALITY �/,/{��I-////hn^.�LG^:")"�"�Y•I�I�Xw/Ai/�I�teI.//��/ / /1yA/y�,�g;�//1 A�G/�I . RECEIVLE/D/6SY' D,,ATE 7O�Fis AP P✓/PLCL. DAT/EI�/1.S 9UEs D N�AREST .CROSS STBUILDEOWNER `/"11 1! .Q ADD NO S MAIL LOCALITY ADKESS/449/y " K TEL- 0 EL. CRO HE BST y CITY /i �C ��Y�� / ND. /N// TA FIRE NO.OF 9 TYPE GROUPZ ARCHITECTOR TEL. " ZONE PLANS / ENGINEER NO. LOS. t� (� /. ADDRESS SETBACK LINE �.' V � /i O APPROVED f TEL. By DATE CONTRACTOR NO. USEAPPROVED ADDRESS ZONE �7 BY DATE LEGAL � � Y DESCRIPTION LOTNOZ�/(�� BLOCK // � //1 CORRECTIONS J� b TRACT GS/ - �.- ND.OF BLOCS. SIZE OF LOT NOW ON LOT AJ USE OF lli r J 4 �/` NO.OF ' EXISTING BLDG Y� f /FwM MES ROOMS DESCRIPTION OF WORK NEW ALTERATION ADDITION O REPAIR MOVING DEMOLISH SG.FT. NO.OF 2 SIZE ROOMS STORIES y WALLr COVERING A///- /(F I COVERING USE OF NEW I I BUILDING // 1/ r i 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION INSPECTOR DATE AND AGREE TO COMPLY WIT)4 ALL COUNTY ORDINANCES FORMS,MATERIALS AND STATE LAWSREGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, SIGNATURE OF- _ ^ BRACING.BOLTS !/,f Ar PERMITTE �-Q9;x,/ LATH, INT. AUTHORIZED A / LATH, EXT. 76A636A 9-40 V D66-3 6DM SETS $ P,C.$ PLASTER. INT. FEE PLASTER,EXT. VALUATION FEE 3/ �] FINAL (Af'�O�'✓t /> - S`-yy WORKERS' COMPENSATION DECLARATION hereby affirm that I have certificate of consent to self - APPLICATIONS .FOR .BUILDING PERMIT - c cl insure, or a certificate of Workers'Compensation Insurance, or o certified copy thereof (Sec. 3800, Lab. C.) COUNTY'OF LOS ANGELES BUILDINGFETY Policy No.. ' Company _ ❑ Certified copy is hereby furnished. V FOR APPLICANT.TO FILL IN BUILDING 2O r J E] Certified copy is filed with the county building inspec- ADDRESS BUILDING _ - tion department. ADDRESS _E Dote/. r Applicant 1 -�/ CITY I `� IP LOCALITY ER FICATE OF EXEMPTION FROM WORKERS' ` NO. 9LDGS. - NEAREST. COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need norbe completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR - hundred dollars ($100)or less.) �j MAP BOOK PAGE PARCEL f7 M (� '� �f I TEL. -7 USE ZONE MAP I fJ I certify that in the performance of the work for which this OWNER "'E' G l� LEAS TEL. /Q MA } permit is issued, I shall not employ any person in any manner ADDRESS ear E O N - C� SPECIAL - d so as to become subject to the Workers'Compensation Laws. CONDITIONS• O V Date Applicant - CITY m 6 ZIP - " - - 2 - ARCHITECT OR TEL. O NOTICE TO APPLICANT:'If, after making'this Certificate of ENGINEER �� NO. I DISTRICT- GROUP TYPE_ FIRE PROCESSED BY �rJ Exemption,' you should become subject to the Workers' O CONST.; ZONE Compensation provisions of the Labor Code, you must forth- W with comply with such provisions or this permit shall be ADDRESS - - I1TEC .O IFICA deemed revoked. CONTRACTOR H� C0_ACJNO. STATISTICAL CIASSIFIJCATION APT. ONDO. Z LICENSED CONTRACTORS DECLARATION ( LIC CLASS NO. DWELL. UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS �. d �. NO. Z' (commencing with Section 7000)of Division 3 of the Business and a LIC SEWER MAP Professions Code, and my license is in force and effect. CITY /— L R. Cc- (� CLASS BK. L VALIDATION ' Q Q SO. FT. _ NO. OF NO.OF _ CHECK License Number ` `?-' Lic.Closs SIZE STORIES FAMILIES �fEDtO�tL= CV,,4 cs� NEW —VALUATION .. 00, Contractor Date ( DESCRIPTION OF WORK ADD $ IF 2 QV �- ❑ am exempt under Sec. l 1l0 /� - ❑ - ALTER ❑ , B.BP.C. for this reason REPAIR $ - - - ate: USE OF DEMOL EXISTING BLDG. Signo 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 FIN "Professions Code): - PRESENT - - - - By - ❑ I, as owner of the property, or my employees with BUILDING ADDRESS wages as their sale compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY ' A. .. .�1 /7`j 7044, Business and Professions Code). MOVING TEL ❑ CONTRACTOR NO. IO 3�S AAq I, as owner of the property, am exclusively eject (Sec- tion with licensed Business and Pro construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY "- RSET BACKEQUIRED YARD HWY TOTAL ETBAPROPLINE WIDTH T r I hereby affirm that there is a construction lending agency for FRONT �i!�,UM j^ �(tk-J�{S't'rg the performance-of the work for which this permit is issued - P.L \/ --- - 6(150U1 (Sec. 3097, Civ. C.). SIDE Ill"" "'VVV"'�� P.L. Lender's Name - - - -- :12 3 O—8 5 LOMA Ref. If Lender's Address P.C. Fee$ - - Permit Fee -- . I certif that I have read this application and.state that the - Y PP -- Issuance Fee O[�D. CDMA P/C N above information is correct. I agree to comply with all County Investigation Fee �� g ordinances and State laws relating to building construction, Total Fee '-S and hereby authorize representatives of this County to enter [ CDMA Perm. q - m upon the 'd pF60erty for inspection purposes. � d / Q•(�(y/ � A i SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent - Date - - - -.--- - - _ Or I