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Home My Public Portal About9331 BROADWAY_Building__ 'rRKERS' COMPENSA:IQN DECLARATION , ar a•,irm4that have certificate-of cmuent to selfT=WlSertrAcNjgaf Workeri"Compensotion Insurance, fj/& PPLOCAMO N FOR—Bv OLDON G PERNh L.) or,y certified copy thereof (Sac.3800, Lab. C.) - _ �OUNT,Y OF LOS ANGELES BUILDING AND SAFETY Policy No. Company _ Ct Cepjfind-cofjCA y is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ❑ ADDRESS Certified copy is filed with the county building inspec- BUILDING pp �sVtion deportment. J' ADDRESS J�� `• ,(J �J�E L i Date _/p7 APPIico PYL > CITYEll/_-[E C/p7 ZIP LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT X SO •I NOW ON LOTNO.OF S CROSS SST. LCC f •P� COMPENSATION INSURANCE (This section need not be completed if the permit is for,one TRACT la?t1119 BLOCK LOT NO. �� ASSESSOR - hundred dollars(EI00)or less.); j TEQMAP BOOK PAGE PARCEL L.� E - L�-/i//�l/f�✓3'CiE 3/ USE N . • I'certify that'in the pe'rformonce of the work for which this OWNER NMAP NO. permit is issued, I Shall not employ any person in any manner . ADDRESS E _ ' SPECIAL (}L' so as to become subject to the Workers'Compenss�aolti/on Low � /g-o - CONDITIONS 0 Date 7��07 A IicaM/""' �/%kIG+^✓ CITY ZIP - PP ARCHITECT OR iEl. 71 DISTRICT GROUP TYPE FIRE PR ESSED BY 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO 7 J"�ll' �C Exemption, you should,become subject to •thee Workers D - CONST. / ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS �• UJ with comply with such provisions or,.this permit sholl be EL deemed revoked. TEL. -J,,qy STATISTICAL CIASSIFICATION APT. 9NDO. In CONTRACTOR NOJ�/'/7jI /1 / / Z LICENSED CONTRACTORS DECLARATION . - - LIC C1A55 NO. DWELL, UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ?'/ � yQlir� NO. (commencing with Section 7000)of Division 3 of the Business and. - LIC SEWER MAP ' Professions Code, and my license is in full force and effect. CITY CLASS BK / VALIDATION IN License Number Lic.Class SIOZEFT��IXJr ST ORIIES FAMILIESCO E� VALUATION 7 5 1. Contractor Date DESCRIPTION OF WORK f�4��T/ NEW ❑ s —q�ADD # e I am exempt under Sec. �Wo, ALTER ❑ U Ie44 4 4 Q 4B.BP.C. for this reason •�� moi. REPAIR 9Date: USE Of /1DEMOI / 7.22"87EXISTING BLDG. Signature - APPLICANT .TEL. OWNER-BUILDER DECLARATION PRINTgGE �i/1•y/i.JJ.u.� NO✓°�9�7 '/ FINAL I hereby affirm that I am exempt from the Contractor's License ADDRESS l�-3/ G /,/�i�/llyt Low for the following reason (Section 7031.5, Business and FINAL i 8 b Q 0 A Professions Code): By • • ,•I, 01 I, as owner of the property, or my employeis 0 es with ADDRESS ,~`�' a'fe a •/' •q7 wages as structure sola compensation,will f o the work and LOCALITY the structure is not intended or offered for sale(Section v 7044, Business and Professions Code). MOVING TEL I I, as owner of the property, am exclusively contracting NO. cting with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS ` t• t t Y C 8% •�. REQUIRED TOTAL SETBACK LINE CONSTRUCTION LENDING AGENCY SET BACK YARD• HWY PROP. LINE WIDTH - � � : H275 e e 1 hereby affirm that there is a construction lending agency for FRONT - I ' S 5 2 7 5 the-performance of the work-for which this permit is issued P1, 555 2756 - (Sec. 3097, Civ. C.). SIDE P.I. 1215-87 Lender's Name ( �/s ( LDMA R.I. M P.C. Fee E t Permit Fee P F al.� Lender's Address /� - I certify that I have read this application.and state that the / Issuance Fae LDMA P/C If o above information is correct. I agree to comply with all County Investigation Fee S n q ordinances and State lows relating to building construction, Total Fea •.J ^ / LDMA Perm. p R and hereby authorize representatives of this County to enter upon th7 ( n/ti,/o;prperty r inspectionpur�p�o{/se�s,. /AVJ '1SEE REVERSE FOiI EXPLANAfO0.Y LANGUAGE Signature f ApplicaDate - - - - COUNTY'OF LOS ANGELESr'` .�,. BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION BUILDING AODREFOR APPLICANT TO FILL IN BUILDING A Fes% S$ij� J ` I hereby affirm that I have a certificate of consent to self insure. !%% _ or a certificate of Workers'Compensation Insurance,or a certified ' copy thereof(Sec.3800,Lab. C.) .. .. CITY ZIP Policy No. Company (Q LOCALITY�j'' u SIZE OF LOT - NO.OF BLESS.NOW ON LOT /L/% '��•�'l ❑ Ceitifietl Copy is hereby furnished. NEAREST ROSS ST. ❑ Certified copy i5 filed with the county building inspection TRACT BLOCK LOT NO. department. USE ZONE MAP NOF Date ApplicantASSES�^yp:(�MAP K PAGE PARCEL I V �,7 SPECIAL CONDITIONS -- CERTIFICATE OF EXEMPTION FROM WORKERS' WNER n/f�E o_q j - COMPENSATION INSURANCE !! WITHIN 1000 FT.of SCHOOL? YES No This section need not ADDRE be completed if the permit is for one hundred dollars($700)or less.) �� DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY "' _ I certify that CITY 21P the performance of the work for which this permit � PiFGi - 9�7�J �0 is issued, Lshall not employ,any person in any manner so as to 0 f'/ ✓ become Subjectt0 the Workers Compensation Laws. ARCHITECT OR ENGINEE TEL NO. STATISTICAL C�LA�SSIF�ICATION APT- CONDO J Date Applicant ADDRESS CLASS NO. �L DWELL UNITS NOTICE TO APPLICANT If, after making this Certificate of REQUIRED E .TOTAL SETBACK FROM EXIST T Exemption, you should become subject t0 the Workers' CONTRACTOR ) TEL N0. 5BACK NIT YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRO comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION SIDE CITY UC.CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)Of Division 3 of the Business and SQ S E NO.OFTORIES NO.OF AMILIES Professions Code,and my license is in full force and effect. �. NEW ❑ BK PG D EL License Number Lic.Class - DE RIPTION OFG RK r_ ADD ❑ VALUATION Contractor Date ALTER $ 000• PO O ElI am exempt under Sec. REPAIR ❑ $ l- B.SP.C.for this reason DEMOL ❑ COMA PrC♦ _ W Date: USE OF EXISTING BLDG. URM ❑ - - d co Signature AP�LI N/T/vM..�T�L TFC jJ� !J l tDNA Perm M k Z I, as owner of rhe,property, or my employees with wages as 2 L 'r^'�� .�.� c.�O/%T// Z ACT'l ,a - their sole compensation, will do the work and the structure is ADDRES O_ __ _ _ not intended Or offered,for sale (Section 7044, Business and �� FINAL DATE - I}4 �_ftA a _ Professions Code.) j 1 ITEM'. WILL THE APPLICANT OR FUTURE!!DU OCCUPANT- NDLE A HAZARDOUS MATERIAL DR.A NTSMIXTURE CONTAINING A A2ARC HAZARDOUS MATERIALLS EQUAL TO OR GREATER THAN THE❑ I, en owner of the property, am exclusively contracting 44, AMOUNTS SPECIFIED ON THE HAZARNUB MATERIALS INFORMATION GUIDE? FINAL BY f C licensed contractors to construct the project (Section 7044, ' `J ICITHL 2.3-4 ® 4--' Business and Professions Code.) ves❑ No 8' LIF'_ _ - `WLL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �.(iCl�'\ i•z'4,rT I -OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH uL _ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT BCAOMDI SEE PERMITTING CHECKLIST FOR -H'l'a- GUIDELINES '1- h •)�= I hereby affirm that there is a construction lending agency for YES❑ No,El the performance of the Work for which this permit is issued(Sec. p 3097.Civ.(i,) IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING { CHECKLIST,I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, _)_II TIRE 2,CHAPTER 280 SECTIONS 2^ ICO THR.9UGH 2.20 CONCERNING HAZARDOUS Lender's Name WUERI PORTING AN AININC PERMIT HE SCAOMD o 7i= Lender's Address ` 1. r11�11.1.1i O oa A.M4T - - 0 1 certify that I have read this application and state under penalty o P.G.FEE PERMIT FEE of perjury that the above information is correct.I agree to comply $ with all county ordinances and State laws relating to building construction, and hereby authorize representatives of this County - - ISSUANCE FEE / , /O ro two e�nte/r ppon the above-me�nh/pried pr erty inspection purpose-s./ (O r�/ L eaFi n.�w � /y' X -1;- - INVESTIGATION FEE TOTAL FEE q SEE REVERSE FOR EXPLANATORY LANGUAGE