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HomeMy Public PortalAbout9450 BROADWAY_Building__ WORKERS'COMPENSATION DECLARATION ` / / C , I hereby affirm that I have d,certificate of consent to self APPUCATMN FOR s M�dONG PUNT ' insure, or a certificateof Warkera" Compensation Insurance, ' or a certified copy thereof(Sec. 3800, Layy. C.) rr'vS. Gar+ Bi✓� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. 73'7 Company n 4^ •ri.iw-�iw/F'{� (Eal Certified copy is hereby turnishe, FOR APPLICANT TO FILL IN BUILDING -� Certified co is wi th aunt bui inspec ADDRESS 5� PY Y P BUILDING {�!/f'T Qf)nA�1� tion ep tment. t ADDRESS ^'/`I`U D iJOK� 0 LOCALITY 71-6 � /� NEAREST Date�Appl ica CITY ! L///��c .Ce ZIP CROSSST. RTIf CATE OF EXEMPTION F M WO E .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 O hundred dollars ($100)or less.) TRACT BLOCK LOT NO. NO. A4L py� TEL. y SPECIAL I certify that in the performance of the work for which this OWNERAfileT� G(7SJ/¢ys/7//(/ljplp.t3sc5- rS'ry �� CONDITIONS d permit is issued, I shall not employ any person in any manner �,// /� Qn,+ STRICT GROUP TYPE FIRE PROCESSED BY C) ADDRESS %64 t' . 4014DAI / CONST. ZONE V so as to become subject to the Workers'Compensation Laws. ✓ p � CITY /!i/'+ ' - e177 ZIP 1, v ' O Date Applicant STATISTICAL SSIFICATION CONDO. F NOTICE TO APPLICANT: If, after making this Certificate-of ARCHITEC70R/r.,� - TEL./�/� - Exemption, you. should become subject to the Workers' ENGINEER CJ UJIM-97b NO.�/l/n�L-�.tS.� CLASS NO.�LDWEU UNITS_ 6 Compensation provisions of.the Labor Code, you must forth- - ADDRESS 9 - .f1-L/�aA AVC-, /wW. #iJ, SEWER MAP y with comply with such Provisions or this permit shall be iEL. ` deemed revoked. ;: CONTRACTOR S/M1--- fi'S NO. BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION `1 '1{J `/�/ hereby affirm that am licensed under provisions of Chapter ADDRESS A'✓ ��T NCO✓ lW 773 V ILLATION' VVf, fIo FEP� •7'f'C�[! Dea- (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. CITY CLASS i. 7 SQ. NO. OF NO. OF CHECK D 1 + :TTL t fF'r License Number LlLiicc.Class/; SIZE STORIES FA�M^ILIES ONE /+ A Contract J 1 m `(Tate D DESCRIPTION OF WORK �/V6[C 14171i44 NEW $ / �D4 0 =2 9 1' 1 Ft DivcZ[iu� trJ A /)I� • ADD ❑ e o o e 23 ❑ I am exempt under Sec. // ALTER C] FINAL B.BP.C. for this reason C�Ann,w" C - REPAIR [:] DATE Date: USE OF .— FINALIJ' o o c`t 1 0.8 8�' EXISTING BLDG. DEMOL ❑ By CJ • Signature APPLPRIN T) CYJC� C.l 7AA/'Tlii' j,;�?S- 8` - - 0 6 1 6 -8 3 OWNER-BUILDER DECLARATION D _nr I hereby affirm that[am exempt from the Contractor's license �C Law for the following reason (Section.7031.5, Business and ADDRESS �7 - Professions Code): PRESENT0 / Q - I, as owner of the property, or my employees with BUILDING ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). - MOVING TEL. ;_ S I, as owner of the property, am exclusively contracting CONTRACTOR NO. ,f. 1 o e o 0 0 with licensed contractors to construct the project (Sec- ADDRESS '_ -tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM EXIST. - a c 6 3.2 5 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT D _ o�o V.5 O 2 S u the performance of the work for which this permit is issued P.I. (sec- 3097, civ..C.). - SIDE - , 0.9.0 8—8 3 Lender's Name -t Lender's Address P.C. Fee$ O - Permit Fee I certify that I have read this application and state that the Issuance Fee S s V above information is correct. I agree to comply with.all County Investigation Fee �� MS )nature ate laws relating to building construction, F(o ✓ Dize r esentatives of this County to enter Total.Fee U e one roperty f inspectittiion•pur osees�. - r! qg/ SEE REVERSE FOR EXPLANATORY LANGUAGE Applicant or A ant D le WORKERS' COMPENSATION DECLARATION err PPdO0Q�DOf� 001 [�MOdDD I�1C� pER�11 0r lJS' K ereb affirm that I have a certificate of consent to self •insure, or o certificate of Workers' Compensation Insurance, r or a certified copy thereof (Sec. 3800, Lab. C.) Policy Noe, t�:J"TSmpany fAl2At�0-1 COUNTY OF LOS ANGELES, BUILDING AND SAFETY Certified copy is hereby furnished: FOR APPLICANT TO FILL IN BUMING ( / , ADDRESS Certified copy is filed with the county building insec- BUILDING tion de riment. (�J 1/`$` ADDRESS S6 LOCALITY Date 3 t) SS Applicant Vim- CITY 1 ET�Pus ZIP CROSSSST. ,) / - CERTIFICATE OF EXEMPTION FROM WORKERS' I NO. OF BLDGS. ASSESSOR ' COMPENSATION INSURANCE SIZE OF LOT O NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one US ZpI NE TRACT hundred dollars ($100)or less.). TRABLOCK LOT NO. 1 NO. AE� (r' - 4EL. ./Z 6 SPECIAL y I certify that in the performance of the work for which this OWNER H1-slf= C—O wiTgtSIL� NO.2QS" CONDITIONS d permit is issued, I shall not employ any person in any manner p y� - DISTRICT .GROUP TYPE FIRE PROCE ED BY O so as to become subject to the Workers Compensation Laws, ADDRESS 1 T E 6S�v.'Q �� �-P CONST. ZONE CITY tv&4+_C- C "C y ZIP 3 O Date Applicant STATISTICAL CLASSIFICATION APT. CO (- NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. V 'Exemption, you should become subject to the Workers'' ENGINEER NO. CLASS NO. DWELL. UNITS_ 1 Compensation provisionsofthe Labor Code, you must forth- ADDRESS - SEWER MAP with comply with such provisions or this permit shall be Z deemed revoked CONTRACTOR `1 L.@Z '_, TEL f BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION t uC. r I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1 S�s�LJ icDli NO. ka VALUATION - (commencing with Section 7000)of Division 3 of the Business and tic t � ProfessionsCode, and my license is in full force and effect - CITY Iat���•(� CLASS $ Q� D F{il ` rig SO. FT. NO.OF NO. OF- '-CHECK License Number. (iY(,77L Lic Class Z IJ p� SIZE STORIES FAMILIES ONE $ Contractor Lt'L�� `-"�Ay� Date `� �I OJ DESCRIPTION OF WORK O NEW ❑ L. C - I am exempt under Sec. �T 'ADD ALTER ❑ FINAL B.BP.C. for this reason DATE ' REPAIR ❑ r� ,� 1 '69..0A Dai USE OF _ LU DEMOL ❑ FIN - - #•- e e e s 1 11 p� EXISTING BLDG. Signature-lr0_. APPLICANT TEL. BY r .( - - 4'9.88 OWNER-BUILDER DECLARATION PRINT NO.. - I hereby affirm that I am exempt from the Contractor's License 17 Law for the following'reason(Section 7031.5, Business and ADDRESS - D ��t ` • ••- 4 9.8 8 v Professions Code): - P O 3.1 4 8 S OBUILDING 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 sole(Section LOCALITY 7044, Business and Professions Code). - MOVING TEL. F . I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- 'ADDRESS 'tion 7044, Business and Professions Code). _ 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 Lender's Name Lender's Address RC. Fee$ ' Permit Fee F' I certify that I have read this application*and state that the - Issuance Fee J-0 above information is correct. I agree to comply with all County Investigation Fee g ordinances and State laws relating to building construction, C and hereby authorize representatives f this County to enter Total Fee - upo he above-menti rbperty f inspection urp es. t SEE REVERSE FOR EXPLANATORY LANGUAGE _ Signature of Applicant or Agent Date Os WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of.consent to self , //p�� O O C //E �Ip�Ip� gyp} O D O •�. .insure;or a certificate of Workers'Compenstion Insurance, or //'"�\ P �,`V- 4'11��®LI V LL O l�"�d D 0�1 G P C Ql�nl� a,certified copy thereof (5ec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Policy No. Company - I, Certified co is hereby furnished. BUILDING ❑ ,copy y - -FOR APPLICANT TO FILL IN • ADD s .� Certified copy is filed with the county building'inspec- BUILDING' 4i 4 4 tion department 'ADDRESS �y�� { LOCAL NEARE Dote Applicant CITY [i l4f�,I L�j C(•� ZIP _ CROSS ST ` CERTIFICATE'PE EXEMPTION FROM WORKERS' SIZE OF L TlQ7LCC'i lfY� NOW ON LOT. "I NO. OF BLDG5r MAP BOOK P E PARCEL ASSESSOR ' COMPENSATION INSURANCE ' (This section need not be completed if the permit Vis for one /� �L� USE ZO MAP TRAGI BLOCK LOT NO, NO. T hundred dollars ($100)or less.) i /� C05fAN Al SPECIAL - ' 06 certify that in the performance of the work for which this, OWNER ��/V V No.9- 77 CONDITIONS O DISTRICT GROUP TVP FIRE PROCESSED BY, permit is issued, I'sholl'not employ any person in any manner ,r` /' n✓J n�},�� / C_ V so as to become subject to the Workers'Compensation Laws. ADDRESS fY/VJ , r_V 'v CITY �G� C 'ZIP 6 �� 0 'Date Applicant STATISTIC AL CLASSIFICATION APT. CONDO. ARCHITECT O . TEL i t V' NOTICE TO APPLICANT: If, ofter makingthis Certificate of _ ,r� � 1 �.{�i!� �- / uL Exemption, you should become subject to the Workers ENGINEER �l �V./�/ql�T� NO. ,�i�� f'-� / CLASS NO.__!(f:2_/_DWELL. UNIT IL d 9 xf ,I bn;n N Compensation provisions of the Labor Code, you must forth- ADDRESS 3(G ' 5•-'A�' ���/ ACUr-'r'z •r/N� SEWER MAP Z with.comply with such provisions or this permit shall be deemed revoked. - - CONTRACTOR- NO. .BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION LIC.. Ehii©;JiFI C .tl] REUUIREB 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. r1;IJtiH Ci :�b:�1s rl PP R DV EO: Professions Code, and my license is in full force and effect. CITY CLASS S 0/ 000 FjNT1t GRADING APPROVED; SQ. FT/�Z� NO. OF NO.OF CHECK License Number Lic.Class - SIZE 'd 7 STORIEESS 11 FAMMIILIES ONE _ Cant rector Date DESCRIPTION OF WORK NEW g 0 1 am exempt from the licensing requirements as I am a �• 'L� S'� (�[.[= =���j�(l[, ADD ' licensed architect or'a registered professionol'engineer 7L-� ALTER FINAL . acting in my professional capacity (Section 7051, ic,//v1 0411 rly y�}�yj{' ( rPAIR 0 DATE Business and Professions Code). USE OF - 'DEMOL FINAL - EXISTING BLDG. B tic Or Reg. No. Date APPLICANT ,{//� �x TEL�,F G Y OWNER-BUILDER DECLARATION" - (PRINT) /T/y/ / NO.'"1�1�0�•S ; I hereby affirm that I am exempt from the Contractor's License Q o, Low for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT - ❑ - r� r,3J I, as owner of the property, or my employees with, BUILDING ADDRESS wages their sole compensation,owill o the work and the structure is not intended or offered for for sale(Section LOCALITY 7044, Business and Professions Code): - MOVIVINGG TEL ' t I, as owner of the property;am exclusively contracting CONTRACTOR NO. _ �� , c r with licensed contractors to construct the project (Sec ADDRESS_ tion 7044, Business and Professions Code). - REQUIRED TOTAL SETBACK FROM EXIST, CONSTRUCTION LENDING AGENCY SET BACK YARD NWV 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 (Sec. 3097, Civ. C). .. . SIDE - P.L. Lender's Name ' P.C. Fee$Cit�f Permit- Fee Lender's Address 1 w I certify that I have read this application and state that the Issuance Fee `t aabove information is correct. I agree to comply with all County Investigation.Fee $ ordinance and State laws relating to building construction, Total Fee - a and h re authorize representatives of this County to enter m upon he bove-menlio erty for ins'action purposes. < `T41 , S.Fill SEE REVERSE FOR EXPLANATORY LANGUAGE _ Signora re of A pll r Agent ate Os t COUNTY OF-LOS ANGELES _ R T BUILDING-AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESSr�' I hereby affirm that I have a certificate of consent to self insure, tA' �910L11� �, or a certificate of Workers' Compensation Insurance,or a certified / lJ ITIJ copy there (S 8�Q/0 Lab.C.). CITY m / n / ZIP 9 Rd I d Policy No. L�'Compan SIZE OF LOT NO OF BLDGS.NOW ON LOT L /[r V�' ❑ Certified copy is hereby furnished. - NEAREST GROSS ST. Certified copy is filed with tl county building inspection TRACT BLOCK -LOT NO. - d rtm nt�. - USE ZONE MAP NO. DateA7Z ..PPlica ASSESSOR MAP BOOK PAGE PARCEL - . . SPECIAL CONDITIONS ��Q O/ CERTIFICATE OF EXEMPTION FROM WORKERS' o R N L NO. ' WITHIN 1000 FT OF SCHOOL? VES NO COMPENSATION INSURANCE (This section need not be completed if the AD S p permit is for one hUrMfetl �GISTRI dollars($100)or less.) GROUP TYPE CONST. FIRE ZONE PROCESSED BY GI ZIP - I certify that h the.performance of the work for which this permit btimed, I shall not employ any person at any manner So a5 to ARCHITECT OR ENGINE? - TEL NO. > /V become subject t0 the Workers'Compensation Laws. _ STATISTICAL CLASSIFICATION ' ' APT CONDO Date Applicant ADDRESS - CLASS N0, DWELL UNITS NOTICE TO APPLICANT. If, after making this Certificate OfREQUIRED TOTAL SETBACK FROM EXIST Exemption, you should become Subject to the Workers' CO ALTONO // SET BACK YARD HWV PROP USE WIDTH T L Compensation provisions of the Labor Code, you must forthwith —63 FRONT comply with such provisions or this permit shall be deemed revoked. ADJ11 4 Vj ` LIC.NO. P L LICENSED CONTRACTORS DECLARATIONSIDE Our uc.c sb P L - I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO. E NO.OF ST RIES NO.OF FAMN �" Professions Cc ' and my Ii se is In full force d effect. NEW ❑ BK PG D - d License Nu Lie.Class DES R TION OF WORKr _ I, ADD VALUATION Q ContractorDate (%� Jj_, ALTER $ `7 cc ❑ 1 am exempt under Sec. REPAIR ❑ $ cc BBPC.for this reason P 3 DEMOL ❑ LDMA P/C x 0 Date[ USE OF EX G URM ❑ - __ a EL 33ft� _M 4 Signature APP CANT( T TEL LA0. LOMA Perm♦ ±a z ❑ 1, as owner of the property, or my employees with-wages as T 2 their.sole compensation, will do the work and the structure is A S5 0 Ar-P _g F KIL.I =F Net intended or offered for sale (Section 7044, Business and FINAL DATE G fir, PfOfeSSi005 Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL – S O ��IJr _ , OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE r ❑ I, as owner O( the property, am eXC1U51Ve1y COOIraCtlOg with AMOUNTS SPEC�I�FIE(qf ON THE HAZARDOUS MATERIALS INFORMATION GLADE° FINAL BY 1 y, ON J licensed contractors to construct the project (Section 7044, ves❑ Nl)�•,L_/ n�i- BU51p25a and PfOfeS510O5 Code.)- , WILL THE INTENT 09 ED USE OF THE BUIDIUNG BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH r-C, CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT(SCAOI SEE PERMITTING CHECKUST FOR �C: 2�.'J=�(T GUIDELINES CHECK I hereby affirm that there is a construction lending agency for YES 1:1 NO t H;-}j'{U� the performance Of the work for which this permit is lSSUed(SBC. JTL ADTHEAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING m 3097,CIV.C.) ST.I UNDERSTAND MY REWIRE MENTS UNDER THE LOS NGELES COUNTY CODE, CHAPTER 2.2U 5 TIONS 2.20.100 THflO H 22p RNING HAZARDOUSLenders Name L R POm UNG A P H FRO TH cLenders Address JA AceRT nni j7 i i•,7 '4,V.: o I certify that I have read this application and state under penalty ' prlurY that the above information is correct.I agree to comply PC FEE PER FEE n all county ordinances and State laws relating to bUiltling 'Jf/ m ISSUANCE FEEeltWpriny o mentioned property for inspecti purposes. !L/._ a INVESTIGATION FEE TOTAL FEE Urew,�m rogium o.M�1 w� SEE REVERSE FOR EXPLANATORY LANGUAGE