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Home My Public Portal About8752 BURGHARDT RD_Building__ WORKERS'COMPENSATION DECLARATION hereby affirm that I have acerflfimte of consent to self APPLICATION FOR BUILDING PERMIT LS insure, or a certificate of Workers' Compensation Insurance, • or a certified copy thereof (Sec. 3800, Lab. C.) �-�(,�i COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.�1SR3 ompany h"e/T1On+ _rjemnr' � . 7�U} Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS -Tsz �VRCxIF glLs�1 Certified copy is filed with the county building inspec- BUILDING i tion department. ADDRESS SZ v NwR.QnLT G I—� LOCALITY bv�r TL"Ms�P%-L_ CA- NEAREST I Date Applicant CITY ZIP •I� O v CROSS ST. V�5�01' 'v'VVSCAT�L•- CERTIFICATE OF EXEMPTION FROM WORKERS' ASSESSOR SIZE OF LOT S q.7 %q� '� NOW ONLLOTS �— MAP BOOK PAGE PARCEL COMPENSATION INSURANCE (This section need not be completed if the permit is for one 47V USE ZONE AP hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MNO. / . TEL. SPECIAL } I certify that in The performance of the work for which this OWNER (pMS Vr_%'ro NO. CONDITIONS A. permit is issued, I sholl not employ any person in any manner // s,, L. DISTRICT GROUP TYPE FIRE PROCESSED BY O so as to become subject to the Workers'Compensation Laws. ADDRESS(ooiS MQ-s-cA rZ , CONST ZONE V �y n � CITY Tf IM 10 L-l: C-4 r ZIP _`LII Ci 0 •« O Date ' Applicant STATISTICAL CLASSIFICATION APT. CONDO. V NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL. ''v.r ,, W Exemption, you should become subject to the Workers' - ENGINEER NO. CLASS NO. DWELL. UNITS_ Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP N with comply with such provisions or this permit shall be g TEL deemed revoked. CONTRACTOR�S�.(O6•S WPA T NO.n'6).--54T BK. PG, VALIDATION _ LICENSED CONTRACTORS DECLARATION ''II LIC ry I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 101 . ORrRr�{15� S'fL?L NO.9.2 7-�3b VALUATION (commencing with Section 70DO)of Division 3 of the Business andLIC. ' .� _M Professions Code, and my license is in full force and effect. CITY wE� CAV)r4A CLASS� $ 00.4 2753!0 SZ F . STO OF F OF CHECK License Number Lic.Class SIZE STONO.RIES IF ONE Contractor 2 I n Date DESCRIPTION OF WORK NEW r o19 ADD I am exempt under Sec �Vsv.A N S'T'OFy, ALTER E] FINAL /� , •+ it �' 1( q 2 B.BP.C. foLJLjj eascm 28s1bc�.tci REPAIR CO] DATE4 �(O ( C .. j? Dates: USE DEMOI ❑ FINAL Les t 1 1 -83 LwT— EXISTITI NG BLDG. Y Sign atu APPUCAN7 TEL. O NER-BUILDER DEC RA ON PRIN7 NO. I hereby affirm at I am exempt from t ontractor's License Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT (` f E] 1,I, as owner of the property, or my employees with ADDRESS wages os 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. _ E] 1, N(T ; I, as owner of the property, am exclusively contracting 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 Q r1 li, I hereby affirm that there is a construction lending agency for FRONT p� pop the performance of the work for which this permit is issued P.I. O - •: o o ) .(Sec. 3097, Civ. C.). hI� j r ,, I SIDE Lender's Nam e�a'so �M a- q(S7 /V a ho/,s x P L 8t Lender's Address5c) Er 691 oudo• —Paso_ &ia_ P.C. Fee$ /rA Permit Fee I certifythat I have read this application and state that the 0 f PP 4P. Issuance Fee above information is correct. I agree to complywith all County Investiga on Fee s ordinances and State lawrelating to'building construction, Total Fee_ G and hereby authorize repres totives of this County to enter po he above- enT p per for inspection pure es. nature o Applicant or Agent l $^ ,/ G� SEE REVERSE FOR EXPLANATORY LANGUAGE t] L S SigD ®r • 11� V tba rric3'COMPENSATION DECLARATION "` APPLICATION FOR BUILDING PERMIT hereby affirm than I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec 3800, Lob. C.) ' - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. O FOR APPLICANT TO FILL N BUADDREILDSS ING Z �V Q� D+Q. ❑ Certified copy is filed with he county building inspec- BUILDING Q 76Z SqQqWA �T b� g,-4m-MC tion department. ADDRESS 7 r I �s Date Applicant CITY 1J ASWI s/ nEL ZIP r - LOCALITY .// u r CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT $ 4 res q.-Ir NOW ONNo. OF LOTI CRASS ST. USCA F GL S lay b{.oI Uc COMPENSATION INSURANCE (This section.need not be completed if the permit is for one TRACT BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL Ln� TEL ZONE MAP �� I certify that in the performance of the work for which this OWNER I� E NO.� ri NO. (21 permit is issued, I shall not employ any person in any manner _ SPECIAL at ADDRESS CONDITIONS so as too�become subject to the Workers' mp lotion Laws. � z 6 Q D � U 4 1779 Date-f.-{- —Applicarii CITY ,� ZIP ARCHITECT OR T NOTICE TO APPLICANT: If, aft on ng�this Cert cafe of Z.li DIST GROUP TYPE FIRE PRO SSED BY ENGINEER CONST. ZONE Exemption, you should become subject to the Workers' //yy Ls/1 ' / U Compensation provisions of the Labor Code, you must forth- ADDRESS "L5 n R �•' L/ a with comply with such provisions or this permit shall be TEL., STATISTICAL GLASSIFK TION APT. C DO. Tn deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION IC CLASS NO. Z DWELL UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP n Professions Code, and my license is in full force and effect. CITY / CLASS BK. PG. v VALIDATION SQ. FT - NO.OF NO.OF CHECK License Number Lic.Class SIZE STORIES Z FAMRIES I ONE ❑ VA TION 9 0 7 9.3.A Contractor � Dote DESCRIPTION OF WORK NEW rl "'fes -rib ADD # e e o ° 23 L exempt under Sec. ALTER ❑ ( e 3 2$ E� �. t� L RW 5 ❑ $ 3 pZ � O�,d� . o• F� ,./,SfEti' w P.C. far this reason i AIR 7 Date: EXISTIING BLDG. I MOL ❑ #).9.y,1e i,i � $ignature APPLICANT I TEL. FINAL ( ° ° ��j OWNER-BUILDER DECLARATION PRwT A NO. DATE ' D p q q _g I hereby affirm that I am exempt from the Contractor's License /, Low for the following reason (Section 7031.5, Business and ADDRESS 11 7 FIN Professions Code): PRESENT IF - By i ❑ I, as owner of the property, or my employees with BUILDING 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. I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS 'Y (" _l� �,1 ;1.Q 7 A tion 7044, Business and Professions Code). `f S_2 1:0 17�A CONSTRUCTION LENDING AGENCY SETT BACK QUIRED YARD HWY TOTAL ROP.SETBA NE WIDTH ' �s _ S ` `f V I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.I. (Sec. 3097, Civ. C.). SIDE 1. 1 0 �T-9�9J��=8 PA. Lender's Name LDMA Ref. E m Lender's Address D.C. Fee S c Permit Fee /!� certify that I have read this application and state that the t Issuance Fee i.J� LDMA P/C A above information is correct. I agree to comply with all County Investigotion Fee ' ordinances and State laws relating to building construction, Total Fee LDMA Perm. M 1 1 3.5A and hereby authorize representatives of this County to enter m up o the wove-mention d property fo inspection purposes. Tl # e o e e e 1 \ �l7 ( SEE REVERSE FOR EXPLANATORY LANGUAGE YR�Sd7 / Signature of Applicant or Agefit' Date t