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HomeMy Public PortalAbout5635 CAMBURY AVE_Building__ a� ! WbRKERS' COMPENSATION DECLARATION �I,hereby affirm that have a certificate of consent to self �Pp��C�AMON FOR 'BUMMII VO' PISUOIIV 7 insure, or a certificate of Workers' Compensation Insurance, -+ or a,gertifiecl copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES ' BUILDING AND SAFETY- Policy No. Company' ❑ •Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN ADDRESS `�' G -� U .❑_ Certified copy is filed with the county building inspec- BUILDIN .�'�6 3� �if��L'>'g In tel/�i tion department. ^ /.� /� per, -sDate Applicant-• CITY' L-6 G17- ZIP /d o LOCALITY ' ,, NO. OF BLDGS... NEAREST - + CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT U 6Z :3 S NOW ON LOT CROSS ST. I COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK I LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL ff1 USE ZONE MAP q OWNER CHILI c!4dA1 [/VU NO.I J`rD // MAINC1 ' I'certify that in the performance of,the,.work for which this _ SPECIAL - > permit is,issued, I shall not employ any person in any manner ADDRESS P'-7 W wL5Ti41l �r� �� CONDITIONS Ou Q l`x/Ys�o as to beco a subject to the Workers'Com tiomlaws. - - - U N ARCH11 - CITY ���" ZIP ate D Appica 4 ARCHITECT OR TEL' DISTRICT GROUP TYPE FIRE PROCESSED BY O OTICE T APPLCANT: If, after.makin this ertificate o ENGINEER NO. CONST. ZONE Exemption, you should become subje t to the, Workers' - w Compensation provisions of the Labor Code, you must forth- ADDRESS . with comply.with such provisions or this permit shall be TEL STATISTICAL CIA551FICATION APT. CONDO. Z deemed revoked. _ CONTRACTOR NO/ ' t LICENSED CONTRACTORS DECLARATION qCLASS NO I DWELL UNITS_ 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. LIC SEWER MAP (commencing with Section 7000)of Division 3 of the Business CITY CLASS and Professions Code,and my license is in full force and effect. BK PG VALIDATION 5IZ FTC L STONO.RIES OF NO.Of CHECK NI, License Number - Lic. Class SIZE /(/.7S STORIES FAMILIES ONE - ' - •- - VALUATION � r.,,x•n DESCRIPTION OF WORK • NEW .Contractor Date ADD t .J$ ❑1 a exempt under'Sea. - "� D ` ALTER . B.&P.C. for this reason igs�'Pi�'bPOM c 76 REPAIR ❑ $ . . ' Date: USE OF. -. - - - REPAIR ❑ EXISTING BLDG. �1 '1 _ Signature - APPLICANT�`�N G�v NNocei8�a6- �G FINAL C - OWNER-BUILDER DECLARATION - �/ DATE i I herebyaffirm that I am exempt from the Contractor's License 11��yy '(, l f!'T/ -' ' "Law for the following reason (Section 7031.5, Business and ADtR S$"' wtST �--C p�• FINAL, Pro ess ions Code): - PRESENT - - _ t' By I, as owner of the property, or my employees with BUILDING ADDRESS _ ALLT.T •- wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section' LOCALITY CONTRACTOR NO. 1 ITEMS D 337 ' 77,011 7044, Business and Professions Code.) MOVING: - TEL. t ❑ I,as owner of the property,am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESSL •TOTAL . 77.00 tion 7044, Business and Professions Code.) . -IST. _ _ CONSTRUCTION LENDING AGENCY SETT REQUIRED YARD HWV TOTALPROPLINEFROM' WIDTFI• t. �•NLCYc 77.00 I hereby affirm that there is a construction lending agency.for FRONT -_ _ _ - GE - - ..01I the performance of the work for which this.permit is issued P.L .. (Sec. 3097, Civ. C.). - So Lender's Nome 0000-0001 6/30/89 _ LDMA Ref. q P.C. Fee S Permit Fee D 4'� 1 +� _ :v(f Lender's Address _ - , o I certify that I have read this application and state that the Issuance Fee J • LDMA P/C# above information is correct. I agree to comply with all County . Investigation Fee ff^^ ordinances and State laws relating to building'construction, Total Fee V LDMA Perm. p Abybauthorileprespernlpotvesfoorflhis iCounty to enter oveed ot inspection purposes. SEE REVERSE FOREXPLANATORY LANGUAGE N a of Applicant or a Date WORKERS'COMPENSATION DECLARATION i - y - I hereby affirm that I have a certificate of conseriVto self /�p� I��lj �(/�l �Ip�Ip� I��y �1 �Ipglp�l/�m D �p}�r�y��j _� insure, or a certificate,of Workers' Compensation Insurance, - - /r1 P UCCA �•O11 V FOR, 13 D 11 G, PLSU MrT or a certified copy thereof (Ser 3800; Lab C.) COUNTY OF LOS ANGELES - BUILDING AND SAFETY " Policy No. Company ��n�-F h ❑ Certified copy*is hereby furnished FOR APPLICANT TO FILL IN BUILDING _. !�> ADDRESS' _�- . - (AI2 ® Certified copy is filed'with.the county building inspec-" BUILDING 5b7 ��.� NNS tion deportment. - ADDRESS G / /(e",�' _ �V .Date' Applicant i* CITY - %}•r ZIP LOCALITY NO. OF BLDGS. _ NEAREST-• -- ' CERTIFICATE OF EXEMPTION-FROM WORKERS' - SIZE OF LOT' - NOW ON LOT CROSS ST. ' COMPENSATION INSURANCE. ASSESSOR _ - r(This section need not be completed if.the-perrtiit is.for one - - TRACT BLOCK LOT NO MAP BOOK PAGE PARCEL hundred dollars ($100)'x; less.) _ TEL. `- OWNER' M S p; - USE:ZONE MAP S' 7 - I certify that-in.the performance of the work for which this - NO. P employ Y-P Y 1 ) _ SPECIAL . Fermi is issued;I shall not em Io an person In an manner ADDRESS - �'�/ •2 CONDITIONS O so as to become subject tothe Workers'Compensation.Laws. „ r,� _ ,-, _. U • - _ CITV - ZIP. Date Applicant. - ARCHITECTOR TEL. -DISTRICT "GROUP TYPE FIRE PR ESSED�BY O ,,,NOTICE,TO APPLICANT: If, after making this Certificate of - ENGINEER - - NO. - CON ZONE m Exepfion, you should.become,subject to the. Workers' - 9 U Compensation,provisions of the Labor Code,,you,must forth - ADDRESS with comply with such provisions or.this permit shell be • - L. - STATISTICAL CLASSIFICATION ./ CONDO. deemed revoked CONTRACTOR '`.� O. J° __ Z LICENSED,CONTRACTORS DECLARATION LNS Z CW55 NO. LDwEL1. ONIT$ - I hereby affirm that I om licensed under provisions of Chapter 9 _ ADDRESS 0 -.1.1 h NO. Y I D't"L LIC. SEWER MAP (commencing with Section 7000)Of Division 3 of the Business H q.r'�I g..,j C�� t2 and Professions Code and my license is in full force and effect. CITY vi 1 V gK N .� , VALIDATION 1 , SQ. FT. NO. OF NO. OF CHECK � License Number_ eq 812- Lic. Class SIZE - - STORIES - FAMILIES ONE _ •s�„ yI VALUATION ' t �- - VALUA O Contractorf VLOn�hll�' o4i '.Ijr �at'e � elsil DESCRIPTION OF WORK. NEW ❑_ $ __ - -_ ,DM - 1 '� q ADD- 1:1 _ 1-5 1' ❑I am exempt under Sec ,ALTER - - - i - B:BP.C. for this reason - REPAIR ❑ f .. . .. -. - Dote: - USE OF .. „ .. _. . EXISTING BLDG. 'DEMOL Signature- - - APPLICANT _ TEL ... .- FI NA , .OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License DATE ',' - - . Low.for the following reason (Section.7031.5, Business and ADDRESS Professions Cade): _ _ . - -_ P RESENT - -B - -} ❑ LDING I, as owner of the property; or my employees with - wagesastheirsolecompensation,will do the workand ••••the structure is not intended or offered for sale(Sction7044;Business and Professions'Code ) - - • - -- -- TEL.1, as owner of the property, am exclusively contractingEl ORNO. Ifwith licensed contractors to construct the.project(Sec- - - _Fi% tion 7044, Business and Professions Code.) _ - - 1, rtl i5U m _+ REQUIRED TOTAL SETBACK'ROM _ CONSTRUCTIONLENDINGAGENCY SET BACK YARD HWv PROP. LINE WIDTH f`��'! .: _ ifi' • I.f, hereby affirm-thaflhere is a construction lending agency for FRONT _ - .the performance;of the work.for which this permit,is':issue, P.L' (Sec.,3097, Civ. C.).. 'SIDE Lender's Name. _ - ' LL LDNW.Ref N �.Itt-� M1 C� r is :� a ` _ PC Fee$ , Permit Fee - _ Lender's Address - - - - - ns r fa. I \ C l ' I certify that+I have rend this applicationand'state that the - - Issuance Fee LDMA P/C# g' above inform ton is correct. gree to comply with all{aunty Investigation Fee._- - t' -5t."`\ �.'-.:r. _ `��. �'�•'`• t- 0 di c n State laws ntain tiv s building construction, Tocol Fee z" LOMA Perm. N ' 0' d he a au horize re entatives of this County.to enter upon t e ov -mentione propcerty for inspecptio rpos a - . .SEE REVERSE FOR EXPLANATORY LANGUAGE f Signature of Applicant or Agent ' p t - - -- WORKERS' COMPENSATION DECLARATION ' 01,thdd�cffirm that I have"a certificate of consenj to self G �.•: O O //I��\y�I �p`pl�� �I�p �Fr^�l OR �Ip�1p�(/��. PERMIT 1��y�(ry�p/L7� �aSure, or a certificate of Workers' Compensation Insurance, •,? � APP-UC � u OOa �, .-FOR UU��D�NG PIS U�l11v IT or 4ertified copy thereof (Sec. 3800,11L�ab. C- � © ��,� � COUNTY;OF LOS ANGELES � BUILDING AND SAFETY - Policy No. Company S?hrAa "�. . .-. .. BUILDING 5/_3/_-'. LAA -Certified copy is hereby furnished. . 'FOR APPLICANT TO FILL IN ADDRESS LO ✓ T Certified copy is filed with the county building inspec- \ BUaNG / tion department. ADDREDISS /J f CITY' FIU LE ZIP LOCALITY Pi C Date Appli<a n� NO.OF BLDGS. 1 �fj,, _ NOW ON LOT NEAREST �O _ C�. l ERTIFICCO OF EXEMPTION FROM WORKERS' SIZE OF LOT Q CROSS ST. t I COMPENSATION INSURANCE {� C(� ASSESSOR _ (This section need not be completed if the permit'is for one TRACY `J�,- J l BLOCK LOT NO. MAP BOOK ' PAGE PARCEL hundred dollars ($100)or less.) ,., I _ TEL ••-� OWNER -rY.7W S(4 NO. 1FfF - USE ZONE MAP 1 ZLU I certify that in the performance of'the.work for which this - �. - NO. permit is'issued, I shall not employ any person in any manner ADDRESS - ;q/J•f` y., SPECIAL - d R so as to become subject to the Workers;Compensation Laws. CONDITIONS. - O • •• ary -b!9 ZIP V Date ' - Applicant - ARCHITECT OR TEL. tX •NOTICE TO APPLICANT: If, after making this Certificate of -- ENGINEER... NO DISTRICT GROUP TYPE FIRE, PROCESSED BY'" Q CONSSr— ZONE F- Exemption, you should become, subject. to the'Workers' �0. 3, \ / 3 V VV ��L w Compensation provisionsofthe labor Code, you must forth- . - ADDRESS - 2 with comply with such provisions or this permit-shall be «_ 7EL. N W�ys1h_JS rN EZ13 SIS)4Y-(fq, STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked.' CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. . CLASS No. O I DWELL. UNI75 T hereby affirm that am licensed under provisions of Chapter 9 ADDRESS I•Po7 S. 31(0 :P4 NO. b uQd w Z� ;(commencing with Section 7000)of Division 3 of.the Business r1 •-7 LIC. SEWER MAP and Professions Cade;and my license is in full force and effect. _ CITY A"r�a�ll,/ t(A �Q/ L CLA55 BK. PG. 2'7 VALIDATION (� SO. FT. NO. OF NO. OF CHECK I - License Number Y1d `t' Lic.-Class SIZE 2 36 0 STORIES IFAMILIES ONE ''__((ll `` VALUATION _ Contractor V`m7.1�1'k IA) F49 pate '3/N '1 DESCRIPTION OF WORK i( 1 ' - 1 r ��D 'Gcz�= D /IUfLD 7 rv� ADD ❑ Eli am exempt under Sec u _ - ALTER ❑ "� '` B.BP.C. for this reason - ` H04,S� REPAIR ❑ s a ' Date: USE OF. p r s. .� HL a EXISTING BLDG. k"I D 'f 1 0'� DEMOL ❑ _ t !(I7_ .,,f. r 75 ,S•-TLI Signature APPLICANT f7' (A/ C�h. TEL FINAL OWNER-BUILDER DECLARATION (PRINT) (- NO. '13DATE Z 11 CM` I hereby affirm that am exempt from the Contractor's License � 71,rt 3 7 rn Law for the following reason (Section 7031.5, Busines's and ADDRESS S. /ID af' FINAL ILITHL {7r,� ® � Professions Code): - PRESENT - - ey •I - r--V 704.71-1 ❑ I, as owner of theproperty; or m employees with BUILDING 1_HC IG z : YADDRESS J wages as their sole compensation,will do the work and - - - � �, t' 1,CHAhc�E the structure is not intended or offered for sale(Section LOCAUTY t 7044, Business and Professions Code.) - MOVING TEL. CONTRACTOR NO. ❑ I, as owner of the ro ert ,.om exdusivel contracting t 7 !•-� P P Y v g J ITllill}-IlQi=1 � 1•G>' with licensed contractors to construct the project (Sec- - )( ADDRESS tion 7044, Business and Professions.Code:) J ; t ( J t r i 1"1 ((�i 1 flf11 i:r CONSTRUCTION LENDING AGENCY ^ REQUIRED YARD HWV TOTAL SETBACK FROM EXIST. SET.BACK PROP. LINE WIDTH. fl ,•. hereby affirm that there is a construction lending agency for FRONT q� t t ( the performance of the work for which this.permit is issued 'P.L.' 201101 00 (Sec. 3097; Civ. C.). - SIDE Lender's Name "4 ' (O- LDMA Ref. .C. S -{ �7• ' � Lender's Address PFee Permit Fee p , o7 Lt,� ' IY- I certify that'[ have read this application and state that the Issuance Fee / J ,.� Q LDMA�RiC q 8 above info m on is correct. I agree to comply with all County Invesligotion Feec ordinanc n State low relating to building construction, Total Fee 9 S 7 ' LDMA Per O lYFA an er a horize r r sentatives of this Coun y to enter on t a -men ton d property for inspec' purp es. O Y• E O D• ' 1 SEE REVERSE FOR EXPLANATORY LANGUAGE _ CO p V� VV ignaNre of Applicant or Agent - Dota G! `O Cl A S.fl WORKERS' COMPENSATION DECLARATION .� I hereby affirm that I have a certificate of consent to selfA O O 'C //OM"' �p� F RD D �FI��Ip�11/♦�q D �l�}�r��y�//��� insure, or a certificate of Workers' Compensation Insurance, ), /r1I�P.���yW��OU V -FOR ����DD �U.V V .P LS U�lI1 C/U�� t or a certified copy thereof (Sec. 3800�, Lab.C.) - COUNTY OF LOS ANGELES BUILDING AND SAFETY , . .Policy_No.—. Company >T%I i '4�-4 - BUILDING ❑ Certified copy, is hereby furnished. FOR APPLICANT'TO FILL 1N ADDRESS G rn r � WJ Certified copy is filed with the.cou building inspec- - - BUILDING - tio department. i- ADDRESS S vnr•q f�jr , CITY'-_ �/`� L� L/ / "ZIP fes' LOCALITY'" _ Date V _ Applicant NO. OF BLDGS. NEAREST - CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT. ' g'• NOW ON LOT .. CROSS 57. L.. COMPENSATION INSURANCE - ASSESSOR - t (This section need not be completed if the permit is for one TRACT' ^ BLOCK - LOT NO. '- - hundred dollars ($100) or less:) MAP BOOK - PAGE PARCEL' OWNER. . _ C. U NO. ( USE ZONE MAP - - ' , � NO. - I certify that in the performance of:the work for which this - q• 1 p _ permit is issued, I shall not employ any person in any manner ADDRESS 1_)7. W. W pp SPECIAL CONDITIONS a- so as to become subject,to the Workers'Compensation Laws. O -- CITY J 6A -t' 06 .ZIP r VU Date Applicant '' ARCHITECT OR TEL. DISTRICT. UP TYPE FIRE PROC SED BY Q NOTICE' TO APPLICANT: If, after making this Certificate of ENGINEER NO. CON FIRE r Exemption, you should become subject to the Workers' 14 Compensation provisions of the Labor Code, you must forth- ADDRESS rn r - d with comply with such provisions or this permit shall be ♦ TEL j o - STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR A706-ti/A) (. AL1 NO. L moi/ J ._ z LICENSED CONTRACTORS DECLARATION • LIC CLASS NO. Dwt:u. UNITS_ I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS . (o• L.1 _ Li A R7J0 '�r, NO. 4.90 *-/L SEWER MAP (commencing with Section 7000)of,Division 3 of.the Business UC. and Professions Code,and my license is in full force and effect. CITY L Gi'/ CLASS p�r� $Q. FT. f NO. OF NO. OF CHECK BK' PG. 27, VALIDATION License Number V/)- 1` L- Lic Class SIZE - STORIES FAMILIES ( ONE ACCT.4 " / 1�,('` / / VALUATION f� ContractorLLYI/�h 17 //y Date' `• 7 J DESCRIPTION OF WORK •fJ (()/�/ NEW ❑ $ TION 3307 33.6 ❑1 am exempt under Sec. ADD ❑ D ALTER 1 ITEMS - - _ 11 _ . B.BP.C. for this reason - S TOTAL J,3 e69 REPAIR ❑ L1 V .. Date: USE OF BLDG. / - . . DEMOL.❑. . .ruErV,. .. . .33.69 EXIAPPLICANT. �? 111 Signature - PRINT ! /A� TIO C FINAL MANGE .0[I 'OWNER-BUILDER DECLARATION ( I ' DATE ' I hereby affirm that I am exempt from the Contractor's License 'T 5 >. - - ADDRESS )-f J W• C P D?!D 4tdff ON 1" .LA Low for the following reason(Sedion`7031.5, Business and � FINAL . 1,A �T Professions Code): PRESENT _ . . .. By 0000-GOOI - _-1/17/90 ❑ I, as owner of theproperty, or'm :em to eeswith BUILDING S<f�'� _ Y t Y ADDRESS 8313 1 AM11:v wages ct their sole compensation,will do the work and - - - - - D - the structure is not intended or offered for sole(Section LOCALITY 7044, Business and Professions Code.) MOVING _ TEL. • . . - - CONTRACTOR❑ NO.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. p _ CONSTRUCTION LENDING AGENCY SET BACK YARD " HWV PROP. LINE WIDiH 1Q\ 1,V I hereby affirm that there is a construction lending agency for FRONT V ,} - the performance of the work for which this permit is issued - P.I. - (Sec. 3097, Civ. C.). SIDE , ' P.I. Lenders Name _ LDMA Ref. If _ P.C. Fee$ / Permit Fee u r � Lender's Address - _ �^� I certify that I have read this application and state that the Issuance Fee 3 rr 19V•. LDMA P/C q. D - - 8 above informat,o is correct. I agree to comply with oll, aunty Investigation Fee ryy� ordinances S to laws re ting to building conch <tion, Total Fee ♦ �/ LDMA Perm. q a and hereb a th ize repr a tatives of this County o enter e b e- endo d operty-for inspectiop i� S. - - - - ( SEE REVERSE FOR EXPLANATORY LANGUAGE gnat a of-Appficooff or Agent Date - - -