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Home My Public Portal About4812 CLOVERLY AVE_Building__ dT' WORKERS' COMPENSATION DECLARATION `i.-'-�eby affirm 'fico I have r certificateoo '"of consent;to self APPLICATION F OR BUILDING P E RM I T ins�re,.�or a certificate of Wor�Cers' Compensation Insurance, or a �ti.ied copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY � licy No. Company BUILDING Certified copy is hereby.furnished. FOR APPLICANT TO FILL IN ADDRESS BUILDING e1 QZ El copy is filed with the county building inspec- ADDRESS T p�Z r 0 vF�4 y YA6 tion department. y+ / CITY / A� rr T ZIP LOCALITY Date Applicant / NO. OF BLDGS. / NEAREST �J CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 7 / //_5X �� NOW ON LOT CROSS ST. COMPENSATION INSURANCEp �' ASSESSOR. (This section need not be completed if the permit is for one TRACT D!5`D BLOCK 02 0 1 LOT NO. 0/0 MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. Q OWNER YEL t�vRE'SA 1; NO. 5r2d 6( USE ZONE 1 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 CONDITIONS a \rso as to become subject to the W s' Co n Laws. U I CITY ZIP 0 Date (� Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certi ' to of ENGINEER NO. r CONST__, ZONE ` U Exemption, you should become subject to the Workers' / �" wa Compensation provisions of the Labor Code, you must forth- ADDRESS v ` A N with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR NO. — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of.the Business LIC. and Professions Code,and my license is in full force and effect. CITYCLASS BK. 4—PG. VALIDATION SQ. FT.*7` NO. OF NO. OF CHECK License Number Lic. Class SIZE J/ STORIES FAMILIES ONE Q J4D Jr/ 0 I VALUATION DESCRIPTION OF WORK �T l�' NEW ❑ Contractor Date $ ADD ► ❑I am exempt under Sec. f" �y7 ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF (. DEMOIEXISTING BLDG. k�7 0/�FI y7 ❑ Sinature APPLICANT TEL. FINAL g OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS FINAL 1 Law for the following reason (Section 7031.5, Business and ro ssions Code): PRESENT BY A BUILDING �t'�T°T I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and75 intended o �3�7 17 ° the structure is not r offered for sale(Section LOCALITY c 7044, Business and Professions Code.) MOVING TEL , f ITEMS ElI, as owner of the property,'am exclusively contracting CONTRACTOR NO+ with licensed contractors to construct the project (Sec- TOTAL .� 75 ADDRESS tion 7044, Business and.Professions Code.) CHECK 7c 171 REQUIRED TOTAL SETBACK FROM EXIST. s r_t CONSTRUCTION LENDING AGENCY SETBACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE °[IO the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE . Lender's Name. P.L. �p -I}�— i LV I '7? {r m I �{�' LDMA Ref. # �71t 1 A1I 7°F - P.C..Fee$ Permit Fee 'tel ° Lender's Address t �! oIssuance Fee O --� `� LDMA P/C# , o I certify'that I have read this application and state that the 8 above information,is correct. I agree to comply with all County Investigation Fee R ordinances and State laws relating to building construction, Total Fee LDMA Perm. # a and hereby authorize representatives of this County to enter ` upon-tfie bov ned property for inspection p rp es. ' ' N SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica or Agent at V }• 6 WORKERS' COMPEN5;\TION DECLARATION hereby � s'it 'consent lfi9sureor bcertifcane off WerCompenstonsuraneAPPLICATION FOR BUILDING PERMIT tj orga certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS '� g� C L 0VtWL ve ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS g Z. V� V E CITY G1)')' ZIP y a /LOCALITY ( Z_C� c 17-1 Date Applicant NO. OF BLDGS. CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT i i 116 x NOW ON LOT NEAREST CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. OWNER C , NO&IPj USE NE MAP I certify that in the performance of the work for which this NO. �-� SPECIAL >_ permit is issued, I shall not employ any son in any.manner ADDRESS � �Z �-"�+�V�'fZL r�l/Fs - CONDITIONS � so as to become sub'ect To the Wo_ rs'C•mpensation Laws. O CITY Cal"r ZIP U Date NOTICE \ Applicant ARCHITECT OR TE . DISTRICT GROUP TYPE FIRE OCESSED BY � Exemption, TO APLIC NT: If, after mating thithe - i to of ENGINEER A .5 1 N 5,()y h CON&i-rf�' ZONE O Exemption, you should become subject to The 'Workers' ✓h U �J�t'/�. 3 U Compensation provisions of the Labor Code, you must forth- ADDRESS / tL with comply with such provisions or this 1 STATISTICAL CLASSIFICATION APT. CONDO. N p y p permit shall be TE Z deemed revoked. CONTRACTOR ��V NO. _ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I her affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP ACC. a8CITY CLASS and Professions Code,and my license is in full force and effect. BK PG �-,f -)VALIDATION ¢7t y�l SQ. Fi .C� NO. OF NO. OF CHECK �i30 as License Number Lic. Class SIZE 110.3 STORIES FAMILIES ONE VALUATION 1 ITEMS DESCRIPTION OF WORK p 0_F* NEW ; /I TOTAL 472 - 40 Contractor DateLLLJJJ TOTAL Z Pao1�� ' V ADD ❑I am exempt under Sec. �s , �t tom.-. B.BP.C. for this reason /L �'.H�sp�w15 NAV t-_r ACW ALTER El {•LlEC•i 71 i ■f31� _ REPAIR ElS kI�^C t� aCICI Date: USE OFEXISTING BLDG. DEMOL ❑ CHANGE Signature APPLICANT TEL. OWNER-BUILDER DECLARATION (PRINT) NO FINAL 0000—OCIO1 10117/89 1 hereby affirm that I am exempt from the Contractor's License DATE , '*16 Law for the following reason (Section.7031.5, Business and ADDRESS FINAL 6252 1 Ate 8 Pro ssions Code): PRESENT By I, as owner of the property, or my employees with BUILDING ADDRESS wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section �, R � , 7044, Business and Professions Code.) MOVING TEL. -,- CONTRACTOR NO. �� {.=�(}s 46.3i ❑ I, as owner of the property, am exclusively contracting h�.y./��•/ �� •! ITEMS)with licensed contractors to construct the project (Sec- ADDRESS "r N'' �/� 1 1 i E11a tion 7044, Business and Professions Code.) r REQUIRED TOTAL SETBACK FROM EXIST. TOTAL 46 - 37 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH `J� C�� I hereby affirm that there is a construction lending agency for FRONT 3J __HE{'.'. �� •-7 the performance of the work for which this permit is issued P.L. 6.31 (Sec. 3097, Civ. C.). SIDE -- -- CHANGE P.L. Lender's Name •LDM^ Al Ref. # P.C. ee$ PermitFeeS�G Lender's Address ff�ICl_ CC12/ Ie a I certify that I have read this application and state that the Issuance Fee LDMA P/C# �z}= i� 11=sy 8 above information is correct. I agree to comply with all County Investigation Fee d ordinances and State laws relating to building construction, Total Fee s LDMA Perm. # a and hereby authorizer ntatives of this County to enter upon the o tioned ploperty for inspection purpo�c, a `� I SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of pplicant or gent Date ' t' WORKERS' COMPENSATION DECLARATION" Phereb 6ffirm'that I liave'o certificate'of consent to self insutl,or a certificate•of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT r^' a CA, -c.copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY olicy No. "Company Certified co is hereby furnished. FOR APPLICANT TO FIL IN BUILDING copy y ADDRESS G— ❑ Certified copy is filed with the county building inspec- BUILDING I tion department. ADDRESS �d Date Applicant CITY C� ZIP LOCALITY PP NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT 7g IX NOW ON LOT CROSS ST. COMPENSATION INSURANCE " s r, ASSESSOR (This section need not be completed if the permit is for one TRACT Q BLOCK LOT NO.G/ V MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) F' ^/� r TEL. ��7 / USE ZONE MAP OWNER V L J a e t NO. NO. I I certify that in the performance of the work for which this'. SPECIAL } permit is issued, I shall not employ a erso ' manner ADDRESS CONDITIONS so as to become su�lect to the Wor cer 'Compen o Laws. U CITY ZIP W Date ^I Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE ROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate/oftom ENGINEER NO. (� CON§= ZONE Exemption, you should, become' subject to the Wo ers: i 1b W Compensation provisions of the Labor Code, you must forth- ADDRESS i' 3 N with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. z deemed revoked. CONTRACTOR 9NO. — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I 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 SQ. FT. NO. OF TNO. OF CHECK License Number Lic. Class SIZE STORIES IFAMILIES ONE VALUATION /-� Contractor Date DESCRIPTION OF WORK NEW ❑ $ b�I0 . V Q ADD ► El am exempt under Sec. ALTER El BAP.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. I)Wff)DATE. I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Profgssions Code): PRESENT BY BUILDING hh Ct•I =s I, as owner of the property, or my employees with ADDRESS .. ' 4 �. 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. 1 ITEMS CONTRACTOR NO. _ I, as owner of the property, am exclusively contracting TOTAL '�$-� m��.sv with licensed,contractors to construct the project (Sec- EADDRE tion 7044, Business and Professions Code. CHECK 49.83 r :+:: EFee. TOTAL SETBACK FROM EXIST. �•Fl�l• 'I f e L'L CONSTRUCTION LENDING AGENCY PROP. LINE WIDTH CHANGE n t I hereby affirm that there is a construction lending agency for CHANGE s IU the performance of the work for which this permit is issued(Sec. 3097, Civ. C.). -�,�Lender's Name I3�—�10T19/11/89 LDMA Ref. # CCffLLpw}q{ - Permit Fee 5626 1 AM11:0811Lender's Address1 certify that I have read this application and state that the Issuance Fee /�J LDMA P/C# popabove information is correct. I agree to comply with all County dordinances and State laws relating to building construction, Total Fee LDMA Perm. # a and hereb aut _ presentatives of this County to enter I upon e o do ed property for inspection pure s. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica or Agent Date r WORKERS' COMPENSATION DECLARATION I;hereby affir'm^that I halve-a certificate of consent to self insuPe, or a certificate-of Workers' Compensation Insurance, APPLICATION. FOR BUILDING PERMIT or•czl'Jrtified copy thereof (Sbc. 3800,*Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy'No. Company BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING J tion department. ADDRESS Date Applicant CITY -- e__ ZIP LOCALITY e NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LO7 v M NOW ON LOT CROSS ST. COMPENSATION INSURANCE y�. a ® ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK C✓v� LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) 1� p *� TEL. ? OWNER y�L 4 f NO. / O"16 USE ZONE MAP I certify that in the performance of the work for which this SPE } //�/�1 r+ SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS {/�. CONDITIONS O so as to become sub'ect to the Wor s'Co Tion Laws. U CITY ZIP Date �� Applicant ARCHITECT OR TEL. DISTRICT qMJ TYPE FIRE CESSED BY O NOTICE TO APPLICANT: If, after making this Ce ificate of ENGINEER NO. CONST. ZONE U Exemption, you -should become subject to. the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS / a with comply with such provisions or this permit shall be L STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION' LIC. CLASS NO. DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business ' LIC. J, and Professions Code,and my license is in full force and effect. CITY CLASS BK�^ PG U Zj- VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number' Lic. Class SIZE STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ S ADD ❑ ► ❑I am exempt under Sec. ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. � L-� DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE , . ... I hereby affirm that I am exempt from the Contractor's License ADDRESS FINAL96.7� Law for the following reason (Section 7031.5, Business and 3M7 _t Professions Code): PRESENT, BY I, as owner•of the property, or m employees with BUILDING 1 ITEMS P P Y� YADDRESS wages as their sole compensation,will do the work and [ADDR LITY 96. 75 the structure is not intended or offered for sale(Section ror�. 7044, Business and Professions Code.) ING TEL. ► CHECK 4 �75 ❑ I,.as owner of The property, am exclusively contracting A��-� TRACTOR NO." t j,�' with licensed contractors to construct the project (Sec- ESS ��HttNE..... .00 tion 7044, Business and Professions Code.) QUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for ONT M—OW 1 B1 7/89 the performance of the work for which this permit is issued . (Sec. 3097, Civ. C.). E . 4918 1 M 9:10 Lender's Name $ LDMA Ref. # Fee$ Permit Fee ,Lender's AddressI certify that I have read this application and state that the Issuance Fee LDMA P/C#above information is correct. I agree to comply with all County tigation Fee //' 6 ordinances and State laws relating to building construction, Total Fee f� /�✓ LDMA Perm. # a and hereby authorize representatives of this County to enter g;Mbove-m d property for inspecLion purpo shy SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica or Agent Date WORKERS' COMPENSATION DECLARATION ansboarI hc�ve,a certificate,of consent to insurance,inAracertifcate of Workers' Compensation - APPLICATION FOR BUILDING PERMIT or a c:Nified copy th*ereof (Stc. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY olicy No. Company BUILDING �G Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS T r ❑ Certified copy is filed with the county building inspec- BUILDING �� rj; ea tion department. ADDRESS --Q'i/ r\ Date—.Applicant CITY ZIP LOCALITY r ° �1 I f NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT `> NOW ON LOT CROSS ST. s COMPENSATION INSURANCE !9 �t1 ASSESSOR (This section need not be completed if the permit is for one TRACT (� O BLOCK q,� r LOT NO. 0/ 0 MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) T TEL. 70 fjG U ONE OWMAP NER JJ iL- '�' l= NO 11 NO. r/ I certify that in the performance of the work for which this SPECIAL >_ permit is issued, I shall not employ rson ' manner ADDRESS CONDITIONS a so as to become ct to the orke pens Laws. O CITY ZIP U Date _ �� Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this.Certificate fENGINEER NO. CONS�� Z Exemption, you should become subject to the Work rs' �/ G w Compensation provisions of the Labor Code, you must forth- ADDRESS r V Ja►^- O N with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION APT. CONDO. Z deemed revoked. CONTRACTOR NO. — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I amlicensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC' v- and Professions Code,and my license is in full force and effect. CITY CLASS gK. PG. 01 fl Q VALIDATION SQ. FT. 0J� NO. OF NO. OF CHECK License Number Lic. Class SIZE �J3 STORIES F ILIES ONE �j SAI 11053 �� Contractor Date DE RIPTION F WO w/� NEW ❑ ADD ► ❑I am exempt under Sec. ALT ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS FINAL 1 Law for the following reason (Section 7031.5, Business and g Proessions Code): PRESENT _ By ACCT.T _ BUILDING –, -, I, as owner of The property, or. my employees with ADDRESS 330-1 wages as their sole compensation,will do the work and y the structure is not intended or offered for sale(Section LOCALITY , 1 ITEMS 7044, Business and Professions Code.) MOVING TEL. t� ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 0 TOTAL 20131' m 25 with licensed contractors to construct the project (Sec- ADDRESS C 2 I� roc tion 7044, Business and Professions Code.) �'�''r� J'�"j°`�" REQUIRED TOTAL SETBACK FROM EXIST: L}�44�__== 00 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH {.•ftttNE ° 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.). SIDP.L. ODOCI-0001 9111189 Lender's Name Ct 7 °i r .19SLDMA Ref. # :tG2 r 1 ASI 11°��t_ P.C. Fee$ Permit Fee Lender's Address , 1 certify that I have read this application and state that the Issuance Fee ' LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee ✓�j 8 ordinances and State laws relating to building construction, Total Fee O . LDMA Perm. # a and y auth iz€Tr+p esentatives of this County to enter on ih a-me property for inspection purpo s. , C> SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant Agent Date /