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Home My Public Portal About5755 CLOVERLY AVE_Building__ WORKERS'COMPENSATION DECLARATION K affirm that I have r certificate of consent to selfAPPLICATION FOR •BUILDING PERMIT r a certificate of Workers' Compensation Insurance,fied copy/thereof (Sec. 3800, Lab. C.) �� ""'Wt�1�3 — Company S �e COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ BUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN " ADDREss J 5 ertified copy is filed witli/vyhe county )�buuild' g inspec- BUILDING — �^ tion departmentdL�� Y". ADDRESS "7 LOCALITY -� �'GYK NEAREST.200 ��!-/ �y Date - --" Applicant CITY ZIP 7 CROSS S W-e4 " CERTIFICATE OF EXEMPTION F WORKS ' ` r'No. 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 �, Gi `W `7 NE MAP hundred dollars ($100)or less.). TRACT BLOCK LOT NQ. - NO. E— TEL SPECIAL } I certify that in the performance of the work,for which this OWNER Ili( Z6 7� CONDITIONS EL ermit is issued, I shall not employ in manner DISTRICT GROUP TYPE FIRE PROCESSED BY O p p y an y person any CONST. ZONE _ U ADDRESS so as to become subject to the Workers'Compensation Laws. ICS e2C-� Date Applicant I.- ARCHITECT OR ZIP TEL. STATISTICAL CLASSIFICATION ' APT. CONDO. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CLASS NO. DWELL. UNITS UA Exemption, you should become subject to the. Workers' Compensation provisions of the Labor.Code, you must forth- ADDRESS SEWER MAP with comply with such provisions or this permit shall be ` !'� deemed revoked. CONTRACTOR � /j / P p O - '�' BK. ipG J� VALIDATION k'f?� T . LICENSED CONTRACTORS DECLARATION LIC. r �y Q I hereby affirm that I'am licensed under provisions of Chapter 9 ADDRESS I ?� 14 Ur=ftlf a NO. ✓ / v -VALUATION (commencing with Section 7000)of Division 3 of the Business and /t LIC. "'rr Professions Code, andmy license is in'full force and effect. CITY T-e k, e \ f CLASS $ 7 �j�1 6 C'` �� SQ. FT. STORIOES FAMILOIES CHECK License Number �J Lic.Class Contractor r Date DESCRIPTION OF WORK NEW ❑ J �( ADD ❑ ❑ I am exempt and r Sec. ` ALTER FINAL p f 5 6 3 0 A ❑ DATE SCJ 0 0 a 0 0 B.&P.C. for this reason s "n" REPAIR USE OF ;V12 OL FINAL r EXISTING BLDG. DEM13Y O Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT ��jj in NO. 7q t/q,2 5 5 I hereby affirm that I am exempt from the Contractor's LicenseADDRESS O. 2 n —� 3 Law for the following reason (Section 7031.5,Business and Professions Code): PRESENT ❑ BUILDING 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 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 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 d construction lending agency for FRONT , the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE m P.L. ' v Lender's Name _ Lender's Address P.C. Fee$ Permit Fee Q I certify that l have read this application and state that the Issuance Fee 1 O� �,C above information is correct.I ae greto comply with all County Investigotion.Fee LL ' g ordinances and.State:laws relating to building'construction TotaLFee. $1 'J u and hereby authorize representatives of this County to enter upon the abo r. bon7do!��qwy ` section purposes. a ( �' SEE REVERSE FOR EXPLANATORY LANGUAGE n ®3 Signature of Appli -nt or Agent Date " ,WORKERS'COMPENSATION DECLARATION 'insureboraafcertif catfe oaWorkers' Compensative a certificate of on Insurancent to e, APPLICATION FOR . BUILDING PERMIT or a certified copy them (Sec. 3800, Lqb.C.) ' COUNTY OF LOS ANGELES BUILDING,AND SAFETY Policy No. ompany _ Lt � El -Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is filed with the county building inspec- BUILDING ( (� tion department.' ADDRESS t,;5'11r,/J vrC , //�sCG c�✓ Date Applicant CITY t C-L?_ L� ZIP LOCALITY 1 CERTIFICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. NEAREST. COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. , (This section need not be completed if the permit is for one f ASSESSOR hundred dollars ($100)or less.) TRACT i cir� BLOCK LOT NO. _ MAP BOOK PAGE PARCEL OWNE (( id TEL. ! USE Z NE MAP Ltg7�Qjl� "NO �' I certify that in The performance of the work for which this � NO. � perrnit;is issued, I'shall not employ any person in any,manner .e^ �/r' SPECIAL CL - so as to become subject to the Workers'Compensation Laws. ADDRESSIv�-�� ` L��C c:Jf1��)(� (� CONDITIONS Date -Applicant' CITY / �.�: ZIP NOTICE-TO APPLICANT: If; after making this Certificate of ARCHITECT OR TEL. O DISTRICT GROUP• TYPE. u FIRE PROCE SED BY . ENGINEER NO. _ It— Exemption,, Exemption; you should become subject to the Workers' CONST. ZONE U Compensation provisions of the Labor Code,syou must forth- ADDRESS ��V� •-� J hu with comply with such provisions or this permit shall be deemed revoked. CONTRACTOR afl AJN� NO.!T-i'�`Z`V STATISTICAL CLASSIFI ATION APT. C DO.:' LICENSED CONTRACTORS DECLARATION - - CLASS NO. DWELL. UNITS t . I hereby affirm that I am licensed under provisions of Chapter 9 ADDRES Gt rfy�I°�-u' y LIC �c (commencing with Section 7000)of Division 3"of the Business and ,. LIC.- _ J SEWER MAP Professions Code, and my license is in full force and effect. CITY-Apl_�?PaeJi 1 14 CLASS ' ' VALIDATION SQ, FT_. / NO. OF NO. OF-- CHECK BK. PG. License Number= try Lic.Class t� SIZE / STORIES FAMILIES ONE (� �7 �1 (�_ NEW VALUATION. Coniractor �" Date --- �` /�+ DESCRIPTION'OF WORK ❑ ; / /�/)V (/ll J ADD , I am exempt under Sec. - CTER B.&P.C. for this reasonUSE OF ❑ $ DEMOL ¢ - REPAIR � ._ Date: .•� i / ,/ EXISTING BLDG. ❑ Sinnah,rsa l�.>j`:e APPLICANT . . �. TEL. FINAL OWNER-BUILDER DECLARATION (PRINT) /(/' :� NO. DATE - r I hereby affirm that I am exempt from the Contractor's License ,'r z 6 5. rj �{�' 'Law for the following reason (Section 7031.5,.Business and ADDRESS FINAL `Professions Code): PRESENT By / #-o m�o-o o BUILDING I, as owner of the property, or my employees with ADDRESS wages as their'sole-'compensation,will do the work and ( o,� 5300- the structure is not intended or offered for sale(Section LOCALITY - a. 7044, Business and Professions Code). MOVING TEL: '` - --O - 1 5 3-0 O�. I, as owner of the property, am exclusively contracting CONTRACTOR NO. a with licensed contractors to construct the project (Sec- "' "' Q-2.2 4�8.7 tion 7044, Business and Professions Code). ADDRESS REQUIRED.- TOTAL.SETBACK FROM M 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 P.L. Lender's Name o LDMA Ref. It m - - - P.C.•Fee•$ - .._.. .. .. Permit-Fee' Lender's Address 5 JJ CC I certify that I have read.this application and state that the Issuance Fee a above information is correct. I agree to comply with all County Investigation Fee ordinances-and State laws relating to building construction, U and hereby authorize representatives of this County to enter Total Fee LDMA Perm. N upon th ve�enfi ed ogefty for inspection purposes. f r� dLE.2/' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent, - -- Date - -• - -- - - - • - j