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HomeMy Public PortalAbout5808 CLOVERLY AVE_Building__ WORKERS' COMPENSATION DECLARATION -1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.).X749/ COUNTY OF LOS ANGELES BUILDING AND SAFETY ,?o4icy.No.N -�-2•_ ompany BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS 1, U� ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS ,( (.GUU CITY G�T� ZIP LOCALITY 17 Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS'. SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT NO. MAP BOOK I PAGE I PARCEL hundred dollars ($100) or less.) 0 TEL. OWNER , No.8/B 6 �Q. USE ZONE MAP I certify that in the performance.of the work for which this I 7 •' , SPECIAL N0. permit is issued, I shall not employ any rson in any manner ADDRESS;—?S- P'� CONDITIONS so as to become subject to the Com nsation Laws. O CITY e ZIP 7 Date /2 l A�Appli ARCHITECT OR TEL. DISTRICT JROUP I TYPEFIRE ROCESSED BY NOTICE TO APPLICANT: If,' after making this Certificate of ENGINEER NO. CON ZONE Exemption, you .should become subject 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 CLASSIFICATION APT. CONDO. to 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. (commencing-with Section 7000)of Division 3 of the Business LIC. SEWER MAP and Professions Code,and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number �Qg2/0 Lic. Class 6414SIZE STORIES FAMILIES ONE VALUATION Contractor Date Date �z DESCRIPTION OF WORK .f NEW, $ 5 e ► syr ADD ❑ ❑I am exempt under Sec. ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ Signature APPLICANT >it TEL. 1 FINAL OWNER-BUILDER DECLARATION PRINT i7 NO. it(VfO �Z. 'Z DATE I hereby affirm that I am exempt from the Contractor's License ADDRESS �✓+lv�� OCLiI f/Z Low for the following reason (Section 7031.5, Business and Professions Code): PRESENT By BUILDINE El 1, as owner of the property, or my employees with ADDRESSG G 1=3�•i I zs wages as their sole compensation,will do the work and �� ' 6� - I I ( LOCALITY , L: 7 the structure is not intended or offered for sale Section • 171.75 7044, Business and Professions Code.) MOVING TEL. CONTRACTOR NO. I I i ,{S ❑ I, as owner of the property, am exclusively contracting r t with licensed contractors to construct the project (Sec- ADDRESS /> TOTAL I yL 17�, o 75 tion 7044, Business and Professions Code. cT CHECK REQUIRED TOTAL SETBACK FROM EXIST. / r• 171.75 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDT I hereby affirm that there is a construction lending agency for FRONT C"NANGE CIO I the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name 0000-000 �, ? � LDMA Ref. # ' _ P.C. Fee$ Permit Fee ?ii{C j fl�l�or4 Lender's Address r o I certify that I have read this.application and state that the Issuance Fee 10.5 LDMA P/C# 0 pol- above information is correct. I agree to comply with all County Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee r� LDMA Perm. # a and by authorize repr tatives of this County to enter n e ove-men ' pro ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Applicant or Agent Date 2_ k <ORKERS'COMPENSATION DECLARATION in afcertif carte of Workersve a �tComtpensat e of conon5ensurancent to f APPLICATION FO `fl R BUILDING PERMIT or certified copy thereof (Se 3800,'Lab. C.) •.y � j mp y�;ga&-& P*)C� COUNTY OF LOS ANGELES BUILDING AND SAFETY Polic No. om an -Certified copy is hereby furnished. FOR APPLICANT TO FILL IN. gpDRENS ❑ Certified copy is filed with the county building inspec- FADDRESS Q O p LOV��I ,( L, 1� 6,bG O tion department. -���^, ,•nCJ 9 �G.`' �l Date C�� Applicant�F/rZW) -0, H' �'r ZIP LOCALITY t CERTIFIC TE OF EXEMPTION FROM WORKERS' NO, OF BLDGS. Y♦ NEAREST COMPENSATION INSURANCE T 00 (�'S NOW ON LOT CROSS ST. l (This section need not be completed if the permit is for one S 6 BLOCK LOT NO. ASSESSOR hundred dollars ($100)or less.) MAP BOOK PAGE PARCEL TEL USE ZONE MAP /� I certify that in the performance of the work for which this �'. N �.�' _,44? NO. /5 0'pC.& permit is issued, I shall not employ any person in any manner . k SPECIAL 8f, so as to become subject to the Workers'Compensation Laws. � F�t� QCONDITIONS 0 [v4ft'�il�*6 ZIP U U Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT TEL. I DISTRICT GROUP TYPE FIRE PROCESSED BY O Exemption, you should become subject to The Workers' ENGINEER ��r� NO .�.� \\ �!�� �JJ�/ CONST. ZONE (oI- Compensation provisions of the Labor Code, you must forth- ADDRESS �'l O T�{, c with comply with such provisions or this permit shall be LU deemed revoked. 't) TEL STATISTICAL CLASSIFICATION APT. CONDO. fq CONTRACTOR j ?+t .�l�+jj O. pgcic� LICENSED CONTRACTORS DECLARATION LIC.�t1�2 7 O. CLASS NO.�DWELL. UNIT I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS t C.1. cr f9 N (commencing with Section 7000)of Division 3 of the Business and LIC: SEWER MAP Professions Code, and my license is in full force and effect. CITY gq • ' Z• /� CLASS L J VALIDATION r-�Z� SQ. F NO. OF NO.OF CHECK BK. PG.( License Number kt Lic.Class SIZE 2� STORIES T�0 FAMILIES ONE p 1 -�r�� v VALUATION �( r Contract ar�lr v V. Date DESCRIPTION OF WORK 1 J�� NEW O $ /?Jl Od r1 3 I am exempt under Sec. ��C> '� UJ ALTER - (1(/ ❑ � %x`1. 72 B.BP.C. for this reason REPAIR $ USE OF 111 Date: DEMOL L EXISTING BLDG. c QSI T18. Si nature APPLICANT r L. FINAL Signature PRINT) � C C- C NO. j-�.0— / OWNER-BUILDER DECLARATION a DATE Z CJ I hereby affirm that I am exempt from the Contractor's License ADDRESS ZOO 4(V fJ' Law for the following reason (Section 7031.5, Business and C©c.) FI w Professions Code): PRESENTY 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. \ .l I, as owner of the property, am exclusively contracting CONTRACTOR NO. •�,� � .,, , •�y ,�. � with licensed contractors to construct the project (Sec- ADDRESS ;2 0 8 T 2 A- tion 7044, Business and Professions Code). > REQUIRED TOTAL SETBACK CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH ht o o,o i® ®t� I hereby affirm that there is a construction lending agency for FRONT '.I 2"2 8 0,7 5 the performance of the work for which this permit is issued P.1. T. `-: (Sec. 3097, Civ. C.). SIDE R P.L. .0 2280 ]Jr L) Lender's Name m P.C. Fee$ 1 Permit Fee R , 2 . LDMA Ref. N I Q 07,r 8 Lender's Address o I certify that I have read this application and state that the /011� e Issuance Fee LDMA P/C q above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee of 0 t /v LDMA Perm. # N and hereby authorize representatives of this County to enter < upon the above-mentioned property for inspection purposes. M r ( d 7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applic nt r Agent Dole WORKERS'COMPENSATION DECLARATION insure boroafcertif cafirm tharte of Worke s' Comtpensat on eInsuran elf APPLICATION FOR BUILDING PERMIT •or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Polic o. Company f, �Nfi� BUILDING --V y�1' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with th ounty buil i'g inspec- BUILDING O /l�v{y- do de rt t. / ADDRESS 1'c- C,l 6J-, Date �� Applicant CITY `� cwt ZIP LOCALITY &RTI CATE OF EXEMPTI ROM WORKERS' NO. OF BLDGS. NEAREST COMPENSATION I SU SIZE OF LOT ��{ NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one TRACT ] V BLOCK LOT NO. MAP BOOK PAGE PARCEL ASSESSOR hundred dollars ($100)or less.) TEL. I certify that in the performance of he work f hick this OWNER NO USE Z NE OP U permit is issued, I shall not employ y person i y manner /� ' 1 SPECIAL so'as to be omm ct to the W rs'Co n tion L ws. ADDRESS S V1f ��h CONDITIONSUDate "' 7Applican CITY (� ZIP 7S ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE OAP LICANT: If, afte making this Certificate of ENGINEER NO. CONST. ZONE F— Exemption, you should become subject to the Workers' ` �� � 1 2� W Compensation provisions of the Labor.Code, you must forth- ADDRESS i� fil/�"1zV �/ with comply with such provisions or this permit shall be TEL. /[� d STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. CONTRACTOR (/`- NO. �S J"�j LICENSED CONTRACTORS DECLARATION y, UC. ' CLASS NO. ✓ DWELL. UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS l03 as � 0. (commencing with Section 7000)of Division 3 of the Business and �+��'' LIC i SEWER MAP Professions Code, and 4�lic�ense ' n full force and effect. CITY �� l/Yr CLASS ��/ BK & PG yd VALIDATION SQ. FT. NO. OF NO. OF CHECK license N ber � Lic.Class , SIZE STORIES FAMILIES NEVALUATIONf,�7� DESCRIPTION OF WORK 1p'1 4Ib NEWContract Date ! ADD ❑ s ❑ I am exempt under Sec. ❑ ALTER B.&P.C. for this reason REPAIR ❑ $ Date: USE OF DEMO' ❑ EXISTING BLDG. Signature APPLICANT TEL. ✓�s FINAL OWNER-BUILDER DECLARATION PRINT O G Huvl`i►'nh NO. , DATE ✓ I hereby affirm that I am exempt from the Contractor's License ADDRESS 03 r tea IL 0/, - (A)&M 1�- C FIN, Law for the following reason (Section 7031.5, Business and By Professions Code): PRESENT 1 By 9 9 LL 3 BUILDING # ° 0 o e o 1 El I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ° ° 6.Q 5 0 the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL °'° ° 6 Q 5 050 ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS 0621 -88 tion 7044, Business and Professions Code). REIREDFROM EXIST. CONSTRUCTION LENDING AGENCY SET BACK YARD HWY TOTAPROP.ACK 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 m P.C. Fee$ Permit fee LDMA Ref. # Lender's Address I certify th I have re his application and state that the Issuance Fee `1 LDMA P/C# g above inf ation is rr t. I agree to comply with all County Investigation Fee 0 ordinan and Sta I s relating to building construction, Total Fee C/ S LDMA Perm. # R and h y aut ze presentatives of this County en r m upo t `abov - entioned property for inspect 'on rpo s. yy„ SEE REVERSE FOR EXPLANATORY LANGUAGE Y� Signatur of Applicant or Agent D to