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Home My Public Portal About9915 DUFFY ST_Building__ WORKERS' COMPENSATION DECLARATION• I hereby affirm:that I have o certificate ns consent to self A n n��C � V O O H FOR OO n (��(� D O H� n insure, or o certificate of Workers' Compensation Insurance; (� (r (/=V� �v v LL uv _ (r or a certified copy thereof Se_c..3800, Lab. C.) � /:C.1� COUNTY OF LOS ANGELES BUILDING AND SAFETY PolicyNo��Company� ,J • Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING 'I ADDRESS I J ❑ Certified copy is filed with.the county b 'di g inspec BUILDING. tion department. ADDRESS �V Date Applicant -CITY 77P�R"- ry ZIP O LOCALITY - - CER IFICATE OF EXEMPTION FR WORKERS' 0 ®�� -� $S�IO..OF.BLDGS. NEAREST COMPENSATION INSURANCE SIZE LSF LOT W T CROSS ST (This section need not be completed if the,per'mit is for one ASSESSOR hundred dollars ($100)or less.) TRACT �� BLOCK LOT NO.. MAP BOOK PAGE PARCEL TEL.. UVJ E MAP I certify that in the`performoncecof the work fonwhich.ihis OWNER NO. NO S� permit is issued, I shall not employ any person in any manner ADDRESS A SPECIAL,': so.as to become subject to the Workers'Compensation'Laws. 7 y CONDITIONS .... CITY y. ZIP Date Applicant „ NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR TEL DISTRICT OUP TYPE • FIRE PROCESSED BY., • Exemption, you should become subject to the Workers' ENGINEER NO. CONST. E Compensation provisions of the Labor Code,.you'must forth- ADDRESS 6 -0� with comply with such 'provisions' or this permit shall'be -rTEL. STATISTICAL CLASS ACTION APT. CONDO: deemed revoked. " CONTRACTOR % �/"NOa LICENSED'CONTRACTORS DECLARATION LIC CLASS,NO. DWELL. UNITS• I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS /� NO. �� (commencing with Section 7000)of Division 3 of the Business and LIC. SEWER MAP 'Professions Code, and my license is in full force and effect. CITY 77A /,> r�'�' CLASS BK. VALIDAYIOW �. 3 SIZ F : n INO.STO OF IN FA OF CHECK Q - .License Number� CTL/ Lic.Class SIZE �y7 STORIES FAMILIESONE4 0 •�I� VALUATION U Contractor L' (/ii /1��0� Date / DESCRIPTION OF.WORK B / O ' v. #.,$ 4ADD ❑,I am exempt under Sec. „ ALTER ❑ • Au B.BP.C. for this reason �� REPAIR $ LL Date. USE.OF DEMOL. a EXISTING BLDG. ❑ Z Signature APPLICANTTEL.Y FINAL E -BUILDER DECLARATION PRINT) p NO. DATE I hereby affirm th t I m exempt from the Contractor's License ADDRESS � 1it pocoL^ N� t Low for the foIlo ' g reason,(Section 7031.5, Business.and FINAL Professions Code): PRESENT By ❑ BUILDING - I,.'as owner of the property,�or my employees with ADDRESS r; wages as their sole compensation,will do the work and , the structure is not intended or offered for sole(Section LOCALITY k 7044, Business and Professions Code). MOVING TEL 1', as owner of the property, am exclusively contracting CONTRACTOR NO. {/ -,3-307 -5.20 with licensed contractors to construct the project.(Sec- ADDRESS - 4-.' tion 7044, Business and Professions Code). a (w_••€fL _ REQUIRED TOTAL SETBACK _ CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH e J hereby affirm that there is a construction lending agency for FRONT III) €• -1 05 = 20 the performance of the work for which this permit is issued P.L. _ if{coir (Sec. 3097, Civ. C.). SID CHANGE ; s '' Lender's Name LDMA Ref. # W Lender's Address P. Fee$ o Per t Fee ._ i( i ilo[I IL ,�.r,I fr:n I certify that I have re this application and state that the Is once Fee 7LDM:P/C# 7 4 above information is Fr t. I aree to comply with all Count �+F?: tIJ= 9 PY Y Inves'gation Fee r 0 ordinances and Sta la s relating to building construction, ; R and hereby t o ze r presentatives of this County to enter Total Fee LDMA Perm. # upon b ve ent' ned property for inspect' 0 urpses.s� ' SEE REVERSE FOR EXPLANATORY LANGUAGE !6L' Si na re of Applicant or Agent ate DIVIN OF BUILDING ARID SAFETY Department of County Engineer RUMDNNG County of Los Angeles WM. J. FOX, COUNTY ENGINEER APPLICATION FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY BUILDING DISTRICT NO. PLAN CK.oa REc.�. IF RMI (o ADDRESS 3177{/p13 LOCALIT RE IVSD BY DATE QF APPL DATE__ISSUED NEARHBT ROBS S__ BUILDIADDRESS / 4! OWNER � � 'y- MAIL LOCALITY l� �L''/ ADDRESS NOAREST A A� CROSS ST. _"�-1.4 _ CITY FIRE NO.OF ZONE PLANS U i ARCHITECT D THL ENGINEER .�- NO. BLDG. SETBACK LINE C'r / ,' -t�4 ADDIFEBH ' USE APPROVED TEL. ZONE � BY DATE __ CONTRAOTO NO. HOUSE NUMBERING P ADDRESS MAP NUMBER NO. ASSIGNED BY LEGAL CORRECT% DESCRIPTION LOT NO. 1 BLOCK z r✓ TRACT 17 NO. OF BLOMIL roe - SIZE OF LOT Q I NOW ON LOT ^� USE OF NO. OF �V EXISTING BLDG. FAMILIES DESCRIPTION OF WORK A NEW ALTERATION ADDITION Z D r REPAIR DEMOLITION NO.OF SIZE 1/ ROAMS STORIES EXT.WALL I ROIOF COVERING COVERING USE OF STWC`TIJJqE 41, ._ INSPECTION FOR APPROVALS OCCUPANCY AS INSPECTORA;� IGNATURE DATE FOUNDATION: LOCATION FARMS. MATERIALS 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- PLICATION AND STATE THAT THE INFORMATION GIVEN IS FRAME: FIRESTOPS, .,,,.t.�q �_ CORRECT. BRACING,BOLTS ;/ �E/s Fo— AND STATE LAWS REGULATING I ABREE TO COMPLY WITH ABUI LL COUGH CONTY aSTRUCTIOENB. FURNACE: LOCATION, GAS VENT, DUCTS SIGNATURE O ` LATH, INT. PERMITTE ADORE LATH; EXT�� / PLASTER, ] lb AUTHORIZED AOT. PLASTER, EXT. �dZ (� FEE HOUSE NUMBER COR- , • IIn� RECT AND POSTED VALUATION V VFEE 63 3 Oma_ FINAL 76AG36A DBS 3 1-52 APPUCATMN FORSULMNIG PERMT, COUNTY OF LOS ANGELES BUILDING ANP SAFETY COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING A ) WORKER'S AJ by affirm that I,have a certificate f consent to.self insure, BUILDING or certif' a e of N/or ermpe a n'Insur nc or a c led: CIT ZIP C 8 r _ , I - - LOCALITY - Pei ll - - SIZE OF L - NO.OF BLDGS.NOW ON LOT _ ❑ Certified Copy is hereby fur hed. NEAREST CROSS S23 ••w _ TRACT - BLOCK LOT NO, ✓�' V•' Ce B op filed wit eco t buildi g` tion •," part��J5/y6�� J - USE ZONE MAP NO. Date 'Ap ica ASSE OR•MAP BOOK _ PAGE PARCEL - _ - . : `� . - OW - ". -. "" . . N .• ECIAL CONDITIONS SP CERTIFICATE OF EXEMPTION FROM WORKERS' p� v COMPENSATION INSURANCE / WITHIN 1000 FT.of SCHOOL? YES No (This section need not be completed if the permit is for one hundred AD KESS � 11` DISTRICT ', GROUP P ST: FIRE ZONE *PROCESSED BY dollars ($100)or less.). �s •' , CITY ZIP I certify that In the performance of the work for which this permit —1 6P M6 Is issued,1 shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT .CONDO Date "Applicant I ADDRESS : - '- - _ CLASS NO. DWELL UNITS , NOTICE TO APPLICANT'' If, after making this 'Certificate of REQUIRED TOTAL SETBACK FROM 'EXIST• Exemption, you should .become subject to the, Workers' C SET BACK..• YARD HW.Y PROP LINE WIDTH Compensation provisions of the Labor Code, you musf forthwith `' vV FRONT; comply with such provisions or this permit shall be deemed revoked. A e• ` J LI O PL LICE1.NSED CONTRACTORS DECLARATION CITY �Gl U uc C S FIDE I,hereby affirm,teat-I am licensed'underprovisions Jet7ncl apter:9 SEWER MAP (commencing wi 'o Division 3 of t - SQ.FT.SIZE` - NOrOF STORIES NO.OF FAMILIES .-Professions Co n Ip full force d NEW ❑ BK PGD License Lia Class SCRIP--.TIQN O Ry ` ADD ❑- .VAlunno 0 Contract r1JW Date .' //, / , / `D ALTER ❑ $ ❑ I am'exempt under Sec. 7,1 [� REPAIR ❑ $ i BAP.C.for this reason �`• /f DEMOL ❑ -LDMA P/C# %, W • •• USE OF EXISTING-BLDG. Da - .. URM-. E3 . Date: Signature APPLICANT(PR/NT) ." TEL NO. •LDMAPerm# J � �' z ❑'1, as owner'of the property, ormy y employees with wages as' Z ITEM ' ' — their sole compensation, will do the work and.the structure is, ADDRESS -,: - � - C !'ti. 169 - ^-..a not intended or offered for sale (Section 7044, Business and `FItJAL DATE 6( Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL O✓ V OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 11 J 3.-`:f.-=•e: ❑ I, as owner of-the property, am exclusively contracting with AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL.BY licensed contractors to construct the project (Section 7044, Tat* = I f .YES❑ NO❑ -. - - Busine.ss and Professions Code.) WILL THE INTENDED USE OF THE BUIDLWG BY THE APPLICANT OR FUTURE BUILDING' OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CONSTRUCTION a LENDING AGENCY, COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING _CHECKLIST FOR - LLh_ IE _II rl i ' opo4 4 GUIDELINES. .. S I hereby affirm that there is a construction'lending agency for YES❑ No i = AM fl 4 e+s:; a w the performance of the work for which this permit is issued(Sei O� HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING 3097,CIV.C;) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, TITLE 2,CHAPTER 2.20 SECTIONS 2.20,100 THROUGH 2.20.140 CONCERNING HAZARDOUS Lender's Name - MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. ' CL Lender's Address O OWNER OR AGENT o I I I have read this applic tion and state under penalty oft the ve inform/ Ion is rrect.I agree t compl P.C.FEE --PERMIT FEE wty di antes and tate 1 ws relating t buildi constan h ebyaut oriz r s ntatives Cou y ISSUANCE FEE �7 / - - -- ' toth :)oi- e ne r ert for insp f o OC GS.' �A INVESTIGATION FEE TOTAL FEE Dae • SEE REVERSE FOR EXPLANATORY LANGUAGE