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HomeMy Public PortalAbout9021 EMPEROR AVE_Building__ \ - 1 WORKERS' COMPENSATION DECLARATION to self insurebor°afcertif certirm that Iificate of Works s' Compensat onhve a certificate of5ent Insurance, A P P L I CA`s'I O N FOR B U I L D I NGP E RM I T or a certified co thereof (Sec. 3800�, Lccabb�C.) � Policy N ��� � Company .J(fy7� TU/1.�0 COUNTY OF LOS ANGELES BU12 ILDING AND SAFETY aBUILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS O JE � P Certified copy is filed with the county building inspec- BUILDING tion d2eportment. ADDRESS C DG+/ ice/P 04I�E LOCALITY 1 P Date `3 ol J�/�AZE T ZIP 9 p NEAREST a Applicant CITY J �(,�Q CROSS ST. ERTI ICATE OF EXEMPTION FROM WORKERS' NO. OF BLDGS. ASSESSOR I S� O COMPENSATION INSURANCE SIZE OF LOT 223,4 NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one I // USE ZONE MAP Loo hundred dollars ($100)or less.) TRACT BLOCK LOT NO. c� NO. �w TEL. •� SPECIAL � I certifythat in the performance of the work for which this OWNERf.M DK NO. G CONDITIONS P DISTRICT GROUP TYPE FIRE PROCESSED BY O permit is issued, I shall not employ any person in any manner ADDRESS7561�! /� /� CONST. ZONE V so as to become subject to the Workers'Compensation Laws. /J �• g �✓1 / CITY G'IY ZIP �Z4Z V 0 Date Applicant ARCHITECT O TEL. STATISTICAL CLASSIFICATION Q APT. CONDO. NOTICE TO APPLICANT: If, after making this Certificate of L S DWELL. UNITS�S` LU Exemption, you should become subject to the Workers' ENGINEER NO CLASS NO. mi fi 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 NO. / BK- PG. f VALIDATION LICENSED CONTRACTORS DECLARATION LIC.. WISH � I hereby affirm that I am licensed under provisions of Chapter ADDRESS J S NO. VALUATION CHEk�a6�fliut �j�°hI w"' (commencing with Section 7000)of Division 3 of the Business and hh /n��� LIC. F9P","i. C,,J]zF,!,bQ f j3n F Professions Code,'and my license is in full force and effect. CITY`EJB OA CLASS 1 $ I 260j of)c> ► +� . :?� :' SQ. FT.' / fp N . OF NO. OF' CHECK License Number Lic:Class SIZE / y!�'D STORIES FAMILIES ONE Contractor Date DESCRIPTION OF WORK l.3' J NEW $ ADD ❑ I am exempt under Sec. C©� `� ALTER FINAL B.&P.C. for this reason 6V l S 4 f fG62 . BY 1 REPAIR DAUSE TE Date: EX STOING BLDG. DEMOL FINA Signature APPLICANT TEL. 1 OWNER-BUILDER DECLARATION PRINT �Ci�i�Q NO. I hereby affirm that I am exempt from the Contractor's License r7 ^ r Law for the following reason (Section 7031.5, Business and ADDRESS Professions Code): PRESENT ^j^' DBUILDING doe—, I, as owner of the property, or my employees with ADDRESS '�'� � wages as their sole compensation,will f o 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 1HWY PROP.-LINE .WIDTH,- I hereby affirm that there is a construction lending agency for FRONT / //II ( j I \ -, the performance of the work for which This permit is.issued P.L. (Sec. 3097, Civ. C.). SIDE m P.L. / a Lender's Name p' , P.C. Fee$ Q 7 Permit Fee t : Lender's Address I certify that I have read this application and state that the Issuance Fee142, above information is correct. I agree to comply with.all County Investigation Fee ordinances and State laws relating to building construction, Total Fe t� d and hereby authorize representatives of this County to enter m upon ala v ntioned property for inspection purposes. �t9 3 ? SEE REVERSE FOR EXPLANATORY LANGUAGE n +-t ' Signature of Applicant or Agent Dat ®s WORKERS'COMPENSATION DECLARATION hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT � insure, or a certificate of Workers'Compensation Insurance, or a certified copy thereof (Sec. 3800 Lab. C.) �j rj N /4_ � r COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy N 13 Companv/J �-G�y y BUILDING (L�1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING ,yy�� � tion department. ADDRESS , 4V LOCALITY ' T q NEAREST Date % YV 4,3 Applicant CITY ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' /� NO. OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT L�X 5 O NOW ON LOT MAP BOOK PAGE PARCEL (This section need not be completed if.the permit is for one r USE ZONE MAP hundred dollars ($100)or less.) TRACT J BLOCK LOT NO: �D NO. IIS wS TEL. SPECIAL y. I certify that in the performance of the work for which this OWNER NO: -�� CONDITIONS permit is issued, I shall not employ an person in an manner r DISTRICT GROUP TYPE FIRE PROCESSED BY O p p y y p y ADDRESS SD �7� a/ �� / CONST. ZONE so as to become subject to the Workers'Compensation Laws. M Date Applicant CITY ARCHITECT OR ZIP TEL.!!&,q_4?_ STATISTICAL CLASS KATION APT. CONDO. NOTICE TO APPLICANT: If,.after making'this Certificate of ENGINEER NO. CLASS NO. DWELL. UNITS LU Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP rA with comply with such provisions or this permit shall be z deemed revoked. TEL' BK. PG, VALIDATION CONTRACTOR AJ NO. LICENSED CONTRACTORS DECLARATION �` LIC. p /� I hereby affirm that I-am licensed under provisions of Chapter 9 ADDRESS7r) o)I 40Ja0-7 NLO 7 VALUATION (commencing with Section 7000 of Division 3 of the Business and ( 9 ) /�� LIC. j)u Professions Code, and my license is in full force and effect. CITY �o� f,/t- CLASS 6' $ 12,q a� 001.�,...� SQ. FT. NO. OF NO.OF CHECK License NumbberLic.Class_ SIZE STORIES FAMILIES ONE Contractor) 'J$? Date DESCRIPTION OF WORK NEW ❑ $ I am exempt under Sec. LO ^7� (� ADD ❑ ALTER ❑ FINAL/ REPAIR B.&P.C. for this reason ❑ DATE USE OF FINAL f a Dare: EXISTING BLDG. DEMOL ❑ By Signature APPLICANT TEL. OW ER-BUILDER DECLARATION PRINT NO. 1 herebyaffirm that I am exempt from the Contractor's License �r ° o 711 _ Law fothe following reason(Section 7031.5 , Business and ADDRESS ( � :`.o C 0 'o Professions Code): PRESENT ° " 1 21, BUILDING D I, as owner of the property, or my employees with ADDRESS Q wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY rz 3 1 ` F 7044, Business and Professions Code). MOVING TEL. 11 1, as owner of the property, am exclusively contracting• CONTRACTOR NO. o 0 0 0 0 1 with licensed contractors to construct the project (Sec- tion 7044, Business and Professions Code). ADDRESS L o 1 T J. O C REQUIRED TOTAL SETBACK FROM dWXID'STTH CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE I hereby affirm that there is a construction lending agency for FRONT C the performance of the work for which this permit is issued P.L. `n (Sec. 3097, Civ. C.). SIDE Q . 16-83 m P.L. o Lender's Name P.C.Fee$ `� •3 Permit Fee Lender's Address I certify that l have read this application and state that theIssuance Feeabove informalion is correct:I agree to comply with.all County Inve3ti.gation Fee ordinances and State.laws relating to building construction, Total.Fee u and hereby authorize representatives of this County to enter ove-mentioned property for.inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ®s Signature of Applicant or Agent Date WORKERS'COMPENSATION DECLARATION �� y hereby affirm that I have a certificate of consent to self APPLICATION FOR BUILDING. PERMIT insure, or a certificate of Workers'Compenstion Insurance, or a certified copy thereof (Sec. 3800, Lab. C..) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. FOR-APPLICANT TO FILL IN' ADDRESS —2� Certified copy is filed with the county building inspec- BUILDING J tion department: ADDRESS Q �(J LOCALITY -GL /'� NEAREST Date Applicant CITY l.-i ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' 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 USE ZONE MAP TRACT BLOCK LOT NO. NO. 'hundred dollars ($100)or less.) _ � o � > TEL. SPECIAL ��A- / r CL certify that in the performance of the work for which this OWNER �E/vv� le NO. CONDITIONS O permit is issued, I shall not employ a erson in any manner DISTRICT GROUP TYPE FIRE PROCESSED BY (J so as to be o e subject to the Wor r 'Comp sation Laws. ADDRESS CONST. 3NE /(/ Dote Applicant l CITY 3 ZIP STATISTICAL CLASSIFICATION APT. CONDO. U ARCHITECT OR TEL. yd NOTIC T APPLICANT: If, after ma i this Certificate of ENGINEER NO. CLASS NO. �- DWELL.,UNITS �� D- Exemption, you should 'become s b` ct to the Workers' y Compensation provisions of the Labor Code, you must forth- ADDRESS SEWER MAP z with comply with such provisions ori this permit shall be /6 Q deemed revoked. CONTRACTOR E)ed Jftl,'471A0. 4�T Y 23 BK. t"PG, ` � VALIDATION LICENSED CONTRACTORS DECLARATION ��tt 'r LIC. I hereby affirm that I am'licensed under provisions of Chapter 9 ADDRESS�ed 6.Qk ''"1.� NO. � I� VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. /1� Professions Code, and my license is in full force and effect. CITY %CL CLASS L/2 Z� $ C f SQ. FT. NO. OF NO. OF CHECK License Number 4-0 � Lic. Class C/7" C,2_ SIZE STORIES FAMILIES ONE Contractor �1�C/Q�.ri,�n�/�' DESCRIPTION OF WORK j, :NEW ❑ $ _T 7X[L+ Date K . .�' ADD ❑ I am exempt from the licensing requirements as l am a -tii licensed architect or a registered professional engineer ALTER ❑ FINAL acting in my professional capacity, (Section 7051, REPAIR ❑ DATE Business and Professions Code). USE OF EXISTING BLDG. _ DEMOL B,,"AL Lic:or Reg: No. _Date APPLICANT TEL. y OWNER-BUILDER DECLARATION (PRINT) r� NO. Z 4i$iZ3 I hereby off irm that I am exempt from the Contractor's License �y.,�. ' Law for the following reason (Section 7031.5, Business and. ADDRESS-?0_5 �' L" kt Professions Code): PRESENT �( F-1BUILDING I, as owner of the property, or my employees with ADDRESS z 5'3 5 9`A 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. #.0 0 0 0 0 ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. 2 with licensed contractors to construct the project (Sec- 2'a ° 3.8 5 0 tion 7044,Business and Professions_Code). ADDRESS REQUIRED TOTAL SETBACK FROM EXIST. ° ° 0 3$5 0:=3 CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT 0 37 8 2 the performance of the work for which this permit is issued PL L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name Lender's Address P.C. Fee$ Permit Fee w 1 certify that I have read this application and state that the Issuance Fee Q S v aa bove'information is'correct. I agree to comply with all County Investigation Fee (/ ordinances and State laws relating to building construction, Total Feea and reby authori representatives of this County to enter e up e above-m rationed property for inspection urp es. a SEE REVERSE FOR EXPLANATORY LANGUAGE Si Lure of Applicant or Agent j WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self I insure, or a certificate of Workers'Compenstion Insurance, or APPLICATION .FOR. BUILDING PERMIT a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. B WING FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- FG tion department. u LOCALITY NEAREST IDate Applicant ZIP CROSS ST. CERTIFICATE.OF EXEMPTION FROM WORKERS' NO. OF BLDGS. i ASSESSOR COMPENSATION INSURANCE J �, NOW ON LOT ` MAP BOOK PAGE PARCEL (This section need not be completed if the permit is for one USE ZONE EMAP hundred dollars ($100)or less.) TRACT BLOCK LOT NO.' TEL. AL1 certify that in the performance of the work for which this OWNERNOITIONS permit is issued, Isha11 not employ ahy.person in any manner c'r _ `` ,, DISTRICT GROUP TYPE FIRE PRO SSED BY V so as to become subject to the Workers'Compensation Laws. ADDRESS ��J 1L4/hlCq� 4.ttyJ� Qu CONST. ZONE Id I CITY ROZIP 0 Date Applicant STATISTICAL CLASSIFICATION APT. CONDO. I NOTICE TO APPLICANT: If, after making this Certificate of ARCHITECT OR s TEL. 2 p Y ENGINEERv JMA V N0. Z63� CLASS NO. DWELL. UNITS CL400 Exemption, you should become subject to the Workers' 4A Compensation provisions of the Labor Code, you must forth- ADDRESS / 14,0.02 ,F�e SEWER P with comply with such provisions or this permit shall be j deemed revoked. TEL' '� VALIDATION CONTRACTOR n►g'L NO. BK. PG, - LICENSED CONTRACTORS DECLARATION LIC. �� I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS S �Q� (,L '�Z, NO a VALUATION (commencing with Sectio 7000)of Division 3 of the Business and LIC. f/ �Do, IVU Professions Code, and m license is in full force and effect. CITY CLASS $ SQ. FT. NO. F NO. OF CHECK License Number Lic.Class SIZE STORIES I FAMILIES ONE $ Contractor Date DESCRIPTION OF WORK NEW . ADD I am exempt from the licensing requirements as I am a, l' AC licensed architect or a registered professional engineer ALTER ❑ FINAL acting in my professional capacity (Section 7051, va—o .t,! REPAIR DATE Business and Professions Code). USE OF EXISTING BLDG. DEMOL FINAL Lic.or Reg. No. _Date APPLICANT TEL. By OWNER-BUILDER DECLARATION (PRINT) NO. I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and ADDRESS r' Professions Code): PRESENT � -:Z3 Y BUILDING ] D I, as owner of the property, or my employees with ADDRESS xt .5� 7 2 D v I 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. 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, 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 P.C. Fee$ (o/ .Z 0 Permit Fee 71 Lender's Address w I certify that I have read this application and state that the Issuance Fee aabove information is correct. I agree to comply with all County nvestigation Fee 0 ordinances and State laws relating to building construction, Total Fee and hereby authorize representatives of this County to enter Q upon the above-mentioned property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE o Signature of Applicant or Agent Dote - ©s