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Home My Public Portal About9150 EMPEROR AVE_Building__ • I WORKERS'COMPENSATION DECLARATION,, hereby affirm that I have r certificate of consent to self �A P P L I CAT I O N FOR BUILDING PERMIT sure, or a certificate of Workers' Compensation Insurance, v rpy 2�trfied reof 3800 Lab. C.) W(�D y a COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Compo BUILDING ❑ Certified c p is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDINGC111--' ( vim �i tion department.. ADDRESS � �/17 eh� r v C, LOCALITY t2j NEAREST Date Applicant CITY 2 �(� ZIP CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' //'� NO.OF BLDGS. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT 1OZ /C(QV NOW ON LOT 2— MAP BOOK PAGE PARCEL (This section need not be completed,if-the permit is for one /� USE ZONE MAP hundred dollars ($100)or less.) TRACT. & BLOCK LOT NO. NO. TEL. c� / SPECIAL I certify that in the performance of the work for which this OWNER qi S G 0g �ro�Ooco ! CONDITIONS permit is issued, I shall not employ any person in any manner //S DISTRICT .GROUP TYPE FIRE PROCESSED BY O so as to become subject to the Workers'Compensation Laws. ADDRESS J(! 4 /h e Y—O e- CONST ZONE U !7 S 5 t 4 de Date Applicant CITY e_ ZIP STATISTICAL CLASSIFICATION APT. JCOV. h ARCHITEC TEL. --yy NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER N StF� I CLASS NO. DWELL. UNITS W Exemption, you should become subject to the Workers' � Compensation provisions of the Labor.Code, you must forth- ADDRE64 a SEWER MAP with comply with such provisions or this permit shall be TEL. deemed revoked: CONTRACTOR a Q N -P13 BK. PG, VALIDATION LICENSED CONTRACTORS DECLARATION UC. 1 hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 6 NO-c3_5VALUATION (commencing with Section 7000)of Division 3 of the Business and LIC. J,C0,1dProfessions Code, and my license is in full force and effect. CITY r CLASS $ � , s� SQ. Ft-.,/,,f NO. OF / NO. OF CHECK License Numb e u Lir.Class_ SIZE STORIES / FA ILIES / ONE Confractonava( Date _ DESCRIPTION OF WORK NEW $ J ADD ❑ C ❑ I am exempt under Sec. a V o ALTER ❑ FINAL ' B.BP.C. for this reason ❑ DATE r� a. REPAIR Date: USE OF � FINAL EXISTING BLDG. ,�% v v DEMOL ❑ B `cL_J Signature APPLICANT TEL.'' ``�� _p Y OWNER-BUILDER DECLARATION PRINT) �NO.�y/ !O Q e_' A I hereby affirm that I am exempt from the Contractor's License ADDRESS 6 �L ► ®yam Law for the following reason (Section 7031.5, Business and Professions Code): PRE ENT r r 4 �' ❑ BUILDING ;` 0 0 0 0 0 1 I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and J t r the structure.is not intended or offered for sale(Section LOCALITY ° L J 6 3 7044, Business and Professions Code). MOVING TEL. c c 1 J 3 ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project.(Sec- C. f 0— tion 7044, Business and Professions Code). ADDRESS 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 FFONT ► the performance of the work for which this permit is issued . (Sec. 3097, Civ: C.). E Lender's Name Lender's AddressFee$ Permit Fee, �. I certify that I have read this application and state that the Issuance Fee above information is correct.I agree to comply with.all County Investigation-Fee g ordinances and State;lawsrelating to building:construction, _ u and hereby authorize representatives of this County to enter ToraLFee 2 m upon the above- Toned p er y for,inspection purposes. "^ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appiica or Agent Date, ®s ' DBS-3 25M BETS 6-46 T� DEPA*MMENT OF BUILDING AWD SAFETY APPLICATION FOR PERMIT COUNTY OF LOS ANGELES LDING WM. J. FOX, CHIEF ENGINEER I FOR APPLICANT TO FILL IN FOR OFFICE USE ONLY /�7 / y j��✓, ,� ,g DISTRICT NO. PLAN CK. NO. PERMIT NO. BUILDING ADDREB9 LOCALITY RE�CJC�EI`V�ED �S7Y DATE OF APPL. DATEISSUED � NEAREST CROSS ST. BUILDING OWNER �w✓�'�"9 ,'.'"•""�, ADD ESS ADDRESH LOCALITYMAIL TEL. /t-A�y CROSS ST. CITY dam- CO N O. "Y' '1" FIRE NO.OF TYP I GROUP ARCHITECT OR - — TEL. ZONE �- I PLANB— ENGINEER NO. BLDG. )wD. NO. ADDRESS SETBACK LINE c / APPROVED r CONTRACTOIC" -NO. 3 / TJ�I BY DATE Q USE APPROVED ADDRESS /C/�/ /VD Si�. Z. �aj4u l ZONE r BY DATE LEGAL DESCRIPTION I LOT NO. � I BLOCK CORRECTIONS TRACT NO. OF BLDGS2///�,,,,�� SIZE OF LOTS I NOW ON LOT (�4T[t� USE OF NO.Or NO. OF EXISTING BLDG. I FAMILI[S I ROOMS o DESCRIPTION OF WORK NEW ALTERATION ADDITION O A REPAIR p; MOVING DEMOLISH 0 SQ. FT. 4 g NO.Or S— / Z SIZE tCd ROOMS STORIES D r WALL ROOF _ COVER ING.616 e� I COVERING UBE OF NEW BUILDING ! � ✓'�G .'%I' ®G G1 2. 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPROVALS - - APPLICATION AND STATE THAT THE ABOVE IS CORRECT FOUNDATION: LOCATION, INSPECTOR DATE AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES FORMB, MATERIALS AND STATE LAWS REGULATING BUILDING CONSTRUCTION. FRAME: FIRE STOPS, SIGNATURE Or BRACING, BOLTS OWNER LATH, INT.: AUTHORIZED AOT LATH, EXT.: - $ P. C. S �s� PLASTER, INT. n 4.7® !B FEE PLASTER, EXT. I p' ^ - VALUATION FEE /eD,4 FINAL