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HomeMy Public PortalAbout4840 GLICKMAN AVE_Building__ WORKERS' COMPENSATION DECLARATION swe,-or h er fica I •haver certificate of consent to Self APPLICATION F O:R BUILDING PERMIT ihs'ure,-or A certificate of Workers' Compensation Insurance, pr a certified copy thereof (Sec. 3800, Lab C. ' /�j _ COUNTY OF LOS ANGELES. BUILDING'AND SAFETY ♦Policy No./4�����y ompany /a �� BUILDING ❑ Certified copy --�-'is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department.' ADDRESS t?- Date Applicant CITY" CrZIPC 7/75--D 5-D LOCALITY NO. OF BLDGS. NEAREST, CERTIFICATE'OF EXEMPTION-FROM WORKERS' SIZE OF LOT !6 -? �, NOW ON LOT f CROSS ST. COMPENSATION INSURANCE' ASSESSOR p (This section'need not be completed if.the permit is for one TRACT 0 s^- BLOCK LOT NO. MAP BOOKJ�J PAGE�/� PARCELDa�� hundred dollars ($100) or less.)_ , qd TEL. 6 USE ZONE MAP E' OWNER ! I' Hf/tr C7 NO. �'d u���� NO. '7 r* I certify, that in the performance of the work far which this SPECIAL ' permit is issued, I shall not employ any person in any manner ADDRESS F (� CONDITIONS a so as to become subject to the Workers'Compensation Laws. O CITY ZIP Date— Applicant, ARCHITECT OR TEL. DI TRICT GROUP TYPE FIRE PROCESS51)BY I Q NOTICE TO APPLICANT: If,- after mal' g this Certificate of ENGINEER. _ NO.? �°j CONST. E Exemption, you should become subject .T the Workers' 1Iwa e, 9L&,Z1 I j'e a Compensation provisions of the Labor Code, you must forth- ADDRESS �Cll +^ with comply. with such .provisions or this permit shall, be / TE. STATISTICAL CLASSIFICATION APT. CONDO. deemed revoked. CONTRACTOR J �/✓ - No. �- O Z LICENSED,CONTRACTORS,DECLARATION �(� S• SL4.✓ 4g/�'�=[pC CLASS NO. DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ' O. .O (commencing with Section 7000)of LIC. SEWER MAP Division 3 of the Business - ./' - and Professions Code,and my license is in.full force and effect. CITY $�N.��� L CLASS t, BK PGS J 23 VALIDATION SQ. FT. TNo. OF NO. OF CHECK `-- ;e?n g � Lic. Class SIZE �� STORIES FAMILIES ONE ■s License' IVUm UCI __ - .. � •�•� DESCRIPTION OF WORK o._ TD NEW �fl VALUATION 407 Contractor - � Date - 1�� ADD- ❑ �' , i ITEMS. ❑I am exempt under Seca ALTER ❑ TOTAL. f 7 33 BAP.C.Jor this reason /� �I ."_ � '. REPAIR ❑ $,�G9/ !<' f'�t�hV Date: / - v UStEXIOF BLDG. (� tl E DEMOL ❑ CHECK 6381.78 Signature A_ PPLICANT `, TEL. FINAL ca' CHANGESII (PRINT) c, NO.77--_' Xe DATE 7 �j OWNER ILDER DECLARATION I hereby affirm that.l exempt from the Contractor's License 1�� t tel/ f - �f'�� fo ADDRESS ) �{ FINAL8 8 Law for the followi g reason_ (Section 7031.5, Business and � : /�j/ ,y ��t,�,t-���. of AMI 1: Professions Code): BUILDING NG By �t1J��Til:V ' ❑ I, as owner of the property, or 'my employees with ADDRESS t wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING: TEL. r y CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting �� with licensed contractors to construct the project (Sec- ADDRESS /'� !• i .41 tion 7044, Business and Professions Code, REQUIRED TOTAL SETBACK FROM EXIST.- CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH hereby affirm that there is a constructionlending agency for FRONT the performance of the work'for which this permit is issued P.L. (Sec. 3097, Civ: C.). SIDE P.L. Lender's Name 7 DA4 Ref. # Lender's Address P.C..Fee$ _3 Permit Fee 7• / P-4ab 3 + aI certify that I have read this application and state that the Issuance Fee 8 above information is correct. I agree to comply with all County Investigation Fee + � - r ordinances and State laws relating to building construction, Total Fee r' LDMA Perm. # a. and hereby authorize representatives of this County to enter aupon the above-mentioned property for inspection purposes. a `" SEE REVERSE FOR EXPLANATORY LANGUAGE - ' + u n n n Signature of Applicant or Agent Date S �! C-5 + .. WORKERS'COMPENSATION DECARATION here -ors'a affirm that I'have a certificate of consent .o self APPLICATION FOR BUILDING PERMIT inslNre,•or:a certificate of Workers' 'ation Insurance, or a certified copy thereof (Sec. 3800rLab. C.) %0 COUNTY OF LOS ANGELES BUILDING AND SAFETY ,Folic No.�2-23029 Com Company P Y , ❑ Certified co is hereb furnished. /%�V/�/ FOR APPLICANT TO FILL IN BUILDING PY Y• ADDRESS —A lie ms;34 ❑ Certified copy is filed with the county building inspec- BUILDwG / tion department. ADDRESS p CITY Z ` LOCALITY Date / Applicant O. 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 tJ BLOCK LOT NO. MAP BOOK . PAGE PARCEL!/Oi hundred dollars ($100)-or less.). TEL OWNER NC � . USE ZONE MAP NO. `* I certify that in'the performance of the'work for which This _ SPECIAL permit is issued, I shall not employ any person in any.manner ADDRESS 1-7 Q �� CONDITIONSCL so as to become subject to the.Workers'Compensation Laws. O 61,TY iUW V (�6�—`,ZIP D� V Dote �Applicant. ARCHITECT OR :// \ TELiL� /' NOTICE TO APPLICANT: If,, after. ma g this Certificate of ENGINEER !s k NO• •� DI TRICT GROUP TYPE FIRE PROCESSED BY O CONST. ZONE I Exemption, you .should become.'s ject to the Workers' ` \ (� `_ U Compensation provisions of the Labor.Code, you must forth= ADDRESS) ( v /I CONST. �` -� a- with comply with ,such provisions or This.permit shall be STATISTICAL CLASSIFICATION, APT. CONDO. N deemed revoked. CONTRACTOR �F�JC.�/✓rrct�!� ;"'�J NO, �'T6 G?�(r7 ,,��qq Z LICENSED CONTRACTORS DECLARATION !v3 �. 5.,�.r{_ E 9 `t'QC• CLASS NO.�J DWELL. UNITS I hereby affirm that l am licensed under•prov"isions of Chapter 9 'ADDRESS'' O.' p:_ LIC. SEWER MAP - �. (commencing with Section 7000)of.Division 3 of the Business —,-/ _ 23 - and Professions Code,and my"license is in full force and effect. \ CITY -d-pp- �z CLASS '� BK. PG: VALIDATION SQ:FT. NO. OF NO. OF CHECK License Number e_ 7 ��Lic. Ciass 0� SIZE j STORIES FAMILIES / ONE 7�/xlD ^J ��Date p DESCRIPTION OF WORK �y�1j'tp NEW VALUATION yry ' � Contracto ❑I am exempt under Sec. f-71 ADD ❑" �/� TE r ALTER .❑. r ► I DIAL 6.u6 a 60 B.&P.C. for this reason REPAIR1:1a/� o�o. Q� CHRK Dater=��/ EXISTING BLDG. ytiS� DEM OL ❑ l +�-L,�I� CHANE t Signature `��' APPLICANT.. TEL, /� _�� OWNER LDER DECLARATION - (PRIN7g ` NO. �,� FINAL 7- / I hereby affirm that I exempt from the Contractor's License 1. '� : DATE Law'for The"following reason (Section 7031.5, Business and ADDRESS � L �'i 77 FINAve ;A " ��i �'Pr.ofessions.Code): PRESENT BY5001 AM Je�l1l ❑ I; as owner of the property, or `m employees with BUILDING P P Yt YADDRESS wages as their sole compensation;will do the work and a , 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 r with licensed contractors to construct the project (Sec- ADDRESS I /�'�' l ," tion 7044, Business and Professions Code.) h CONSTRUCTION LENDING AGENCY SET BACK REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. 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 F.=4 i a Lender's'Name, i...,i LDMA Reft i# fTt P.C. Fee$ p 6 Permit Fee /�%�'�� '�i i• Lender's Address , 0 1 certify that I have read this application and state that the Issuance Fee f- LDMAP1C# 8 above information is correct. I agree to comply with all County Investigation Fee O ordinances and State laws relating To building construction, Total Fee LD/vt,- Perm. # a and hereby authorize representatives of this County to enter i upon the above-mentioned property for inspection.purposes. o SEE REVERSE FOR EXPLANATORY LANGUAGE T. n Signature of Applicant or Agent Date F' ` t,rni WORKERS: COMPENSATION DECLARATION igsuret'graa certificate of Workers' Compensation eIn uran el,, APPLICATION FOR . BUILDING PERMIT or a certified copy thereof CC��(Sec. 3800, L C.) COUNTY-OF LOS ANGELES BUILDING AND SAFETY V� Po&Y Ng� .�r/—CoA pony BUILDING • ❑ Certified copy is hereby furnished. cJ FOR APPLICANT TO FILL IN - ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESSO.r CITY °t ZIP v LOCALITY Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE-OF EXEMPTION FROM-WORKERS' SIZE OF LOT v S,' NOW ON LOT ' CROSS ST. COMPENSATION INSURANCE ASSESSOR �^ (This section need not be completed if the permit is for one TRACT O � BLOCK LOT NO. MAP BOO AJ - PAcFe�� PARCELleag43 hundred dollars ($100) or'less.) . TEL. US ZONE MAP •. 17 3 <'. OWNER- � NO. .. NO. � I certify that in;the performance of the work for which this SPECIAL permit is issued,']shall not employ any person in.any manner ADDRESS' 7 ' ECIAL ONS n- so as to become subject To the Workers'Compensation Laws. O CITY IF p, U Date �/ v 'Applicant ARCHI ECT OR TEL. C a! ENGINEER NO. o DISTRICT GROUP TYPE :FIRE PROCESSED BY NOTICE TO APPLICANT: .If, after.:makin thi ertificate of CONST. ZONE 0 Exemption, you should become subj ct o the..Workers' �� G Gj { p /oG u Compensation provisions of the Labor e, you must forth- A DRESS YCL with comply with such.provisions or this permit shall be TEL // �7 STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked. 'CONTRACTOR M�Ll_ O00 Crr%�S% No. �X60 /1p f'� Z LICENSED CONTRACTORS DECLARATION i / LIC. p iCLASS'NO. V © DWELL. ONITS�/ ADDRESS 1103 ,cE.tf�ji/+g C3LNO. S-7o / 7 I hereby affirm that I am licensed under provisions of Chapter 9 LIC.. SEWER MAP i� (commencing with Section 7000).of Division 3 of the Business CITY ��✓ q?^91st C— CLASS and Professions Code,and my license is in full force and effect. BK pG� q�T�/9d.IDATION 14, e, ic. Cass SQ.. FT. s STORIOF N-0-0F I HEC - 1t14T�^ License Numb 1�f ul g7.P L' I _ p. t.. VALUATION lul.yl_I Contractor — o Date 7 —l7 — DESCRIPTION OF WORK '�Q NEW ❑ �j q ITEMS _ I��v(r I ADD ❑ �/�` 1 I am exempt under Sec. TOTAL. "�0 1.90 ALTER ,❑ l�t1��+lf B.&P.C. for this reason rsfclo� t" REPAIR ❑ $ `��9 c_.t CHECK 701.90 . Date: 9/ —' J U OF q� DEMOL ❑ � I fir✓V v - GV EXISTING BLDG. f/ Signature APPLICANT TEL. FINAL OWN - ILDER DECLARATION (PRINT) (rJ ��� NO. (AIDS DATE�~ � � I hereby affirm that I m exempt from,the Contractor's License -so �� - ��L & O tu`v o ' Law for the following reason (Secfion 7031.5, Business and ADDRESS P FINAL —�4 � ti �i�'��li Professions Code): PRESENT By -Iv �"JV� i t7ldlt�t71 BUILDINGEl 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 \ Er 1 e 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- c �,. ADDRESS17 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. s;d H .r (Sec. 3097; Civ. C.). SIDE f Lender's Name, m LDMA Ref. #+ Irl alh Lender's Address P.C. Fee S Permit Fee M� 1 1 certify that I have read this application and state that the .F,;2. Issuance Fee above information is correct,-I agree to comply with all County Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee s � LDMA P . #_ a and hereby authorize representatives of this County to enter upon the"above-mentioned property for,inspection purposes. r=� + ri• +' C+' a o SEE REVERSE FOR EXPLANATORY LANGUAGE ` )+ 11 rt -,_fit o '-n r ,ti+ rr- r+•. s Signature of Applicant or Agent Date Wq, :ERS'COMPENSATION DECLARATION of conse�t to insure,,-or-affirm certificate of Worke srlificate Compensat on Insuran elf - APPLICATION FOR BUILDING PERMIT pr a certified copy thereofJSec. 3800, Lab. C.) 0. q � ���� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.,42,24WIF Company, ❑ BUILDING Certified copy is hereby furnished. ` FOR APPLICANT TO FILL IN ADDRESS ® ❑ Certified co is filed with the count buildinginspec- BUILDING fr(?�L l / tion department. y p ADDRESS 4. 7-D`- 1- A7,,�/� 4e'��t CI, -r �/f� ZIP(/s-T�17e3-+� LOCALITY Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE"OF LOT �- NOW ON LOT fIfo CROSS ST. I^ COMPENSATION INSURANCE ASSESSOR p pc- (This section need not be completed if the permit is for one TRACT ( Q Z BLOCK LOT NO. MAP BOOK ✓"pjOJ #1{GE d�� �ARCELO d hundred dollars ($100) or less.) TEL. / ' �qq �✓ USE ZONE MAP 027 r OWNER � J"c� '('� NO. �` �oNO. `� I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner ADDRESS �►2 1 � ia� SPECIAL l+ CONDITIONS so as to become subject to the Workers'Compensation Laws. "� O CITY I<UjIS —� �/ '� ZIP l /�7 U Date —/9—��Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE P OCESSED BY 0 NOTICE TO APPLICANT: If, after maki this Certificate of ENGINEER NO. % �/ CONST. ZONE Exemption, you should become subj ct to the Workers' I �, e-AIS ;}��io- fjL-I/t0 4 � l U Compensation provisions of the Labor Code, you must forth- ADDRESS S!1J"_ VT ,/ d with comply with such provisions or this permit shall be T L. STATISTICAL CLASSIFICATION O APT. CONDO. Z deemed revoked. CONTRACTOR _T / G, NO. 2�G(� _ LICENSED CONTRACTORS DECLARATION t/v y S. $/eti G�.a Jt'�C(LIC. CLASS NO. o DWELL. UNITS I hereby affirm that I am licensed under,provisions of Chapter 9 ADDRESS �lO. 5-7D g LIC. SEWER MAP rJ-c (commencing with Section 7000)of Division 3 of the Business SA/✓ �6,� C C. CLASS 1 23 and Professions Code,and my license is in full force and effect. CIN BK. ^PG. VALIDATION SQ. FT. 6,1 NO. OF NO. OF ] CHECK — License Number 5'��Q /?713'1 Lic. Class SIZE ISTORIES �— FAMILIES ( ONE °T �vr` / 3 DESCRIPTION OF WORK ��/ {� NEW VALUATION 37,07 +"++4? -y{, Contractor lfiK (b�Cv Date � f I� Poo. +���',r v IS RLI am exempt under Sec. 8 C4,L&# A _G, ADD ❑ — TOTAL T ��� ALTER ❑ ®�� � tlJlAL1 °° 8.&P.C. for this reason REPAIR ❑ + �,� �! ��� -, USE OF C K K3 ■78 Date:p r� �� EXISTING BLD f V✓�� DEMOL 0 CWGE X00 Signature _ APPLICANT TEL.k �? �u� ZT FINAL / OWNE ILDER DECLARATION �(PRINT) NO,�` DATE (�" / I hereby affirm that I m- exempt from the Contractor's License L� , � � {� U'I�Ot � t•+ Law for the following reason (Section 7031.5, Business and ADDRESS Q L-7 FINALp ; !r !:9 Professions Code): PRESENT BY r l 5003 ) h •� BUILDING J 1-{ C�m■ �t ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY r (C � i 7044, Business and Professions Code.) MOVING TEL. , , r.?, .J,:'< ', CONTRACTOR❑ NO.I, as owner of the property, am exclusively contracting Gj G �J l with licensed contractors to construct the project (Sec- / '� ,' i , •'. Tj'; ADDRESS tion 7044, Business and Professions Code.) REQUIRED /YARD HWY TOTAL SETBACK FROM EXIST. / . CONSTRUCTION LENDING AGENCY SETBACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE -� i°M; -• P.L. �.. P f'.i "-•I Lender's Name, ,� :�� y;,.. c•a. a t' P.C. Fee$ �ps ,� Permit Fee �� LD/NYA Ref. # Lender's Address tl y�• . t-r'i 0 1 certify that I have read this application and state that the rd �(o. / �� Issuance Fee /' '�- LDP/C# 8 above information is correct. I agree to comply with all County Investigation Fee" ordinances and State laws relating to building construction, Total Fee / % /J, LDMA Perm. a and hereby authorize representativesof this County to enter upon the above-mentioned property for inspection purposes. r,, t- r?::t Cxi CX3 a9 .3 _I:•.. 4, SEE REVERSE FOR EXPLANATORY LANGUAGE 'Cl CD C:" Signature of Applicant or Agent Date t_: _. i s - [:r•.