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HomeMy Public PortalAbout4918 GLICKMAN AVE_Building__ APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDINP ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDRESS or a certificate of Workers' Compensation Insurance,or a certified �� GL�LIMA� copy thereof(Sec.3800,Lab.C.) S CITY ZIP Policy No./7-7-302-'! Company Ti-7L GUMO SIZE OF L�1 4-A G� 917-80 N LOCALITY SIZE OF LO NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. G 0^I�� NEAREST CR SST. Certified copy is filed with the county building inspection TR T / BLOCK LOT NO. ZuS�I department. �� ! ASSESSOR MAP BOOK PAGE PARCEL��d�v USE ZONE MA�ny2O! Date 9-14 Z£__ Applicant �L�QD� WNy ///��� S 7 _ /`— SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TE NO. / YES NO COMPENSATION INSURANCE :5-7AJZTJ ��r� /.7k'✓'. -/S'✓ WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS V DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) �/1j`�N I certify that in the performance of the work for which this permit /-zj 'IrE—m ZIP r O� 12-� ? is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. J .J become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO. D L UNITS NOTICE TO APPLICANT. If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject t0 the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith ?L� af' - C"`-ST FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS Jy�p LIC.NO. /.1 P L //`�' Ae�(/ Q SIDE ` LICENSED CONTRACTORS DECLARATION y LIC. LASS P L I hereby affirm that I am licensed underprovisions of Chapter 9SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ.FT.SIZ NO.OF STORIES I NO.OF FAMILIES Professions Code,and my licen a is in full force a/nnd effect. 7--.7NEW El BK PG ® a License Number Lic. Class 3`E—TION OF WORK App VALUATION Q T�'�y'J 60,15-f Date 3 ��^ ALTER E] $ 0 Contractor ElI am exempt under Sec. REPAIR 1:1 $ BAP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTINr 05-jo URM ❑ SignatureAPPLICANT(PRINT) T NO. J LDMA Perm# s z ❑ I, as owner of the property, or my employees with wages as C-0�s�' $ Z ��00 0 ANT.a ''=I e their sole compensation, will do the work and the structure is ADDRESS r S4N �' not intended or offered for sale (Section 7044, Business and j G/4 FINAL DATE a goo =11Ji 86.70 Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE { y {'� _ ❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY J !E"�[ licensed contractors to construct the project (Section 7044, YES Business and Professions Code.) WILL ❑ N I}a IL -F6 o 70 WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING _ OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH H t -86'.7^ CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKUST FOR CHECK [f I GUIDELINES. I hereby affirm that there is a construction lending agency for YES EIN J❑ CHANGE i{-NGE ,130 N the performance of the work for which this permit is issued(Sec. IHAVE READ THE RDOUSMATERIALS INFORMATION GUIDE AND ESC MDPERMITTING 3097,CIV.C.) CHECKI. U STAND MY RE4?,�RENUNDER THE LO ANG S COUNTY CODE, TITL 2.20 5 CTI SOUGH 2.20.14 C ERNING HAZARDOUS Lender's Name M RIA POR ING A D R P MIT FROM SCAQMD. j jit f l—� ISI f Ew' / j itl o Lender's Address 0 r i! s R OR Ac NT L;�1 11 o I certify that I have read is application and St a nder penalty 0 of perjury that the ve formation is correc agr e to comply P.C.FEE PERMIT FEE ©� with all dina es n State law/relafiiA to building co ction, d her y ze represe tativ of thi County ISSUANCE FEE ��1 enter up the ove i n propert ispectio urpo es. J a / � INVESTIGATION FEE TOTAL FEE ����wa o Avvuwm o[Agem SEE REVERSE FOR EXPLANATORY LANGUAGE Wt )MPENSATION DECLARATION insure,bor°a ..e offi Worke s'tCompensat Compensations Insurance, AP P L I L, . ION FOR BUILDING PERM.. or a certified copy t re4 jSec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy �0* i�� Company-5T74TC FLrJ3> Certified co is hereb furnished. FOR APPLICANT TO FILL IN BUILDING PY Y ADDRESS Certified copy is filed with the county building inspec- BUILDING �i G � J tion department. ADDRESS moi' /4 191-7W av-t Date �'1 9—�z Applicant CITY I:B� (.� GT ZIP LOCALITY —TV 1EM L-� 4-4 1 CERTIFICATE OF EXEMPTION F M WORKERS' SIZE OF LOT�B,)Dt:v NOW ON LOT VAC-At-YT NO. OF BLDGS. NEAREST CROSS ST. ( D COMPENSATION INSURANCE //,� ASSESSOR (This section need not be completed'if the permit is for one TRACT � MA �i�� BLOCK LOT NO. ' c� MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. �� OWNEf�jj�iL?S 6 NTL_ ©��/ N0�3( 1Ss US NO. T 1 certify that in the performance of the work for which this _ SPECIAL >- permit is issued, I shall not employ any person in any manner ADDRESSgq� S ��1 rd_ 1����j CONDITIONS fl- so as to become subject to the Workers'Compensation Laws. +, ^ r, U CIT Py =�L� � zip 00 Date Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER & L1NL " SOL NOZ13 j 5� ' DISTRICT GROUP TYPE FIRE PROCESSED BY Q _ CONST. SNE � Exemption, you should become subject to the Workers' F. ' U Compensation provisions of the Labor Code, you must forth- ADDRESS' I 6�a� .0 ���� �l` t / GLS CL with comply with such provisions or this N p y p permit shall be TEL. deemed revoked. CONTRACTOR—TAX*IJ C6'h ,NO. 7 , � STATISTICAL CLASSIFICATION APT. CONDO. Z LICENSED CONTRACTORS DECLARATIONIrk 5 �j�� G �13f�LC— LIC. tJ_ CLASS NO.�,0 DWELL. UNITS - I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS .NO. 0" �•w o (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP / 1 -z and Professions Code,and my license is in full force and effect. CITY h J f„tir Pl GL CLASS � BK -VALIDATION SQ. FT. NO. OF NO. OF CHECK PG' - - 4'' 11 ?2 1 License Number }HCl 6'14`,5 -Lic. Class � SIZE a STORIES FAMILIES ONE _ f I'!:_ /-- _ VALUATION Contractor �x�� 1� �`�J Date DESCRIPTION OF WORKI��tT LffJ NEW $: ���,d' e Ey'?.0 �p ADD ❑ „ ..,. ❑I am exempt under .& ALTER ❑ ® �� _ _ s i BP.C. for this reason $ CHANGE . -P REPAIR ❑ • Date: SE OF (\ EXISTING-BLDG. DEMOL' ❑ Si nature } APPLICANT r�TEL g FINAL (PRINT) OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License4. ,(, S � � ' n l _ Law for the following reason (Section 7031.5, Business and ADDRESS Y s V� FINAL L Professions Code): ESENT By BUILDING I, as owner of the property, or my employees with ADDRESS /Z' - •• 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 704 0 4, 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. Lender's Name, r d 11 w /'— r// A /,2'3J LDMA Ref. # , P.C. Fee$ Permit Fee Lender's Address o I certify that I have read this application and state that the Issuance Fee LDMA P/C# 8 above information is correct. I agree to comply with all County Investigation Fee n ordinances and State laws relating to building construction, Total Fee �a LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � Si n re of Applicant or Agent Date I