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Home My Public Portal About4928 GLICKMAN AVE_Building__ OMPENSATION DECLARATION I herebyI have a certificate of consent to self1.. " �� APPLr _ : ION FOR BUILDING PER►: insure, or a ce ncate of Workers' Compensation Insurance, or n certified copy thereof (Seca 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No 41Compariy ��Tis f'00 > BUILDING ❑ Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN . ADDRESS `j QI2� �jLle_1 -,yt1-yrd 16'Via Certified co 'is filed with the count building inspec- BUILDING p PY Y 9 P 9 2 G U C.1e,ivt n-nJ Pv c` tion department. ADDRESS O T�✓v�, LK CJ T' Date �— ? Applicant CITY �-m s�' .C T`? zip �11�p LOCALITY l�.✓�� = GIS Q NO. OF BLDGS. - NEAREST l CERTIFICATE OF EXEMPTION OM WORKERS' SIZE OF LOT' _7R 39(G NOW ON LOT CROSS ST. COMPENSATION INSURANCE, // ASSESSOR (This section need not be completed if the permit is for one ' TRACT SU�(o<o BLOCK — LOT NO. E/! MAP BOOK Sf�S PAGE r PARCEL hundred dollars'($100) or.less.) TEL- OWNER S'T/at7�'r LIw'�L. DEV NO.M -1^aS S USE ZONE OP _/7�`�7 I certify that in the performance of the,work for which this tL 7 —Z SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS��( S �`IvuE�n � lZ1s'p I CONDITIONS so as to become subject to the Workers'Compensation Laws. O CITY'L'o ZIP C,0-V (U Date Applicant Cie ARCHITECT OR TEL.213 DISTRICT �GROUP,J,TYPE FIRE PROCESSED BY O NOTICE TOAPPLICANT: If, after making this.Certificate of ENGINEER S-r,6.(t-TS J114-TL {��v NO. (p'L�p�t 5 S CONST. ' ZONE �- Exemption, yoshould become,subject" T the Workers' Lfi 1e-G p s1 / 1 a Compensation provisions of the Labor Code,you-must forth- ADDRESS y S lb U� A �� !� a J )/ -- _ with comply with such provisions or this, permit shall be TEL.R 1 STATISTICAL_ LASSIFICATION. - APT. CONDO. N deemed revoked.. CONTRACTOR 1l.QTR_zN C�� •. NO. Z_ LICENSED CONTRACTORS DECLARATION LIC. ' CLASS N - DWELL. I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS(1 O3 S 51�+ 6 A'I 14t �•NO. GMEW (commencing with Section 7000)of Division 3 of the Business CITY $h.J LIC. SEWER MAP Ga(j(3l t--��- and Professions Code,and my license is in full force and effect. CLASS � BK. PG. - VALIDATION SQ."FT. NO. OF NO OF CHECK License Numberti7fi'� 'Lic. Class SIZE Qf2 D. STORIES FAMILIES ONE DESCRIPTION OF WORK SAd S b G VALUATION Contractors C` Date 'I T�� F'r f. L NEW, ❑ / ADD ❑ $ ❑I am exempt under Sec. �: .. ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF EXISTINGBLDG. `?FIS DEMOL ❑ Signature APPLICANT TEL.213 FINAL (PRINT,) 5?/!.(LTS I►.s"CL PIeV NO. , l SS C OWNER-BUILDER DECLARATION DATE 7—J I hereby affirm that I am exempt from the Contractor's License _ C�l4_ �oSO Law for the following reason,(Section 7031ADDRESS-G,6 1 S FIS(4r--A4..5, Business and '� FINAL •- , Professions Code): PRESENT. By' BUILDING ' ❑ I; as owner of the property, or'my employees with ADDRESS F 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. G Z t y ' CONTRACTOR NO.. .. ❑ I, as owner of the property, am exclusively contracting t:i. . 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 r S 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. 3 (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name i' r' G� 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 42,Y. 7 LDMA P/C# g above information is correct. I agree to comply with all County Investigation Fee R ordinances and State laws relating to building-construction, Total Feed LDMA Perm. # and hereby authorize representatives of this County to enter upon-the above-mentioned,property for inspection_purposes. a 3 SEE REVERSE FOR EXPLANATORY LANGUAGE. Si Lure of Applicant or Agent Date W:'. :OMPENSATION DECLARATION insure, arna cam. :: ;te of,Workers'have a tCompensation ificate of Sensuranent to lf A P P L I�,�:� ,`: ION FOR BUILDING PERM,- ,. or a certified copy thereof (Sec. 3800, Lab. C.) " COUN'TY OF LOS ANGELES BUILDING AND SAFETY Policy1_Z 236'Z —�(ompany .�Tfk`�'�—�.� ❑ Certified copy is hereby furnished. _ FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING / L�G�1✓I�I�I /�V�i ' .49 ZS (,LL&yA.Ntiondepartment. BDRESS >� Pry Date 3 r '�ZApplicant ?�7 CITY` IM zip O, 10LOCALITY -TeM L_1� -� NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FR WORKERS' SIZE OF LOT C.oN00 NOW ON LOT VVINCIA PT CROSS ST. �'' 1Z,0 SA COMPENSATION INSU NCE ASSESSOR . � (This section need not be completed if the permit is for one TRACT�00(p(p BLOCK LOT NO. MAP BOOK p� �S PAGE, PARCEL hundred dollars ($100) or less.) TEL. r USE ZONE MAP OWNER�j A I>E'�1. NO. NO. 7 �/ 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" 'e-, (.01WEF-- *ItO65 SPECIALCONDITIONS e yy so as to become subject to the Workers'Compensation Laws. O JI CITY L-05, AlaW—L6Ci ZIP 0 ( _ . 0 Date Applicant ARCHITECT O TEL NOTICE TO APPLICANT: If, after making.This .Certificate ofN ENGINEE ,(, ��j�� 7 DISTRICT GROUP TYPE FIRE PROCESSED BY.` O �i L)fJ&Z /"'"�`> N N/415� CONST. ZONE , 0 Exemption,.•you-'shoUld'became• subject to the Workers' p ��( b U Compensation provisions of the Labor Code, you must forth- .. ADDRESS l /�k e 'r/ LU, with comply with such.provisions or This permit shall beTEL. STATISTICAL CLASSIFICATION APT. CONDO. N deemed revoked.' CONTRACTOR _ p i �C NO. .'� Z_ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS s �� I hereby affirm that I am Licensed under provisions of Chapter 9 ADDRESS t d �� - —7 0 LIC. SEWER MAP % ,r",-•`" _ (commencing with Section 7000),of Division 3 of the Business rjyb� t L3 � and Profess ions.Code,and my license is in full force and effect. CIN CLASS BK PG � — ,_U�►LIDATION C. Z2 SQ. FT NO.:OF NO. OF CHECK License Number��0_�7y Lic. Class g SIZE ,f STORIES FAMILIES ONE "��SC L fJ G� S r� � VALUATION Contractor Date �—I —Pi2 DESCRIPTION OF WORK h leis NEW / �� T- ADD ❑ / � i!{g Air ElI am exempt.under Sec. ALTER 1:1 , t• Lt-Ci y?t:' a B.&P.C. for this reason*,, REPAIR ❑ $ Date: USE.OF. (` EXISTING BLDG. DEMOL-❑ Signature v APPLICANT w TEL. OWNER-BUILDER DECLARATION (PRINT] '� ,�` DATEFINAL G �� ``1 ULC, I hereby affirm that I am exempt from the Contractor's License _- -a 4 �., ,' e �_ _a a k ADDRESS ��_ C 3'�. ;... _�! y.: A i t, F Law for the following reason, (Section 7031.5, Business and FINAL _ Professions Code : . PRESENT By j BUILDING ❑ I, as owner of the property, or my:employees'with �I,\ ADDRESS C/��r . wages as their sole compensation,will do the work and .- , a the structure isnot intended or offered for sale(Section, [ADDR ITY ' 7044, Business and Professions Code.) NG TEL. . RACTOR NO. C j ❑ I, as owner of the property,am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code.) UIRED TOTAL SETBACK FROM EXIST. ` q, CONSTRUCTION LENDING AGENCY BACK YARD HWY PROP. LINE WIDTH _ -L a I hereby affirm that there is a construction'.lending agency for NT the performance of the work for which this permit is issued ' - (Sec. 3097, Civ. C.). , Lender's Name �+ LDMARef.:#Lender'sAddressee$ d Permit Fee / '1 certify that I have read this application and state that the Issuance Fee C 7 / LDMAP/C# above information iscorrect. I agree to complywith all County gation Fee N ordinances and State laws relating'to building construction, Total Fee �� LDMA Perm. # a and hereby authorize representatives of this.County to enter upon the above-mentioned property for inspection purposes. a SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ure of Applicant or Agent Date