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HomeMy Public PortalAbout4938 GLICKMAN AVE_Building__ Wr ')MPENSATION DECLARATION insure,hereby of Workers' Compensationve a certificate of Insurance, AP P L I�._- . ION FOR BUILDING PERMent to self ` or a certified cop thereof (Sec. 3800, Lab. C.) Jzz� � COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. v _ C�mpany .5 r FU tJ-'t- Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDINGADDRESS Certified copy is filed with the county building inspec- BUILDING department. BILI Date- ' Z Applicant f ZIP 911 o LOCALITY—`=, NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FRO ORKERS' SIZE OF LOTC�I�-O NOW ON LOT V/k t-� CROSS ST. COMPENSATION INSURA CE ,' �c (This section need not be completed if the permit is for one N TRACTV✓C�Q BLOCK LOT NO. MAP BOOK SV-15' PAGE 1� PARCEL �3.) hundred dollars($100)or.less.) �y TEL. OWNERc' NO,`U z�;,(y�mql USE ZONE MAP 1 certify that in the performance of the work for which this NO, permit is issued, I shall not employ-any person in any manner ADDRE '�_-, W�.�— � SPECIAL CONDITIONS _ CL /�i�JZL so as to become subject to the Workers' Compensation Laws. � CITY Los w&C-L VS ZIP l©� Date Applicant ARCHITECT O TEL. "� 0 NOTICE TO APPLICANT: If, after making.this Certificate of ENGINEEf>(j /y Crc�7� NOvI 3 DISTRICT GROUP TYPE FIRE PROCESSED BY 1 � CONST.' ZONE � U Exemption, you should become subject to the Workers' ��yy }/ w Compensation provisions of the Labor Code, you must forth- �1 ADDRESS �.� JJIE`/� CJ(� _� 6� / CL with comply. with such provisions or this permit shall be TEL. 2 STATISTICAL CLASSIFICATION. APT. CONDO. Z deemed revoked. CONTRACTOR NO. Uv lr o / — LICENSED CONTRACTORS DECLARATION LIC. q CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1 .( b ,�NO. 1-70 `7 5 (commencing with Section 7000)of Division 3 of the Business LIC. SEWER MAP / and Professions Code,and my license is in full force and effect. CITY <'sIJ G�- ►3 P-1 ra CLASS BK L PG ry- int_3VALIpATION �e SQ. FT. NO. OF NO. OF CHECK License Number t7v7¢iT Lic. Class ` SIZE I STORIES FAMILIES ONE V VALUATION DESCRIPTION OF WORK dIJi I'l TJ &5 NEW � r Contractor i.S C'J fJ Date —1 —�2 $ ; ADD ❑ U'a s� i 1 ❑I am exempt under Sec. �D ALTER ❑ ► I IJ i`H` B.&P.C. for this reason REPAIR ❑SE Pf - Date: ISTINGBLDGt' DIE OL ❑ Signature (1 APPLICANT TEL;. g OWNER-BUILDER DECLARATION � V/10 .5aW' N L O S/(y ( FINAL (PRINT)iEV4 DATE < J Z I hereby affirm that I am exempt from the Contractor's License �j t�LO� i_ Y :;_{_i - Law for the following reason (Section 7031.5, Business and ADDRESS 1 '� ' FINALWh Professions Code): PRESENT B _ ❑ I, as owner of theproperty, or m em to employees with BUILDING Y P Y ADDRESS U wages as their sole compensation,will do the work and 'y`;`(-• _-, . . , __ the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code.) MOVING TEL. / - _,• . ❑ j�I, as owner of the properly,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 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 LDMA Ref. # P.C. Fee$ ice Permit Fee 3 Lender's Address _ a 1 certify that I have read this application and state that the Issuance Fee 7.� 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 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 ature of Applicant or Agent Date APPLICATION FOR BUILDING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, BUIL ING ADDRESS VE C.K1%&&N NV or a certificate of Workers' Compensation Insurance,or a certified 41138 C ue KMAN A copy thereof (Sec.3800, Lab.C.) CITY Tempw "� 1 ZIP LOCALITY Policy No. Z-Z-3OZ9 Companys�'�I'�e NO G l SIZE OF LOT NO.OF BLDGS.NOW ON LOT a� 1�1�.. 'C El Certified copy is hereby furnished. C O�O O NEAREST C O�SS'SnT. ` Certified copy is filed with the county building inspection TRACT BILOCK LOT NO. OW w4L— 7A7Pl If department. d O(y�p I, USE ZONE MAP NO. 71 Date Z--) -9 3 Applicant�EXmot-1 GOtMSa'C. ASSESSOR MAP BOOK PAGE P RCEL 3 - a'-2' SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. YES NO COMPENSATION INSURANCEsm/w=S 1r4TU DE-4 tN4 7-13 &72- ( IS 5 S WITHIN 1000 FT.OF SCHOOL? (This section need not be completed if the permit is for one hundred ADDRESS Pcook 5 r-It(.rt,tl:17'� L44coso DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) CITY ZIP Q 2 \, 1 certify that in the performance of the work for which this permit Lc> A- LC'S p S ,C)FaP-3 V is Issued, I Shall not employ any person in any manner So as to ARC ITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. NTA STATISTICAL CLASSIFICATION APT CONDO Date Applicant ADDRESS CLASS NO.pDWELL UNITS NOTICETO APPLICANT.' If, after making this Certificate of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' CONTRACTOR TEL NO. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith "M wrc,N Cr DNS'C. $1 2 (0 (OO S R FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.110. P L LICENSED CONTRACTORS DECLARATION 1103 S S/l.rl G�i3R-Lr0l� SIOCI-1� SIDE CITY LI CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 S�`� SEL-- SEWER MAP I (commencing with Section 7000)of Division 3 of the Business and SQ.FT SIZE NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. j b0 S -- NEW ❑ BK PG a License Number 5109 1 Lic.Class 'J DESCRIPTION OF WORK ADD ❑ VALUATION Contractor-rI 21,16N G6114111.Date °L-It-9Zc ALTER El $ U . ElI am exempt under Sec. REPAIR El $ 0 BAP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. C c. O URM ❑ l _ 0- Signature APPLICANT(PRINT) 7 1- TEL N LDMA Perm# - f•9t*•t-I °�' z ❑ I, as owner of the property, or my employees with wages as x-t ON Go)as-( $I N-S(.,G Vq0 z -,30 -< ;i h their sole,compensation, will do the work and the structure is ADDRESS O `r" not intended or offered for sale (Section 7044, Business and 1103, S 54N &,A6 JVpN c,,&SVL1.C1_ FINAL DATE QJ s i Gl ti Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL ~� -43 ?- c{ �* {�p ❑ 1, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL BY ; S f,I?i�L +L!' l c d 0 Y 9 AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? licensed contractors to construct the project (Section 7044, ` c+•^•99�• irL -i( YES❑ NO i_1"I`Lt_f; +JiJ a i•1 Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING p r ;si OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH Cy`fi,;•)�'+K °.1_v1 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMrTrING CHECKLIST FOR GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ Nox _ i rn the performance Of the Work for which this permit Is Issued(Sec. IHAVE READ THEHA I US MATERIA SINFORMATION D ND THE SCAQMD PERMITTING #jl ljl�_f tl,�lj� 21 1i ?+.' 3097,CIV.C.) CHECKLIST.1 UND S ND Y REQ ENT UNDE LOS ANGELES COUNTY CODE, TITLE 2.CHAPT 0 SE IONS .20.100 THROUG '. 0.140 CONCERNING HAZARDOUS }:�{-I 3 Lender's Name M S R NG A O OBT NTNG A PER' FROM THE SCAQMD. slrry i A ! �+c 21 I IL Lender's Address C) ;01 OR ENT o I certify that I have read this application and state under penalty o P.C.FEE PERMIT FEE of perjury that the above information i correct.I agree to comply N with all co y ordinances and S to laws relating to building m constructi and h reby authorize rep sentatives of this County ISSUANCE FEE 5 to n o - entioned erty for ins ti �{ �{. INVESTIGATION FEE TOTAL FEE .yiature of gppticant or Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE