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Home My Public Portal About5008 GLICKMAN AVE_Building__ WC ' MPENSATION DECLARATION I hereby affi insure, or a cr, of Workers' Compensation Insurance, A P P L I C.- t1,.I O N FOR BUILDING PERM'' _ nave a certificate of consent to self or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company-ST�7E; jzU.tJ�. BUILDING ❑ . Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified co is filed with the count buildinginspec- BUILDING . t� tion department. y P ADDRESS �� C��§l��.tJ Cin O C� �1, (3+;1G1<✓In,AN Cp�Af Date 3`�Q_� Applicant CITY riHMFL✓' C-6 ZIP ' a� LOCALITY �L✓✓� CERTIFICATE OF EXEMPTION FRO/1 WORKERS' O SIZE OF LOT r_AC>0 O NOW ON LOT %//1GA-tr3 NO. OF BLDGS. NEAREST CROSS 5T. �`�1� COMPENSATION INSURANCE - R- ASSESSOR (This section need not be completed if.the permit is for one TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) TEL. OWNER T� hJ-ijL. IAV, NO' j ILjC� USE ZONE O / P ��0� �� 1 certify that in the performance of the work for which this 1 permit is issued, I shall not employ any person in any manner ADDRESS � SPECIAL. �V.1�i � CONDITIONSCL so as to become subject to The Workers'Compensation Laws. O CITY 1---S ZIP �� 1 U Date Applicant ARCHITECT O TEL. tY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEERS (j �� . TEL. DISTRICT JGROUP TYPE FIRE PROCESSED BY g CONST. ZONE 0 Exemption, you should become subject to the Workers' ��y _2 s U Compensation provisions of the Labor Code, you must forth- ADDRESS �ta"( 5 �1�� l�P4 �' J C��°"� a with comply with such provisions or This permit shall be `` TEL. STATISTICAL CLASSIFICATION ? APT. CONDO. N deemed revoked., CONTRACTOR �— (c�ltil !y� S NO. ,-- p Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.—DWELL.CJ DWELL. UNITS �! I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS ,,p $6 �jaf k'ro- NO. p- (commencing with Section 7000)of Division 3 of the Business. LIC. SEWER MAP �hC3�/C> and Professions Code,and my license is in full force and effect. CITY :/A/.J CLASS BK /— pG `�^ V/,LIDATION _ Y SQ. FT. NO. OF NO. OF CHECK - License NumberLic.'Cla'ss d; SIZE' ' STORIES ?/ FAMILIES ONE _ /7 VALUATION Contractor (.exnq/.) �[J Date l 2 DESCRIPTION OF WORK LJWI � L&N 6C-F_ NEW /� h �3; - 6 1 �� ADD ❑ $ ® [�/ �'D'"�J• %,i (_K ❑I am exempt under Sec. PJ es-! ® ,o0p ® -' t ALTER ❑ F_• `iN B.&P.C. for this reason REPAIR ❑ $ Date: USE OF - EXISTING BLDG. DEMOL ❑ iii=lliJ-tJ; ly ' 4 Signature APPLICANT _ TEL.. FINAL INT) _ Lf (PRIr.�IGI� Y`F�► la'�4Fi/.� NO.�I�j OWNER-BUILDER.DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License ADDRES AWG # �� l,o��`�� ' Law for the following reason (Section 7031.5,. Business and FINAL Professions Code): PRESENT By _ BUILDING ❑ 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 �b - 7044, Business and Professions Code.) ® MOVING TEL. ❑ I, as owner of the property, 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 -riH the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE P.L. Lender's Name. i_I.1i.`';.!'•;U.T m yy�} 3VLDMA A Ref. # P.C. Fee$ / Permit Fee /_2' 3 Lender's Address 0 1 certify that I have read this application and state that the Issuance Fee /� A P/C# S above information is correct. I agree to comply with all County Investigation Fee R ordinances and State laws relating to building construction, Total Fee /"7 iI Perm. # a and hereby authorize representatives of this County to enter . upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig a re of Applicant or Agent Date APPLICATION FOR BUILDING PERMIT ] COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION BUILDING ADDRESS FOR APPLICANT TO FILL IN BUILDING ADDRS u UL�A1J I hereby affirm that I have a Certificate of consent to self insure, LI GK/✓�a►`� or a certificate of Workers' Compensation Insurance,or a certified CITY gno 83 r, copy thereof(Sec.3800,Lab.C.) LOCALI Y I Z-L�a 2-1 Company S-P,"rG r-U ND SIZE OF LOT NO.OF BLDGS.NOW ON LOT E✓!� C,i's G/Z' l 7� ✓Y1 L ri/Y Policy No. , �❑,f Certified copy is hereby furnished. Gd NEAR]ST Rh� ' ^��5� la Certified copy is filed with the county building inspection TRACT BLOCK�. LOT NO. Z_o 11_ department. 5-6 042 6 1 USE ZONE MAP /NO�v�� Date -1 to Applicant T�XT d� CiO NSA• ASSESSOR MAP BOOK PAGE PARCEL C +� SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER I TEL O. COMPENSATION INSURANCE STA+eTs JV YL LOF✓. JAlL 01" IS75_3r WITHIN 1000 FT OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS . �td� / f!!��Q DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) CCJJ CITY ZIP 1 certify that in the performance of the work for which this permit �� jE✓M04D /Z.7 is issued, I shall not employ any person in any manner so as to CONDO+� ARCHITECT OR ENGINEER TEL NO. become subject to the Workers'Compensation Laws. STATISTICAL CLASSIF CATION �� APT CONDO Date Applicant ADDRESS CLASS NO. DW L UNITS NOTICE TO 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 -rex-roN c-05 �' FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS .NO. P L (7 S '5 a SIDE LICENSED CONTRACTORS DECLARATION CI Y / LIC.CL P L I hereby affirm that I am licensed underprovisions of Chapter 9 V SEWER MAP (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 d effect. In t--;, NEW ❑ BK PIS �1 a License Number�'�— Lic.ClaDESCRIPTION OF/WORK ✓GTJ� ADD VALUATION � ® O ContractoPI-71, V,1. Date , ALTER El PP U 0 ElI am exempt under Sec. REPAIR El BAP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ Signature APPLICANT(PR NT) / TEL O. LDMA Perm# '� El 1, as owner of the property, or my employees with wages a T xro �r..ST '� 19lb-610 z their sole compensation, will do the work and the structure is ADDRESS f� S'A'N GA'8 FINAL DATE ~ _ `-,^r * 70 not intended or offered for sale (Section 7044, Business and � S' � 0 y �•• =r�10.•_ Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL 6 C-j OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE V— Q TTEMS IJ ❑ 1, as owner of the property, am exclusively contracting With AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY § _ licensed contractors to construct the project (Section 7044, ' ( 8k Business and Professions Code.) YES❑ NO� TOTAL I _ ® a WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING r( OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHECK =L3 a M CONSTRUCTION LENDING AGENCY COAST AIR QUAUTY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR GUIDELINES. CAN GE c j 0 I hereby affirm that there is a construction lending agency for ves❑ No.® ,. ihllY G L the performance of the work for which this permit is issued(Sec. (HAVE REA HE HAZAR ATE RIALS INFORMATIONG IDE AND THE SCAOM E ITTING 3097, CIV.C.) CHEC UNDER MY REOUIR ME TS UND THE LOS ANGELES C U Y CODE, 2,CHAPT O SECTIONS 2. .10 THRO 2.20.140 CONCERN[ AZARDOUS �—Z Lender's Name RIA TING FOR O AI G A MI O THE SCAQM . PML IL Lender's Address OWNER OR AGENT 8.0.2 1 PML°+� o 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 is correct. ree to comply C' with all county ord' ance and ate laws relati g to building CD constr an Eby thori represe ative of this County ISSUANCE FEE to er upon ve- nti e propert for i ecti n p rposes. INVESTIGATION FEE TOTAL FEE 10 Signature of ppli=,t or Agent , • 0 SEE REVERSE FOR EXPLANATORY LANGUAGE