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HomeMy Public PortalAbout5010 GLICKMAN AVE_Building__ W' 1 )MPENSATION DECLARATION insure, or a1 ce.:.'.-ate of Workers' Compensat on Insuran elf A P P L I L . �'ION FOR. BUILDING PERM. or a certified copy thereof (Sec. 3800, Lab. C.) d / COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. �Z3£� -&,pany ✓1 iG7Q �--d//C�. BUILDING . ❑�pp Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS L✓� Certified copy is filed with the county building inspec- BUILDING T ,^ tion department. ADDRESS O 1.1 C M�✓+% Date Applicant ® CITY-M( IL Cil ZIP I ® LOCALITY I (=v" CERTIFICATE OF EXEMPTION FR /� WORKERS' SIZE OF LOT G7�® NOW ON LOT 'v'/. w�NO. OF BLDGS. NEAREST 'a G CROSS ST. L/- [7✓0'>Pk- COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT GC7 BLOCK LOT NO. MAP BOOK D PAGE PARCEL hundred dollars ($100) or less.) TEL. OWNERGj C, I f2F—V, NOn n&p;7_+-1 USE ZONE NO /'/ I certify that in the performance of the work for which this ,� Z- SPECIAL permit is issued, I shall not employ any person in any manner ADDRESS �• © � CONDITIONS EL as to become subject to the Workers' Compensation Laws. O CIN ,/pia J�LhEs*- -ZIP ® U Date Applicant ARCHITECT OR TEL. 0 NOTICE TO APPLICANT: If, after making this Certificate of ENGINEERG Plv !i NOS' ,j DISTRICT GROUP TYPE FIRE PROCESSED BY n CONST. ZCL<{I~ O Exemption, you should become subject to the Workers' iN ++ 05 /�-�? i/ w Compensation provisions of the Labor Code, you must forth- ADDRESS r hh -aA A ` _.t=;-' a a with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATION r APT.^ CONDOS Z deemed.revoked. CONTRACTOR [}(O Cc - NO. -' _i ✓ LICENSED CONTRACTORS DECLARATION LIC. CLASS NO.-O© DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS t u3 NO.S" &9 - " - (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 CLASS 13 BK L PG 51 VALIDATION = ��=r SQ. FT. NO. OF NO. OF CHECK -.}; y License.Number �7V q7 7 Lic. Class SIZE STORIES "� FAMILIES ONES`_ '_• ,_ AVALUATION Contractor X�v ' �1-� Date -nom DESCRIPT••ION••OiiFWORK j.�rl GJFj (iti iT NEW $ b�� 10 �Yfi /t'iF�J �'® ADD j ❑I am exempt under Sec. \ z, ALTER ❑ i_j B.&P.C. for this reason $ _. - - REPAIR ❑ •-;+i-,�i •• - - Date: USE OF EXISTING BLDG. DEMOL ❑ APPLICANT e. TEL. Signature (PRINT)� G6L1/API°�lNO.?.�'� 0 -1555 FINAL OWNER-BUILDER DECLARATION �L`� DATE I hereby affirm that I am exempffrom the Contractor's License DDRESS-I-f f �� � ci� "�5� ' Law for the following reason (Section 7031.5, Business and FINAL6 Professions Code): PRESENT By BUILDING ❑ ;`;-sI, as owner of the property, or 'my employees withADDRESS -_•••• wages as their sole compensation,will do the work and 0 'n the structure is not intended or offered for sale(Section CALITY 7044, Business and Professions Code.) Poo, MOVING TEL. - ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 7� 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 _ 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, - / �' P.C. Fee$ ` Permit Fee LDMA Ref. # Lender's Address _�✓ 0 1 certify that I have read this application and state that the Issuance Fee cJ LDMA P/C# 8 ` above information is correct. I agree to comply with all County Investigation Fee N ordinances and Slate laws relating'to building construction, Total Fee c� � 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. at a of Applicant or Agent Date 9PA 0 APPLICATI®IV FOR BUILDING PERMIT COUNTY OF LOS ANGELES : V, 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, BUILDING ADDRESS or a certificate of Workers' Compensation Insurance, or a certified C 7/0 64C,1L A-Al "+I-& copy thereof(Sec.3800, Lab.C.) CITY ZIP 5% 7 640LOCALITY Policy No. Company rC.7cjpJZ— C4 4/ 1SIZE OF LOT NO.OF BLDGS.NOW ON LOT l✓ J ❑ Certified copy is hereby furnished. NEAREST CROSS ST ❑ Certified copy is filed with the county building inspection TRACT ��`/66 BLOCK LOT NO. department. USE ZONE MAP NO. Date Applicant ASSESf�AP BOOK PAG PARCEL .J r6�J� 0617 SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER/� // �/� TEL NO. 'I Cy COMPENSATION INSURANCE • ° "'� �`O �T� �L WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred ADDRESS c-0®© G .4DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) .✓ �7 CITY ZIP p 1 certify that in the performance of the work for which this permit CITY CL ! ��� A- t. is issued, I shall not employ any person in any manner so as to v(J become subject to the Workers'CO en ati Laws. ARCHITECT OR ENGINEE TEL NO. STATISTICAL—CLLAASSIIFICATION APT CONDO Date7;;�7 :1_3 Applicant �L y ADDRESS CLASS NO. DWELL 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 f�ZL �2vZ comply with such provisions or this permit shall be deemed revoked. FRONT P Y ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION SIDE CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SQ. NO.OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect. •�,,, NEW ❑/ VA PG a License Number Lic:Class DESCRIPTION OF WORK �� ADD Lf� LUATION ®� �® ® 0 Contractor Date ALTER ❑ �N �i4 c 0 El I am exempt under Sec. REPAIR ❑ $ 0 BAP.C. for this reason DEMOL' ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ SignatureAPPLICANT(PRINT) TEL NO. LDMA Perm 1, as owner of the property, or my employees with wages as / `!' ZO --;-,-7 their sole compensation, will do the work and the structure is ADDRESS Y not intended or offered for sale (Section 7044, Business and el-y-1 f4-4-1 A +786 FINAL DATE o Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL - ❑ I, as owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE P P Y, Y g AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL B licensed contractors to construct the project (Section 7044, YES❑ NOX ?p,_':_i._ c L•.' Business and Professions Code.) WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING �-� .. OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH L er CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDEUNES. —j f:='• 1 hereby affirm that there is a construction lending agency for YES❑ No i_I t � s� m _s F the performance of the work for which this permit is issued(Sec. A, rn IHAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD PERMITTING -.C i3,.i --*- -- 3097, CIV.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, �[ �N TITLE 2,CHAPTER 2.20 SEC IONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS L to 7?wL + Z Lender's Name MATERIALS Fj�RPTIN AN FOR OBTAINING A PERMIT FROM THE SCAQMD. e_ IL Lender's Address ��JIs��//C/ 0 OWNER OR AGENT o I certify that I have read this application and state under penalty IJI3; •-# f 0 of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE _ _7 s=�, with all county ordinances and State laws relating to building }+;' �i,s 3 L=-a a construction, and hereby authorize representatives of this County ISSUANCE FEE co to enter al Dve-mentioned property for inspection purposes. oy�Gn- Z L.- INVESTIGATION FEE TOTAL FEE 14 Sg(utu i p Date SEE REVERSE FOR EXPLANATORY LANGUAGE