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Home My Public Portal About5012 GLICKMAN AVE_Building__ W( MPENSATION DECLARATION of consent to sel insure, or affitn cern cate of Worke srlificate Compensal on Insurance, A P P L I L0 /,ION FOR BUILDING PERM. , or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY az Policy No. �&mpony :5�7,6'ZC- BUILDING ❑ Certified copy is hereby furnished.. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING�4i�/ LIG ,��l 1�rc- C tion departmeent. ++ ff a1Z tsi. t 'G'-+MAN AVE Date `j �ipplicant CITY 1 N0 Gl� ZIP {I�(7� LOCALITY 0�Vv� l� GI %I' NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROA ORKERS' SIZE OF LOT G�G9--��0 NOW ON LOT* OT CROSS ST. L /+ ��SA ' COMPENSATION INSURA CE � ASSESSOR � (This section need not be completed if the permit is for one \�1ADDRESS±Ifs.. TRACT kV-000 BLOCK LOT NO. MBP BOOK 57-8 PAGE PARCEL hundred dollars ($100) orless.) r TEL. /" _ OWNER 7� ®�� NO.v�J!�!� �✓-� USE ZONE MAP NO. 1 certify that in the performance of the work for which this1 ,,,� ., r� �� SPECIAL permit is issued, I shall not employ any person in any manner 10`gi5r rT CONDITIONS ✓ aso as to become subject to the Workers' Compensation Laws. ^A1! q '" O CITY W'A ZIP 1®a .I U Date Applicant ARCHITECT OR TEL 0 I--'' �� DISTRICT GROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER �ib�l� � NO. 4.3 tz CONST. ZONE � Exemption, you should become subject to the Workers' U Compensation provisions of the Labor Code; you must forth- ADDRESS � �LJ o&r1/b�tilf� ,�•t� y �� a with comply with such. provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION _ .. APT. CONDO.` N deemed revoked. CONTRACTOR —1; - ; NO. ' 1p LICENSED CONTRACTORS DECLARATIONLIC. CLASS NO. ::PO DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS f9 � ' NO• i v __•, LIC. SEWER MAP _ (commencing with Section 7000)of Division 3 of The Business / •g;i-;l•;: CITY a CLASS .� and Professions Code,and my license is in full force and effect. �✓ ��' BK..Z- PGt --'=VALIDATION Sq. FT. NO. OF NO. OF CHECK' - License Number �7il " Lic. Class � SIZE STORIES FAMILIES ONE M p l/ VALUATION . Contractor �hX ttif J �w�i Date 3�I ! / DESCRIPTION OF WORK L WI tr6, �d7' NEW $ or />f) 1,iH ? -_t' r ADD ❑ � "/ ® .;.: - zw• ❑I am exempt under Sec. ALTER ❑ B.&P.C. for This reason REPAIR $ ❑ Date: SE OF EXI&TING BLDG. DEMOL, ❑ _ Signature APF?L1CA T �j "(PRINT) �IL 'VtQN � G4�IV0 )7�D� ?� FINAL OWNER-BUILDER DECLARATION DATE t_1•' _ ;4i' I hereby affirm that I am exempt from The Contractor's Licens� :�i ( � Law for the following reason (Section 7031.5, Business and ADDRESS 6 +0� � i�(I FINAL Professions Code): PRESENT By ❑ I, as owner of the property, cr m employees with BUILDING P P Y YADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section LOCALITY polo 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 7044, Business and Professions Code.) - REQUIRED YARD HWY TOTAL SETBACK FROM EXIST. ,. CONSTRUCTION LENDING AGENCY SET BACK 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. P.C. Fee$ •(J/ Permit Fee . LDMA Ref. # Lender's Addressk.-._. o I certify that I have read This application and state that The Issuance Fee 76, LDMA P/C#. 0 above information is correct. I agree to comply with all County Investigation Fee �J Q 0 ordinances and State laws relating to building construction, Total Fee /i o V LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. '? 2 SEE REVERSE FOR EXPLANATORY LANGUAGE Si ture 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 BUILDING ADDRESS .-C)12- G' �,�A �� I hereby affirm that I have a certificate of consent to self insure, BIZ LIL�„/r1�IJ p•VEi �• or a certificate of Workers' Compensation Insurance,or a certified u1 copy thereof(Sec.3800,Lab.C.) CITY ZIP Policy NO.IZ-.S45-0e :I2L%()D eYVI LC' C.L-C• 917)%-0 LO�LITY �� L.E�' Company F_ SIZE OF LOT NO.OF BLDGS.NOW ON LOT I-C ❑ Certified copy is hereby furnished. L-ON 0•Q 1 NEAREST CROSS ST. Certified copy is filed with the county building inspection TRACT BLOCK LOT NO. OW logIZ r department. / O��/ V USE ZONE MAP NO. Date 2 11-9 Applicant (��0tu co t47�' ASSESSOR MAP BOOK PAGE PARCEL - 1' SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE S-n�m-r5 ►�6'C C. ��V• 1'S Z •ISCT WITHIN 1000 FT.OF SCHOOL? YES NO ADDRESS s��,{ (This section need not be completed if the permit is for one hundred 1 ..�V�E � Y S Q DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) 2 2 I certify that in the performance of the work for which this permit LO s ANGel—eS CITY ZIP 001"( �, Vo T I N/ '3 is issued, I shall not employ any person in any manner so as to AR HITECT OR ENGINEER TEL NO. "e become subject to the Workers'Compensation Laws. w STATISTI/C�hp SSIFICA /� APT CONDO Date Applicant ADDRESS CLASSvV 6WELL 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 -M-4-ropj cwpm srT FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.. P L 11 IDS N .p LICENSED CONTRACTORS DECLARATION S• SAt4 G��I"SL, S Ay6�9 1� SIDE CITY LI CLASS PL I hereby affirm that I am licensed underprovisions of Chapter 9 $AN 6&454UF-l.. 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 and effect. OQ •— NEW ❑ BK PG �- d �' ADD VALUATION License Number �d�^7 FL Lic.Class D SCRIPTION OF WORK � 0 AT►p Go�S Contractor°Tr=xtoi:l Date ALTER ElU ❑ I am exempt under Sec. REPAIR ❑ B.&P.C.for this reason DEMOL ❑ U LDMA P/C# W Date: USE OF EXISTING BLDG. URM ❑ o- S • �'. D . I ct) Signature APPLICANT(PRINT) TEL NQ. LDMA Perm# z ❑ I, as owner of the property, or m employees with wa es as ��T�l'� �/®N Ste' AG•� Z P P Y. Y9 0 their sole compensation, will do the work and the structure'is ADDRESS I _ not intended or offered for sale (Section 7044, Business and 7 S 7J�J� SA-%�j FINAL DATE Q • j07 10 Professions Code.) "2 __ WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL � �� 3c�—� J i r-I.�.;:-�. OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE 1 j E 1 ❑ I, as owner of the property, am exclusively contracting with FINAL BY > • AMOUNTS SPECIFIEDON THE HAZARDOUS MATERIALS INFORMATION GUIDE? " licensed contractors to construct the project (Section 7044, YES❑ NOV ` ;IJ,AL a 70 Business and Professions Code.) WILL THE INT DED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING ••�• OCCUPANT RE UIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 3�; �1 :,ii{S�j( CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTIN CHECKUST FOR GUIDELINES. � � I I hereby affirm that there is a construction lending agency for GUIYES DELINES. No �•I-.ANGE a�L a the performance of the work for which this permit is issued(Sec. ° MDPE 3097, CIV.C.) CHECKLIST.I UE ERA ANo MY REQUIREM N SOUSMATERIALSIMUNDER GTHDEEL S ANES ES COUNTY ICOIDE, r NG TITLE 2, E .20 SECT 2.2 0 T OUGH 2.20.1 0 CERNING HAZARDOUS + Q Lender's Name MAT S T AN O OBT IN IT FR E SCAQMD. 00130-0100 i .4" y1t •°: IL Lender's Address ;r yQI _ 4 O 0 AGENT '1'i t 1 =21 o I certify that I have read this application and state under penalty 0 of perjury that the above information is correct agree to comply P.C.FEE PERMIT FEE with all county or inances and tate laws r ating to building construction, a ereby authori represe a' es of this County ISSUANCE FEEco / to e po above nti property inspecti n p poses. C� ►J INVESTIGATION FEE TOTAL FEE fy&` y e plica r Agent Dai Q SEE REVERSE FOR EXPLANATORY LANGUAGE