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Home My Public Portal About5014 GLICKMAN AVE_Building__ 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, BUILDING ADDRESS d I L Gs�-Y•� N or a certificate of Workers' Compensation Insurance,or a certified 57 01 G G N copy thereof(Sec.3800,Lab.C.) CITY ZIP 1 zZ.3®�°� S•'fA-t if �L11 Nle T�►M l.E Gtr 91�'�O LOCALITY Policy No. Company SIZE OF LOT NO.OF BLDGS.NOW ON LOT ❑ Certified copy is hereby furnished. G°aNO v ' NEAREST CROS ST. Certified copy is filed with the county building inspection TRACT BL=CK LOT No. V DU6� �JUS�+ �� (�(� ?j USE ZONE M P NO. departure t. LPAGE,/,/ �,�Z'1 2 Date? Applicant-MX�t4 CIW4 ST ASSESSOR MAP Q _ PAGE/ RCE 7 �J �— SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER TEL NO. COMPENSATION INSURANCE S,144ZT5 IN-CL- r2r-iV 1 NG 213 •10; WITHIN 1000 FT.OF SCHOOL? YES No This section need not be completed if the permit is for one hundred ( ADDRESS P DISTRICT GROUP TYPE CONST. FIRE ZONE PROCESSED BY dollars ($100) or less.) 6.b 1 S r-1(,V(✓V-Op. 1 G 5 I certify that in the performance of the work for which this permit CITY AWC3C-LE zip sale) %-7 ®go is issued, I shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL NO. •7• �/ become subject to the Workers'Compensation Laws. p STATISTICAL CLASSIFICATe�}r� APT CONDO Date Applicant 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 rjo. SET BACK YARD HWY PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith -r 0 S,11612.va (0 Cot 0 FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. P L LICENSED CONTRACTORS DECLARATION 1103 S• $AN GAZ94� 570111L SIDE IC,TY �I�� LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 540SEWERMAP (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. O d - NEW El BK PG a License Numberli-70011 A Lic.Class f/ DESCRIPTION OF WORK ADD ❑ VALUATION ® O Contractor-MXn" 6o"S'1 Date PAC-Tv G\!IS . $ U ALTER ❑ CC ❑'l am exempt under Sec. REPAIR El BAP.C.for this reason DEMOL ❑ LDMA P/C# W Date: USE OF EXISTING BLDG. c •�• URM ❑ co Signature APPLICANT(PRINT) 7 TEL N LDMA Perm# z ❑ Cas owner of the property, or my employees with wages as la�'ZO0 C.owS� {.r. air MI6 Z O O z f�:l.�os their sole compensation, will do the work and the structure is ADDR SS A v �• Jt e� A — u l 1j� a+f. �{i 'D 7 vdal�ti�bv✓ Cj IVV FINAL DATE ='0.I not intended or offered for sale (Section 7044, Business and n Q Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL r�(� —q 16 r§i.j ❑ I, as owner of the property, am exclusively contracting with OR A MIXTURE SPECIFIED CONTAINING THE HAZARDOOUS US MATERIALS MATERIAL QUAL TOIONRGUREA ER THAN THE GG FINAL BY g licensed contractors to construct the project (Section 7044, ves❑ NC� ( TOTAL��HL �r�H= 70 Business and Professions Code.) t.� -� WILL THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING CHECK _�a f LI OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH �s CONSTRUCTION LENDING AGENCY COAST AIR OUAUTY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR CHANGE a�dl� GUIDELINES. I hereby affirm that there is a construction lending agency for YES❑ ypP+�, N the performance of the work for which this permit is issued(Sec. O 3097,CIV.C. (HAVE REWHUEND FOCUS MATERIALS INFORMA NGUIDE PORNING MD PERMITTING CHECKLIND MY REQUIREMENTS ER THE LCOUNTY CODE, �i'!_ li li N 00100-0001 !!t 0 f1 t/f IOR SECTION 2.20. 0 T, G 2.20.1HAZARDOUS 5.1 1 d _*�. LLender's Name LN FO OBT IN ROM . o Lender's Address A.N 5) 2'11 O AAENT o I certify that I have read this application and state under penalty of perjury that he above information is correct. agree to comply P.C.FEE PERMIT FEE with all co ordinances and State laws rel ing to building m co UCti and h by authorize repre entativ of this County ISSUANCE FEE t enter on the men one prop y for i pecti n p poses. �' INVESTIGATION FEE TOTAL FEE j r Signa ure of Applicant or Agenl Date SEE REVERSE FOR EXPLANATORY LANGUAGE W_': OMPENSATION DECLARATION to self insureboraa+c:, '. .re of Workers'1Comtpensat on of coent Insurance, AP P L I Lr,. ION FOR BUILDING PERM. or a certified copy thereof (Sec. 3800, Lab. C.) /22302 �/ COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. I otpany SSG Tc7-, �77,0 BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS Certified copy is filed with the county building inspec- BUILDING ADDRESS l�f�i�C°�) ��% 1p� tion department. 0IL4 &L1 CV-AAA N /k V p ? CITY� � e4 ZIP 7 L LOCALITY -YVV1 L—�G C4 l Date 3✓�! `�ZApplicant ® �' a�I NO. OF BLDGS. NEAREST �" CERTIFICATE OF EXEMPTION FRO ORKERS' SIZE OF LOT C -*J� NOW ON LOT y'A&,O O CSSST. L_/L I�S A COMPENSATION INSURA CE ASSESSOR' J �(This section need not be completed if the permit is for one TRACT C✓5C00& BLOCK LOT NO. MAP BOOK J PAGE Z` PARCEL , hundred dollars ($100) or less.) �J 7EL. OWNER �' I ri'I-tG. NOZA3(pZ It-i. USE ZONE NO I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner 1 ADDRESS CONDITIONS a so as to become subject to the Workers'Compensation Laws. � �r [ O CITY L,05 �1t'l�LIX GL� Z I Date Applicant ARCHITECT ORTE. DISTRICT �ROUP TYPE FIRE PROCESSED BY O NOTICE TO APPLICANT: If, after makingthis .Certificate of 9� ENGINEER (� 5r�� NO. N` CONST. ZONE (- Exemption, you should become subject to the Workers' II �r /- �� w Compensation provisions of the Labor Code, you must forth- ADDRESSi f91 A 05.1 OC.��- � �- � � p with comply with such provisions or this permit shall be rO C NO _ STATISTICAL CLASSIFICATION APT. 7CONDO. deemed revoked. CONTRACTOR Z LICENSED CONTRACTORS DECLARATION 6 LIC. CLASS NO. ®y DWELL. UNITS � I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS 1 03 _ 5p� C,/� �iC� NO. p - (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 ��,� �„�V}�/Gi �p CLASS 13 BK PG ��-cJ� VALIDATION SQ. FT��,� NO. OF NO. OF CHECK License Numbers Yy c�_Lic. Class SIZE �!Y'a'O STORIES �/ FAMILIES ONE VALUATION Contractor �EX Coc.) Date �'I l�QZ DESCRIPTION OF WORK(1�I' !��L' NEW D� s - ADD ❑ $ /C��i ► ,-H C c, ❑I am exempt under Sec. G Iv-3 ALTER ..•W - B.&P.C. for this reasonREPAIR ❑ $ Date: USE OF EXISTING BLDG. DEMOL ❑ - .:{ Signature APPLICANT (PRINT)��ILI� /9.ts FINAL WE.GIIF.LNo2�3(c�Z�-OSSS t" OWNER-BUILDER DECLARATION DATE �'�'' - •t�'' 0 -~' I hereby affirm that I am exempt from the Contractor's Licens N Law for the following reason (Section 7031.5, Business and XDDRESS4-,4.�•T""r" I! {1 �sf-° - 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 , �� 7044, Business and Professions Code.) MOVING TEL. / / CONTRACTOR NO. I, as owner of the property, am exclusively contractingwith 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 HW Y PROP. LINE WIDTH f 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 't'= 33 LDMA Ref. # P.C. Fee$ Cl Permit Fee - 3 Lender's Address " 1 certify that I have read this application and state that the Issuance Fee r;2ra 7. LDMA P/C# poll above information is correct. I agree to comply with all County Investigation Fee v 8 ordinances and State laws relating to building construction, Total Fee 11 49 LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property,for'inspection purposes. a ✓ - d „ 3��—�Z SEE REVERSE FOR EXPLANATORY LANGUAGE Si n re of Applicant or Agent Date