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Home My Public Portal About4816 HALLOWELL AVE_Building__ Y WORKERS'COMPENSATION DECLARATION •I h 'bX affirm that I have a certificate of consent to self. APPLICATION FOR BUILDING PERMIT I.insur6,1a-a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lob. C:) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy Na: Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING Pol ADDRESS r ❑ Certified copy is filed with the county building inspec- BUILDINGL� tion department. ADDRESS O'L, ,kk AV v e Date Applicant CITY ZIP ILI 17 O Q LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO.OF BLDGS.SIZE OF LOT sv /kiS NOW ON LOT C ARES COMPENSATION INSURANCE SS ST. (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL TEL. USE ZONE MAP I certify that'in the performance of the work for which this OWNER l.OP Q.CS 1 �� NO. permit is issued, I shall not employ any person in any a er i♦b (i �Ui �.�� SPECIAL 8fi so as to bec me subject to the W r rs'Com et PT, a s. ADDRESS ` (� CONDITIONS U f`1 !Xi CITY ZIP —L Date ! V Applicant ARCHITECT OR TEL. NOTICE TO APPLICANT: If, offer makin thi Certificate of - DISTRICT GROUP TYPE FIRE P ESSED BY O Exemption, you should become subject to the Workers' ENGINEER NO. CONST`./ ZONE U Compensation provisions of the Labor Code, you must forth- ADDRESS !iv/ A �/ � W with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CON U) deemed revoked. CONTRACTOR NO. LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business and LIC SEWER MAP Professions Code, and my license is in full force and effect. CITY CLASS BK PG VALIDATION SQ. FT��1l �� NO.OF NO.OF CHECK c7- License Number Lic.Class SIZE 01� STORIES FAMILIES ADD NEW ONE VALgATION lid Contractor Date DESCRIPTION OF WORK U 'r ❑ $ v F-1I am exempt under Sec. �it✓L , ALTER B.BP.C. for this reason REPAIR ❑ $ DUSE OF Date: DEMOL ❑ EXISTING BLDG. ,r Signature APPLICANTFINAL OWNER-BUILDER DECLARATION PRINT r�S �(p NO.�fk3$ 5 DATE � '� $ �'3 A 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FIN i # 0'0 0 0,o;1 Professions Code): PRESENT Mot t\ B :" I 087.38 BILDING ❑ I, as owner of the property, or my employees with ADDRESS wages their sole compensation,will o the work and LOCALITY CQr. v^ p +� 1?�li-lam o 0 o87,386 the structure for is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING / TEL. ❑ CONTRACTOR �r"'•L- O G.iC'/��1� NO.4L0-��5 `� a Q�:`87 I, as owner of the property, am exclusively contracting r� with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY SET REQUIRED ACKK YARD HWY TOTAL SETBACK NE WIDTH I hereby affirm that there is a construction le}ding agency for FRONT the performance of the work for who/14 ich t is per 't is issued P.L. 19`7 (Sec. 3097, Civ. C �+ .�� SIDE S �T S J P.L. Lender's Name LDMA Ref. N Lender's Address P.C. Fee$ Permit Fee -&S I certify that I have read this application and state that the Issuance Fee .J V kLD P/C# above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee LCiMA'Peim. N ' and hereby authorize representatives of this County to enter upon tp abovejentioned rop r<?,or i ection pyrpo3g�. < _ J� ,lir /v/ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of A pl'ant or Agent Date WORKERS' COMPENSATION DECLARATION- of cOent to sf 'jA:cure boraffirm a certificate of Worke s' Comthat I have aipensat on Insurance, APPLICATION FOR BUILDING PERMIT "or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR ADPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING V tion department. ADDRESS Dare Applicant CITY 1 ZIP "\1� C'� LOCALITY PP C NO. OF BLDGS. ` NEAREST CERTIFICATE OF EXEMPTION FROM'WORKERS' SIZE OF LOT (p J X S_ NOW ON LOT ( CROSS 57. COMPENSATION INSURANCE \2 ASSESSOR (This section need not be completed if the permit is for one TRACT (CLE BLOCK LOT NO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) q TEL i�� `t OWNER ��j l��S�� %VOL. �`-P��T� USE ONE MAP � I certify that in the performance of the work for which this L` 1 SPE permit is issued, I shall not employ any person in any manner ADDRESS 1 (�� .0 �(c> LL U CONDITIONS 0 so as to eco a subject to the W kers'Compe sati Laws./ Q r10>1t CITY �� ZIP �1 U x Date Applicant. UN t/o ARCHITECT Oft:'_ TEL DISTRICT GROUP TYPE FIRE PROCESSED BY O /A 'NOTICE TO APPLICANT: If, after making/this this Certificate of ENGINEER 1 j 1\G lC �XNO. �aI :L"S Z-� U 9 CONST. ZONE Exemption, you should become' subject to the .Workers' '/ ^> ua Compensation provisions of the Labor Code, you•must forth- ADDRESS 10 ��`� R js� V o � �J a with comply with such provisions or this permit shall be / TEL. (C STATISTICAL CLASSIFICATION � ( APT. CONDO. Z deemed revoked. CONTRACTOR fl ICY NO. U � 5� / — LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. _DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS l`�l�P �� `� NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business UC. and Professions Code,and my license is in full force and effect. CITY 'FC L.� CLASS VALIDATION SQ. FT. NO. OF NO. OF CHECK - License Number Lic. Class SIZE �v4- — STORIES FAMILIES ' ONE �� VALUATI N . 23 . Contractor Date DESCRIPTION OF WORK NEW .� ► o 8 ❑ ❑I am exempt under Sec. A4_�" aAC=CT ADD ALTER ❑ 33,07 4 1 CI B.&P.C. for this reason REPAIR ❑ $ 1 jTEM; Date: USE OF TOTAL x-15. 02 EXISTING BLDG. L `�C }�ti vo+^'� DEMOL ❑ Signature APPLICANT �(�k� TEL.16k FINA OWNER-BUILDER DECLARATION (PRINT) r� C.�. NO. 3�`f5 DATE CHECK 415°02 I hereby affirm that I am exempt from the Contractor's Licensep £ :W1 Law for the following reason (Section 7031.5, Business and ADDRESS OMv r�)—La l� �� C pINA 1•�{Ah{�iE .[)�I Professions Code): PRESENT By N*00 y I, as owner of theproperty, or m em to employees with BUILDING V Y P Y ADDRESS 1 ''t713'trr wages as their sole compensation,will do the work and M ,� ?f the structure is not intended or offered for sale(Section LOCALITY , 4232. T At�11:`1 7044, Business and Professions Code.) MOVING TEL. 1 ITEk ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. ` 4tc with licensed contractors to construct the project (Sec- ADDRESS TOTAL • 498/= a�:e tion 7044, Business and Professions Code.) REQUIRED TOTAL SETBACK FROM EXIST. CHECK 498.175 CONSTRUCTION LENDING-AG .SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE ,00 the performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE , Lender's Name P.L. 0000-0001 v/24>l,'_'=9 ✓' LDMA Ref. # m P.C. Fee$ V Permit Fee ► CryC 1 �} :."r� 3 Lender's Address //'�� I certify that I have read this application and state that the Issuance Fe /(,/• LDMA P/C# a Y PP above information is correct. I agree to comply with all County Investigation Fee . 0 ordinances and State laws relating to building construction, Total Fee O 75 LDMA Perm. # a and hereby authorize re resatives of this County to enter u �he abo -menti e p opert for inspectiopurp7e,s. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signatur of Applicant or Agent Date