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Home My Public Portal About4843 HALLOWELL AVE_Building__ o �1 t JWORKERS'tCOMPENSATION DECLARATION leroiGfsure Or a certif catte of Workers' Comtpens ion eInsuran e, APPLICATION FOR BUILDING PERMIT 3 pr a certified copy thereof (Sec. 3800, Lob. C.) • y - COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO TO FILLIN ADDRESS .3 LL L ❑ Certified copy is filed with the county building inspec- BUILDING ADDRESS 'S y�u8 �'r /�✓�' tion department. Date Applicant CITY' ZIP LOCALITY PP NO. OF BLDGS. NEAREST -CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT NOW ON LOT CROSS ST. COMPENSATION INSURANCE 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. IV OWNER p NO. VCE USE ZONE MAP NO. I certify that in the performance of the work for which this ��//� /�, SPECIAL >- permit is issued, I shall not employ any person in any manner ADDRESS 2-44/ A � �'� /� CONDITIONS a so as to become subject to the Workers' Compensation Laws. O CITY - ZIP U Date Applicant ARCHITECT OR r� TEL. L De DISTRICT GROUP TYPE �, FIRE ROCESSED BY O NOTICE TO APPLICANT: If, after—making this Certificate of ENGINEER `1 �/L NO. >-.p�'rJ gCONST. ' E Exemption, you should become subject to the Workers' 2022 Compensation provisions of the Labor Code, you must forth- ADDRESS 0 2 ra with comply with such provisions or this permit shall be TEL STATISTICAL CLASSIFICATIONAPT. CONDO. Z 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. SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. f'l'iAMDATION $ and Professions Code,and my license is in full force and effect. CITY .� CLASS BK. PG. t 4'V SQ!FT. O. OF NO. OF CHECK License Number - Lic. Class' ,SIZE STORIES FAMILIES ONE 330 i !aE l 4 VALUATION �7 1 ITEM Contractor Date DESCRIPTION OF WORK NEW ❑ $ 1 U3�i 9 ❑I am exempt under Sec. 7Tyr.t ADD I , TOTAL. -721 ® 02 �� ,, ALTER ❑ CHECK K r BAP.C. for this reason r/'C"J�� Y�!%��"t REPAIR�-�❑-I E J Date: USEEXIOF BLDG� ��s yGv. u �J7n ' DENGIE MOL U ` � Signature APPLICANT(PRI T) eK NO. r� FINA OWNER-BUILDER DECLARATION DAT 13100-01301 9/111189 I hereby affirm that I am exempt from the Contractor's License n�! Law for the following-reason (Section 7031.5, Business and ADDRESS FIN _r6 j9 1 AM 6,a'_ Professions Code): PRESENT By /;k/ r_ ❑ I, as owner of the property, or my employees with IBUILDIIING ADDRESS !; ;-� ,_ i'',�', --, % wages as their sole compensation,will do the work and 1 LOCALITY the structure is not intended or offered for sale(Section t �• :;�, ' - 7044, Business and Professions Code.) MOVING TEL. CONTRACTOR NO. r; Z ❑ I, as owner of the property, am exclusively contracting _-'? =r�`r ; �. "' ,.a ,�l ?_•_r �F 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 1 Il EMIES, 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. r1"` 858 75 (Sec. 3097, Civ._C.).- SIDE. L.' CHECK __'v n(• $ Lender's Name. V LDMA Ref.'# CHANGE ,0 j � P.C.. Fee$ � Permit Fee v Lender's Address - 0 1 certify that I have read this application and state that the Issuance Fee �� LDMA P/C# ► o 8 above information,is correct. I agree to comply with all County Investigation Fee R ordinances and State laws relating to building construction, ITotal Fee Q f LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for.insp cti niPur ses. n SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant of Agent Orate WORKERS' COMPENSATION-DECLARATION ' APPLICATION FOR BUILDING PERMIT I herebyt'gffirm�that I have a certificate o£consent vo self ' ins4re; or a certificate of Workers' Compensation Insurance, , 5r,a'certified copy thereof (Sec. 3800, lab. C.) COUNTY.OF LOS ANGELES BUILDING AND SAFETY Policy No.—Co o. Company BUILDING ' 1:1 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESSEl �Z Certified copy is filed with'the county building inspec- BUILDING ADDRESS �i� < �O EL- � tion department. �� I � CITY' T-,: L �• ZIP Date Applicant ` LOCALITY NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' SIZE OF LOT X I$� 3 NOW ON LOT CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT BLOCK LOT VO. MAP BOOK PAGE PARCEL hundred dollars ($100) or less.) 1� TE1. 1 i USE ZONE MAP OWNER NCr� 4. NO.f — �(� NO. I certify that in the performance of the work for which this SPECIAL >_ permit is issued, I shall not employ any person in any manner ADDRESS 't .3 �tf 1 ALL -AV CONDITIONS a_ so as to become subject to the Workers' Compensation Laws. O CITY k 1 ` ZIP Date Applicant ARCHITECT OR _ TEL. { r DISTRICT G OUP TYPE FIRE ROCESSED BY O NOTICE TO APPLICANT: If, after makingthis Certificate of ENGINEER d e�1 L NO. 1 1, � h// /) CONSTL E a- Exemption, you should become subject to the Workers' U(yJ[ K1:3b#jc� Compensation provisions of the Labor Code, you must forth- ADDRESS "' with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION APT. CONDO. v7 deemed revoked. CONTRACTOR NO. Z LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL UNITS — I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO` SEWER MAP (commencing with Section 7000)of Division 3 of the Business LIC. and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION SQ. FT. NO. OF NO. OF CHECK License Number Lic. Class SIZE I STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW ❑ $��0 ❑I am exempt under Sec. { e_,s :kA !Ai ADD , ALTE ❑ B.&P.C. for this reason x REPAIR ❑ $ Date: USE OF EXISTING BLDG. �� DEMOL ❑ Signature APPLICANT TEL. (PRINT) NOFINAL ,s OWNER-BUILDER DECLARATION . �V Q� DATE v // I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Prof ions Code): PRESENT By -rt 1) AC-CT a BUILDING °E I, as owner of the property, or my employees with ADDRESS _ 73.10wages as their sole compensation,will do the work and , the structure is not intended or offered for sale(Section LOCALITY ([�.t i T 7044, Business and Professions Code.) MOVING TEL. 1 ITEMS CI S ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. TOTAL 71 ® .g 0 with licensed contractors to construct.the project (Sec- ADDRESS 1 trlL �.8 tion 7044, Business and Professions Code.) -CASH ]8.1 1 REQUIRED TOTAL SETBACK FROM EXIST. fL� CONSTRUCTION.LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH CHANGE .00 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 �ry P.L. tf . 10/19/89�l Lender's Name LDMA Ref. # 6294 1 A y•3 3 P.C. Fee$ Permit Fee i Lender's Address N0 FEE5 , 0 1 certify that I have read this application and state that the Issuance Fee t LDMA P/C# above information is correct. I agree to comply with all County Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee 0 LDMA Perm. # a and hereby authorizerepresentatives of this County to.enter 013130-000l 10/19/81 aupon the above-mentioned property for inspection purposes. 29C 1 AM 9:"�19 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date