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HomeMy Public PortalAbout5534 HARKER AVE_Building__ WORKERS'COMPENSATION DECLARATION' I hereby affirm that I have a certificate of consent to self �O M Do n D (��v$ ❑ insure; ora certificate of:Workers'.Compensation Insurance, LJL uvu or a'certified:copy thereof (Sec. 3800, Lab. Cl ' COUNTY.OF,LOS.ANGELES BUILDING AND SAFETY Policy No. ' Company ❑ Certified copy is hereby furnished.,. FOR APPLICANT TO'FILL.IN ADDRESS Certified copy is.filed with the county building inspec- BUILDING Tion,department. ADDRESS' Lou.IF-k. - LOCALITY NEAREST, Date Applicant DiA�G�E) CITY 1,� + _1 �" ZIP CROSS ST: _ CERTIFICATE OF EXEMPTION FROM WORKERS' NO:OF BLDGS. e ASSESSOR COMPENSATION-INSURANCE SIZE OF LOT NOW ON LOT J MAP BOOK PAGE CEL (This section need not be completed if the permit is for one USE ZONE MAP hundred dollars'($100)or less:) OC TRACT'' •. BL K LOT,NO. NO. TEL. SPECIAL CL 1 certify that in the performance of,`ihe work.for which this OWNER a� N �� CONDITIONS permit is issued, I shall not employ.any person,in.any manner DISTRICT `.GROUP' TYPE FIRE PROCESSED BY' CI so as to-become subject to the Workers'Compensation Laws. ADDRESS CONST. ZONE V . CI Y . 1 �a.e✓`-; ZIP Date Applicant ' STATISTICASSIFICATION APT_. -CONDO: NOTICE TO APPLICANT: If, after making this.Certificate'of ARCHITECT OR TEL: L Exemption; you.should become subject to the Workers' ENGINEER NO. CLASS'NO. DWELL; UNITS CL •Compensation provisions of The Labor Code, you must forth-' ADDRESS SEWER MAP' ka .with comply with such provisions or this permit shall be a TEL. Z deemed revoked. J (� �g VALIDATION CONTRACTOR 1WEe—�1 © LA) NO. /�� -� BK:' 'PG, LICENSED CONTRACTORS DECLARATION LI 1 hereby"affirm that I"am licensed under provisions of Chapter 9 - ADDRESS 0 9®Se�. gANCS. VALUATION' (commencing with Section7000),of Division 3 of.the Business andLIC. ^ Professions°Code, and my license is In full force and effect. CITY L /v �-� ' CLASS ( —�7 $ 798.9'7- � �.- ./ SQ:FT. ' INC.OF.. NO.OF CHECK` D" License Number Lic.Class SIZE STORIES ' FAMILIES ONE 3,v �1� �f4-9,S ' / g .�� OCF C NEW DiadCd f ��Wa Date L (9°-9J DESCRIPTION OF WORK I �IOLI® - ❑ - Contractor ADD ❑ I am exempt under Sec 6{e W�fi ` L/�t1 Y"i.ifl7�0®4. 1 h �. ALTER ❑ FINAL SBF DATE B'.&P.C. for this reason IIn REPAIR te_ _FINAL USE OF �! EXISTING BLDG,. tO fivT i�L DEMOL. ❑ B . Signatur APPLICANT ,/ X TEL: Q ,y O NER;BUILDER DECLARATION PRINT' iA�ll� Or}fJ NO../�3 -5L04I- F I herebyirm th t I,am exempt from the Contractor's License /� r n p� /' X,?"p Law fo 'th'e wing•reason(Section 7031.5, Business and ADDRESS���5 .I-�•vagtN�° t � ,�/„ Professions Code) PRESENT BUILDING ❑ ,1,. as 'owner of the property, or my employees with ADDRESS #lo<.o o OL. wages as their sole compensation,will do the work and LOCALITY the structure is not intended or offered for sale(Section 7044,.Business and Professions Code) MOVING, TEL. o 0 0 ]$ 0 x ❑ I, as owner of the property,'am exclusively contracting'. CONTRACTOR NO. v with lice used`contractors to construct the ro'ect Sec -. P I ( s ADDRESS 07,0 6—8 3 - tion 7044, Business and Professions Code); REQUIRED TOTAL SETBACK FROM EXIST. CONSTRUCTION LENDING AGENCY;. SET BACK YARD HWY PROP: LINE WIDTH. D hereby affirm that there.is a construction,lending agency for, FRONT the performance of the work for which'thm permit is.issued P.L. ` (Sec: 3097,.Civ.1C ). 'SIDE Q Lender's Name' !f� - P.C. Fee.$ Permit Fee Z..� •• _ .. Lender's Address I certify that I,have read this,'application'and state"that,The Issuance Fee /, a above information is.correct. I agree to comply.,with.all County Investigation Fee 8 ordinances and State laws relating to building construction, Total Fee . d and hereby.authorize representatives of this County toa enter - m upon-the i a( ve-menti�d property:for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sigture of Applicant or Age Date - - - - es 76A638A CE.#603 6-62APPLICAION FOR ,.EjUI'L®IN\G PERMIT y � , COUNTY OF LOS ANGELES BUILDING DEPARTMENT OF COUNTY ENGINEER' w aoDREs5. BUILDING.AND SAFETY DIVISION LOCALITY JOHN A. LAMBIE, COUNTY ENGINEER NEAREST WILLIAM A. JENSEN, SUPT OF BUILDING - -.CROSS ST. DIST NO. GROUP TYPE P ESSED BY FOR'APPLICANT TO,FILL IN'" CONST. - BUILDING �I\ a rpt p.ty STATISTICAL CLASSIFICATION S WER MAP. - ADDRESS534 Ave 1 Ze V14 BK PIS CLASS. NO. DWELL. UNITS / - LOT NO1-'vT'� - 'BLOCK WATER NOT REQUIRED ❑ RECEIVED TRACT 277 8 CERTIFICATE: MAP q�,t� HiGHWAY NO.OF BLDGS. NO. (CIRCLE) STATE MAJOR SECOND,(OCAL o!�(/C/ (CIRCLE) " 'SIZE OF LOT 75 x 69 NOW.ON LOT - - USE ZONE SPECIAL USE OF - CONDITIONS - EXISTING BLDG.-- - - — ` OWNERAm6TiCan Ca ital Co oro`GI 11=667' 1• �+ AME BUILDING EXIST: ADDRESSIOI84 F6' Valley, El, MOnt6 SETBACK YARD HWY '$ WIDTH- FRONT ARCHITECT OR - TEL. P. L. ENGINEER. NO. . SIDE _P. L. ADDRESS - - C - TNEL. L V Q CONTRACTOR _ y. O.G __ �Cj6 ,. ADDRESS " 8 E. Valley.' El Mont® N DESCRIPTION OF WORK ' 00 u Lu -NE ADD ALTER' , REPAIR DEMOLISH 1. t� S ZE-T 11195 � 'STORIES 1 FAMILIES USEfOF - - STRUCTURE R®sidental Home - - - SIGNATURE APPLICANT - _VALUATION $ �rf e e7 - !. ,f• ! P. ^' _ APPROVALS DATE INSPECTOR'S SIGNATURE P.C. _pL" PMT. j. FOUNDATION: LOCATION _ Fr. ",3J * A, FEE $ FEE $. v FORMS, MATE=RIALS o o !e7. .;.9.+ 'd� FRAME: FIRE STOPS,' I HEREBYACKNOW EDGE THAT I HAVE'READ THIS APPL(CATION BRACING. BOLTS it l..f"I' W� AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYI /'.,'.- U FURNACE: LOCATION,. � WITH ALL COUNTY ORDINANCES AND "STATE:-LAWS REGULATING GAS VENT, DUCT$ - �� BUILDING CONSTRUCTION. I CERTIFY THAT 'IN DOING THE WORK - AUTHORIZED HEREBY I WILL NOT EMPLOY ANY PERSON IN VIOLA- LATH.'INT. ./ /�'� ��t�l TION OF THE LABOR CODE OF THE STATE OF CALIFORNIA RELAT- INGTO WORKMEN'S, ENSAT ON INSURANCE. LATH,-EXT. SIGNATU O R_E n �./✓, HOUSE NUMBER COR- PERMITT RECT AND POSTED' . ADDRESS - FINAL - �w JOHN F. LEWIS. PRINCIPAL SORAL ENGINEER PLAN CHECK VALIDATION Cr M.O. CASH _ PERMIT VALIDATION CK. M.O. CASH r, r va 2. 0 3 APR �.1 2 3 0 3 0.2 5� t 6 WORKERS' COMPENSATION DECLARATION hereby affirm that I havecertificate of consent to self APPLICATION FOR BUILDING PERMIT insure, or a certificate of Workers' Compensation Insurance, 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 APPLICANT TO FILL IN ADDRESS ❑ Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 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. OWNER NO. USE ZONE MAP 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 CONDITIONS so as to become subject to the Workers' Compensation Laws. } CL CITY ZIP 0 Date Applicant ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY U NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. CONST. ZONE J Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- ADDRESS u_ with comply with such provisions or this permit shall be TEL. STATISTICAL CLASSIFICATION I APT. CONDO. deemed revoked. CONTRACTOR NO. Q LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. DWELL. UNITS 0 1 herebyaffirm that I am licensed under provisions of Chapter 9 ADDRESS NO. 0- P P LIC. SEWER MAP � (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION LU H SQ. FT. NO. OF NO. OF CHECK License Number Lic. Class SIZE I STORIES FAMILIES ONE VALUATION Contractor Date DESCRIPTION OF WORK NEW 1:1 $ ADD ❑ , ❑1 am exempt under Sec. ALTER ❑ B.&P.C. for this reason REPAIR ❑ $ Date: USE OF DEMOL El BLDG. Signature APPLICANT TEL, FINAL OWNER-BUILDER DECLARATION (PRINT) NO. DATE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and ADDRESS FINAL Professions Code): PRESENT By 1, as owner of the property, or 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 7044, Business and Professions Code.) MOVING TEL. ❑ I, as owner of the property, am exclusively contracting CONTRACTOR NO. 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 P.L. Lender's Name LDMA Ref. # P.C. Fee$ Permit Fee Lender's Address , 0 1 certify that I have read this application and state that the Issuance Fee LDMA P/C N 8 above information is correct. I agree to comply with all County nvestigation Fee R ordinances and State laws relating to building construction, Total Fee LDMA Perm. # a and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. ao SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date