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Home My Public Portal About6141 HART AVE_Building__ RKEgS'COMPENSATION DECLARATION, Ln ac certifies a Qf Wo kersrtCompensation ificate of consent Insuran eself 1T�1 F .� CY/�TU U"V FOR` O M d D Gil C� p C G3Gv�i 4 msec or or a certified copy thereof (Seca 3800, Lab. C.) .. . `;. . , . COUNTY.OF LOS ANGELESL BUILDING AND SAFETY' Policy No. Company Certified copy is hereby furnished:, . BUILDING APPLICANT TO FILLIN ADDRESS F�1 Certified copy is filed-with the county building inspec BUILDING tion department. ADDRESS .LOCALITY �. NEAREST DateApplicant CITY - CROSS ST. - CERTIFICATE OF EXEMPTION FROM.WORKERS' ,('�/�� NO. OFBLDGS. t. ASSESSOR COMPENSATION INSURANCE SIZE OF LOT•� %° i:I`J NOW ON LOT MAP BOOK PAGE PARCEL - _ (This section need not be completed if the permit is for one TRACT: BLOCK LOT NO MOP. hundred dollars ($100)or less.,) + TEL. SPECIAL USE ZONE A v OWNER �' { - NO. }IrI� CONDITIONS ('certify TliaT in the performance of the work for which this /J^ DISTRICT.' GROUP TYPE FIRE PRO ESSED BY permit is issued, I shall not employ any person in any manner. ADDRESS b1 '- CONST ZO E U so as to become subject'to The Workers'Compensation'Laws. `/(� � ; = CITY ZIP V '�, Date' Applicant STATISTICAL CLASSIFICATION, .. _ APT., 1CON6P.NOTICE TO'APPLICANT: 'If, after making_this Certificate:of ARCHITECT OR TEL. '.. V ENGINEER NO. CLASS NO. DWELL. UNITS s� Exemption, you- should become. subject to the Workers'- Compensation orkers' w f1' Compensation provisions-of The Labor.Code, you must forth- ADDRESS _SA SEWER MAB" with comply with such provisions or'.this^permit. shall be TEL. deemed revoked. uv� \\_Y� Z. BK.: CONTRACTOR VALIDATION LICENSED CONTRACTORS DECLARATION: LIC I hereby affirm that I am'licensed.under provisions of Chapter 9 ADDRESS NO. VALUATION (commencing with Section,7000)of Division 3 of the Business and LIC.. 3 Professions Code;•and my license is in full force and effect. CITY• CLASS $^ ,� '2 1.1:0.6 a SQ. FT. NO.OF' NO.OE CHECK o License Number Lic.Class SIZE STORIES FAMILIES ONE D # o'o 0 2 3 DESCRIPTION OF WORK NEW � $ a,'®d( .I .0 2 J5 1.8 G Contractor bate EJ I am exempt under Sec �ice'\C7w-�. _ ADD 8 2 cZ� - � ALTER Q FINAL �` _. ® a 251. B.BP:C..for this reason DAT ( 1.2 1 "8 4 REPAIR Date: USE OF DEMOL A EXISTING BLDG. Signature APPLICANT TEL. OWNER-BUILDER DECLARATION PRINT NO. ' ^I hereby affirm that I am exempt from the Contractors License' D Law•for the following reason (Section 7031.5;. Business and ADDRESS Profes ' s Code):: PRESENT BUILDING I, as owner of the property,' my employees with, ADDRESS' „ 1 5 1'A wages as their sole compensation,will do the work and the structure,is not intended or offered for sale(Section LOCALITY ;._.. 1 w # 0 0 0 0 .0 1 7044, Business and Professions Code). MOVING TEL. I,.as owner of the p?operty,:am exclusively contracting CONTRACTOR NO. .. 7 o ❑' with licensed contractors to construct The project(Sec- it 489.90. -tion 7044,'Business and-Professions Code). ADDRESS µr a 0 0 4 0 v REQUIRED TOTAL SETBACK FROM EXIST. 8 9.9 CONSTRUCTION,LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH t Y� I hereby affirm that there is o'construction lending agency for FRONT - y. s , —8 the performance of the work for which this permit is°issued P.L: - ; '` I 1;30 ' 4 (Sec.-3097,:Civ. C.). SIDE o Lender's Name. - - Ey , •. P C. Fee$ Permit Fee - Lender's Address., �/ I-certify that I have 'read this application and state that the C Issuance Fee /U s v above information is correct. I agree to comply with.all County Investigation Fee ordinances and State laws relating to building construction, Total Fee t�S u and hereby authorize representatives of this County to enter . ,a, u on the above-mentione pr erty for inspection purposes. a � SEE REVERSE FOR EXPLANATORY.LANGUAGE Sig Lure f Applicant or Agent - Date ®s ApG° UC AT ON -FOR BULDHO PEM07 i1 COUNTY OF LOSANGELES . BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS BUILDING ADDRESS I hereby affirm that I have a certificate of consent to self insure, 17YA V VE_a certificate of Workers'.Compensation Insurance,or a certified ZIP copy thereof(Sec.3800,Lab.C.) _ _\Y �O., LOCALI �� 1 �/ ® Policy No. Company SIZE OF LOTS `J� NO.OF BLDGS.NOW ON LOT I ❑ Certified copy is hereNEAREST CROSS ST. by furnished. y ❑ Certified copy is filed with the county building inspection TRAgT BLOCK LOT NO�`� USE ZONE AP NO department. " M . CQ ASSESSOR MAP B K PAGE PARCEL p b Date Applicant 4D� � d�Q SPECIAL CONDITIONS OWNER ' TEL.NO. CERTIFICATE OF EXEMPTION FROM WORKERS' �l�_7�� es b 5r1r`►h ves y -NO COMPENSATION INSURANCE WITHIN 1000 FT.OF SCHOOL? . �(This section need not be completed if the permit is for one hundred � � ,�T �V v- DISTRICT GROUP TYPE CONST.' FIRE ZONE OCES D BY dollars($100)or less.) CITY_ ZIP �� /�-• I certify that in the performance of the work for which this permit ._�. \' '(, 5W DW 3 jl 1 is issued, I'shall not employ any person in any manner so as to ARCHITECT OR ENGINEER TEL.NO. • become subject to the Workers'Compensation Laws. STATISTICAL CLASSIFICATION 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.NO. SET BACK YARD HWY' PROP LINE WIDTH Compensation provisions of the Labor Code, you must forthwith FRONT comply with such provisions or this permit shall be deemed revoked. ADDRESS LIC.NO. PL LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS FIDE nom.' 0 i hereby affirm that I am licensed under provisions of Chapter 9 SEWER MAP v (commencing with Section 7000)of Division 3 of the Business and SQ. SIZE NO.OF STORES NO.OF FAMILIES Professions Code,and my license is in full force and effect. ,\ • \ NEW BK PG 0 DESCRIPTION ORKADD ❑ VALUATION' D w License Number Lic.Class - a' Contractor Date —� ALTER ❑ $ �' v Z ❑ REPAIR ElI am exempt under Sec. ' B.&P.C.for this reason w l.�es C DEMOL ❑ LDMA P/C# Date: USE OF EXISTING BLDG. URM 0 " property, Y P Y 9 _. \` DMA Perm# g A ESS I ) 0 �= ❑ Signature saowner of the or m employees ees With wage 8S APPLICANT PRINT TEL.NC L C • their sole compensation,will do the work and the structure Is FINAL BATE f a:.j d s not intended or offered for sale (Section 7044, Business and VkX 'f�?�' / li� ��- • Professions Code.) _ WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL OR A MIXTURE j y ' property,, Y: 9 TTHE AMOU TS PEN FAZED ON T EINING A HAZARDOUS MATER A S INFORMATION GRDOUS MATERIAL EQUAL TO OR UIDE?THAN FINAL BY > 1 EMS • ❑ I, as owner of the am exclusive) :contracting with y >, licensed contractors to construct the project (Section 7044, Business and Professions,Code.) WILYESL ❑ No (� TOTAL '�'Zc _ s 99 WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH CHP-%..K: iii SaQ5 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAQMD)SEE PERMITTING CHECKLIST FOR GUIDELINES e•.: I hereby.affir * r _ Ij 0 that there is a construction lending agency for YES❑ NO `i:. �' tl t� " the performance of the work for which this permit is issued(Sec. I HAVE EAD THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAQMD 3097,CIV.C.). PERMI NG CHECKLIS I UN RSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUN TTL 2, HA 2._.ECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING { ) +mei I o Lender's Name HAZAR MA I REPO T GANDFOROBTAININGAPERMITFROMTHESCAOMD. 7 !t i1 ll–�I11I;� 4/26/E?+ a. Lender's Address wa+ERo _ 0352 1 Aj•'!10 04 li' o° 1 certify that I have read this application and state that the above _ _ information is Correct. I agree to comply with all-county PC.FEE /�� PERMIT FEE ordinances and State laws relating to building construction,and a hereby authorize representatives of this County to enter upon ISSUANCE FEE the above-mentioned property for inspection purposes. a INVESTIGATION FEE TOTAL FEE r sp�re of Aogiwn v Agent Date SEE REVERSE FOR EXPLANATORY LANGUAGE