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Home My Public Portal About4840 HELEO AVE_Building__ ks .WORK'L> COMPENSATION'DECLARATION l .arek :fNva £rrri thaB I huv .•a certificate of consent to self /n1 '( �� , O U,� LD��oPE�n'n �-7,nsur- or acertifcate of`Workers'•Compensotion Insurance, (�=�� Lf /�_�� L� LI, UV(1ClUocertified copy th6feof{Sec..3800, Lob''C _ T.• :. COUNTY OF LOS ANGELES BUILDING AAND SAFETY _ Policy No Company.& `L V - , Certified copy is,hereby furnished. ,. FOR APPLICAN BUILDING T TO ILL IN ADDRESS Certified copy is"fi'led-with the couniy'building'inspec- BUILDING , tion department. ADDRESS Date Applicant) .: - ' CITY" ZIP - .. - i LOCALITY N -OF-BLDGS.- NEAREST,.. ._ CERTIFICATE OF EXEMPTION FROM WORKERS":'" "" '- COMPENSATION INSURANCE SIZE OF LOT - Q NOW ON LOT CROSS ST. (This section need not be completed ifthe.permit is for one - - - ASSESSOR .F - _. _. _ _. hundred,dollars ($100.)or less.) TRACT BLOCK LOT NO. �� MAP'BOOK'': PAGE, PARCEL T - NE MAP certify that in the performance of'the work for which this OWNER N0. 'e f „1 • r_.1._..SPECIAL: _. - - IL j USE 11 permit is issued, I shall riot employ a y p rson m any, anner _ _ so a�'to6 b come sub'ect to the Wor ers'- omp -sahon Lays v 1 ADDRESS CONDITIONS� y CITY _ _ . ,.. .e .'_ZIQ, C/ _. ... .•- -_.. _ .. _ri _, r .r ., n . .. _. &' Dat Applicant' ' ARCHITECT O ' Zr d DISTRICT, GROUP' TYPE_• FIRE _PROCESSED BY... NOTICE-TO APPLICANT: If; after ma ing,th,s Ceftificate o NE ENGINEER CONST. ZO Exemption, you 'should 'become subject to•the-`WorkersRy .44 Compensation provisions of the Labor Code, you.must,forth- ADDRESS.. / -•- - - o R � -_ With comply;with such provisions or this permit shall be - TEL. STATISTICAL CLEj$SIFICATION APT. CONDO _ !1/ deemed revoked.' t a -, CONTRACTOR NO. / (/ LICENSED CONTRACTORS DECLARATION -- --:• •-- - LIC. v" CLASS NO. DWELL: UNITS ` r t I hereb affirm that I am licensed under provisions of Chapter 9 ADDRESS NOi N 7�g I : I (commencing with Section 7000)of Division 3'of the Business and _LIC: -• SEWERP Professions Code; and,my license is in'fuil.force and effect. CITY ALJ CLASS '� BK. LAPG:[ V -'" VALID'ATIOM L . SQ:FT. NO. OF NO.OF - CHECK, License,Number Lie.Class' - ` ., SIZE STORIES FAMILIES •.ONEy , --.VALUATION � • DESCRIPTION-OF WORK -NEW- Contractor Date ADD �`' I am exempt under Sec.' - _ _z 6 9 6::.9 A ALTER ❑ i B.&P.C. for this reason REPAIR- #f o 0 o.'.a.o .. - Date'. USE OF DEMOL ❑ EXISTING BLD ( 0 2 4-6.7 rj s Si nature i. APPLICANT TEL 1 FINAL g PRINT .�; o.°.2 4 6,.7-5 5 • OWNER-BUILDER DECLARATION _ _ ... _ DATE- I hereby affirm-that I am exempt from the Contractor,'s License _ i Law for the following reason.(Section 7031.5, Business and ADDRESS C! FIN 0 5'0 5 8 7 ' Professions Code): ^. - PRESENT BUILDING i I, as owner of the property,. cr. my-employees with ADDRESS _ 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. " 7634A_ I;as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS _ # 0 0 0.0 0`J* ' tion 7044, Business and Professions Code). i REQUIRED . TOTAL SETBACK FROM._ T. CONSTRUCTION LENDING AGENCY SETBACK YARD'- HWY PROP. LINE WIDTH Y ° 2:O.Q;8 2 Thereby affirm that there is a construction lending agency for FRONT v , the-performance of the work for--which this permit is-issued -: P.L. •- - --- __ .. _',0 0 2 . - 0082' (Sec. 3097, Civ. C.). SIDE P.L. 0.6-8 7_' Lender's Name4 _ a .) P.C. Fee$ - 1 Permit Fee...:_ .LDMA Ref. k .i Lender's Address D I certify that.I.have.read this application_and state_that the - Issuance - -LD��P/C,#' Q tabo'a information is correct. I agree to comply with all County Investigation Fee i ances and State laws relating_to building construction,._._ -___... . _ _ __. TotaFfee t ' LDMAPerm.he by authorizer resentatives of this County to enter i •t, ea ove-,menfloed property, for inspection urpos s. - SEE REVERSE FOR EXPLANATORY.LANGUAGE 6 ignat a Applicant or gen _ Date _: ._._.... .._.,_ -_ ..- ..._ - .., :..., Al J ja• WORKERS' COMPENSATION'DECLARATIO /ell •,insureboraa certif catte of Workers' Comtpensation eInsuran of A,P L CAU O LI V F O12 _.M M 0 d D ONG - p E RM O U or.a,certified copy thereof (Sec. 3800, tab. C.) - COUYVTY OF LOS ANGELES' BUILDIWG AWD-SAFETY' Policy No. - Company ElADDR Certified'copy is'kereby'furnished. � " FOR APPLICA ADDRESS T TO FILL IN' ESSss ? ,❑ certified copy is filed with-the county building BUILDING inspec- ADDRESS tion department. CITY' ZIP. v LOCALITY Date` Applicant N OF BLDGS. O. _ 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�raG� MAP BOOK PAGE PARCEL hundred dollars ($100) or less.') t TEL., OWNER :�L ( O'. !y USE ZONE, MAP certify that in the performance of the work for which this / SPEECIA1.7 t permit is issued, I shall not employ any:person in any-manger" ADDRESS CONDITIONS so as to become subject to the Workers' Compensation Laws. O CITY Date Applicant ARCHITECT OR ZIP TEL r ^DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate.of ENGINEER7, --- NO. CONST. NE Exemption, you,.should become subject to:the Workers' U Compensation provisions of the Labor Code you must.forth- ADDRESS..'' `�� - a with comply with such provisions or this permit shall,.be TEL. STATISTICAL CLASSIFICATION. APT. CONDO. N deemed,revoked. CONTRACTORr Y NO. _ LIC. CLASS NO.�DWELL. UNITS- LICZ ENSED CONTRACTORS DECLARATION ADDRESS' NO. I hereby affirm that'I am licensed under provisions of Chapter9 SEWER MAP (commencing with Section 7000)of Division-3 of the Business " LIC. CITY CLASS, and Professions Code,and•my license is.in full force and effect - BK. PG. ; VALIDATION SQ. FT: NO. OF NO."OF ` CHECK License Number Cic'. Class SIZE STORIES= FAMILIES ( ONE ' �VALILJIATION- Coniractor Date DESCRIPTION*OF WORK NEW ❑ 4 ADD E D D OC1 r-p ❑I am exempt under Sec. - D- . ALTER...❑ B.&P.C. for this reason REPAIR $ Date: . USE OF , EXISTING BLDG. ' DEMOL ❑ APPLICANT TEC, , Signat OWNER-BUILDER-DECLARATION . (PRINT) NO. ' FINAL " DATE I,hereb affirm.that.]am exempt from the Contractor's License VI, r the.following reason (Section 7031.5, Business and ADDRESS FINAL ions Code): PRESENT BY s as owner of the property, or m employees with " BUILDING P P ,Y. YADDRESS zA. wages-as their sole compensation,will•do•the work and "' l the structure is not intended.or offered for•sale(Section LOCALITY. 7044, Business and Professions'-Code.) MOVING TEL. - .y " '.f LF D CONTRACTOR NO. ❑ I, as owner of the property, am exclusively contracting" --c .•� with licensed contractors to construct the.project (Sec- ADDRESSrtL '' � tion 7044, Business and Professions.Code.). . -REQUIRED TOTAL SETBACK FROM, EXIST. CONSTRUCTION'LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH e is t, a:li t I hereby affirm.that there is.a construction lending agency for "'FRONT I'�>� .�� • -the performance of the work.for'which this permit is issued P.L. " (Sec. 3097, Civ. C.): SIDE P.L. y ._ Lender's Name. 4!I_li Ell-I_i 113 r �r:y 1 / LDMA,Ref. # -5996 , m P.C. Fee$ Permit Fee Di 16 _t r i j I ( a •ai Lender's Address n D o I certify that I have read this application and state that the Issuance Fee 0 Q ' LDMA'P/C# 8 above information is correct. I agree to comply.with all County Investigation Fee , d ordinance's and State laws relating to'building conslruction, Total Fee CACI LDMA Perm. # a and hereby authorize representatives of this County toenter upon th 6bov -me tioJcd pr rt for is'pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE, Signature of Applican or gent Date'