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Home My Public Portal About4913 HELEO AVE_Building__ WORKERS'COMPENSATION DECLARATION insure bo Aafcertif carte of Workers' Compensation eInsuran e, APPLICATION FOR BUILDING PERMIT or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy.No. Company �" ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS 1013 Ftev Av ❑ Certified copy is filed with the county building inspec- BUILDING /J ) nµ,' rc tion department. ADDRESS 7 /� !t V 07, Date Applicant CITY C-774>Q(.` ZIP 6/ 7eo LOCALITY g �{ pLt�i "! CERTIFICATE OF EXEPTION FROM COMPENSATION INSURANCE ORKERS' SIZE OF LOT FO x lSZ NOW ON LOT 'CROSS NO. OF BLDGS. $ST Llt' _ 76 8 L YD (This section need not be completed if the permit is for one ASSESSOR hundred dollars ($100)or less.) TRACT J BLOCK LOT NO. MAP BOOK PAGE PARCEL OWNER ��fr�G�l/� No.7g�i�338 USE gE MAP I certify that in the performance of the work for which this NO• permit is issued, Ishall not employ any person in any manner ADDRESS 3 SPECIAL so as to become subject to the Workers'Compen tion Laws. CONDITIONS O Date Applicont CITY ZIP /f/1�✓��L� c L ARCHITECT OR TEL. NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO. DISTRICT GR P TYPE FIRE PRO ED BY O Exemption, you should become subject to the Workers' CONSTI ZO U Compensation provisions of the Labor Code, you must forth- ADDRESS `V► LV. with comply with such provisions or this permit shall be TE D..• deemed revoked. STATISTICAL CLASSIFICATION APT. C to 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. (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. O NO, OF NO.OF / CHECK License Number Lic.Class SIZE STORIES FAMILIES 6 ONE VALUATION Contractor Date DESCRIPTION OF WORK PDD 3eC)fV M 4'- NEW ❑ $14 C— ]� 4 .• 1 ADD j9f lJ (/ ❑ I am exempt under Sec. � r��o�� 9 � w gL7ER ❑ B.BP.C. for this reason C O'I'm,,I- n f 0ca4�o ho m e_ REPAIR ❑ $ 2 9 5 4 6'A USE OF v Date: EXISTING BLDG. 0 a� DEMOL ❑ :# o 0 0 0 0 1 Signature APP PR NTT 1 Y1 eeln 1 �7�i'r(4G Eo. .9$6 0338 FINAL � !'•� ° 1 .$ 1, 1 3 OWNER-BUILDER DECLARATION DATE I hereby affirm that I am exempt from the Contractor's License 'L('/? Ne�� AVC eo 1* •'a ° 1 8 1, 1 3 Law for the following reason (Section 7031.5, Business and ADDRESS �I 3 I I FINAL Professions Code): PRESENT By 506.-88 BUILDING I, as owner of the property, or my employees with ADDRESS l' I 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). t REQUIRED TOTAL SETBACK FROM CONSTRUCTION LENDING AGENCY SETBACK YARD HWY 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 (�f Lender's Address ////11 I certify that I have read this application and state that the Issuance Fee (V LDMA P/C# o above information is correct. I agree to comply with all County Investigation Fee 0 ordinances and State laws relating to building construction, Total Fee LDMA perm. # and hereby authorize representatives of this County to enter upon the above-ment ed property for inspection purposes. `o t/y► a �, l $� SEE REVERSE FOR EXPLANATORY LANGUAGE ,{ •, r`.,• Signature at Applicant or Agent Date APPLICATION FORLDING PERMIT COUNTY OF LOS ANGELES. s` BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN_,,,-"_ Bul DI G ADOREs I hereby affirm that I have a certificate of consent to self insure, BU IN Ap ESS ' ` or a certificate of Workers' Compensation Insurance,or a certified —FG G A b copy thereof (Sec.3800,Lab.C.) CIT ZIP8� -461 V LOCALITY Policy No. Company SIZE Of LO NO.OF BLDGS.NOW ON LOT J� ❑ Certified copy is hereby furnished. , I NE REST CROSS ST. ` - ^�!' I ❑ Certified Copy is filed with the county building inspection TRA T BLOCK LOT NO .^ �J (�l I V USE ZONE MAP NO. AAP• department. Date Applicant ASSESSO �OK PAGE PARCEL SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' o IUERTEL NO. / COMPENSATION INSURANCE e- b 3'V WITHIN 1000 FT.OF SCHOOL? YES NO (This section need not be completed if the permit is for one hundred AD E S DISTRICT GROUP TyyCONST. FIRE ZONE PROCESSEDBY dollars($100) or less.) ZIP/ti � I certify that in the performance of the work for which this permit CITY e �, Il v I�� J . is issued, I shall not employ any person in any manner so as to t/11 v 4j� iL -L� become ubject t0 the Worke%Compensatio� ARCHITE OR ENGINEER TEL NO. STATISTICAL CLASSIFICATION APT CONDO Date I �� Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT.' If, ng 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 SIDE LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS P L I hereby affirm that I am licensed underprovisions of Chapter 9 SEWER MAP (commencing with Section 7000)of Division 3of the Business andQ. .SIZ NO.O)STORIES NO,OF FAMILIES Professions Code,and my license is in full force and effect. NEW 11 BK PG Poo. a _, License Number Lic.Class DESCRIPTION OF WORK , ADD ❑ VALUATION O RemContractor Date ALTER ❑ $ 0 cc ❑ I am exempt under Sec. U REPAIR. ;Y $ 0 BAP.C.for this reason Q ., DEMOL Q', LDMA P/C# V W Date: U E X STINGIrG�. / ; URM ❑ d ignature PLIC T(PRINT ll��ll l� L NO. LDMA Perm# Z I, as owner of the property, or my employees with wages as bo ZO ri!_-I°a their sole compensation, will do the work and the structure is ADDRESS not intended or offered for sale (Section 7044, Business and FINAL DATEO 7,fj 7 (^; c ° - Professions Code.) WILL THE APPLICANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL J r� ❑ I, as Owner of the property, am exclusive) contracting with OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE Q +. 1 T I_N•J._ Y g. AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FINAL BY �! , licensed contractors to construct the project (Section 7044, YES El NO ElI I I 65 Business and Professions Code.) . WILL.THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING ��...yyy { OCCUPANT REQUIRE A PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH 11`�� L/ y D ]/ ;-'HE(^'S'• 113.65 CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST FOR ��p r(� lY� GUIDELINES. CHANGE I hereby affirm that there is a construction lending agency for YES ElNo El N the performance of the work for which this permit IS Issued(Sec. I HAVE READ THE HAZARDOUS MATERIALS INFORMATION GUIDE AND THE SCAOMD PERMITTING 3097,Civ.C.) CHECKLIST.I UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE, j-�-111-1 �� .. TITLE 2,CHAPTER 2.20 SECTIONS 2.20.100 THROUGH 2.20.140 CONCERNING HAZARDOUS ' I j1• IJ13 j3;.t. �. ,•'.,`;I.I r'?is 3 Lender's Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 76 T P ° o Lender's Address " °`f O OWNER OR AGENT oI certify that I have read this application and state under penalty O of perjury that the above information is correct.I agree to comply P.C.FEE PERMIT FEE o with all county ordinances and State laws relating to building construction, and hereby authorize representatives of this County ISSUANCE FEE00 " to er u on the above- fioned property,q insp>ction purposes. � 7/J/e`-' 3 S . � INVESTIGATION FEE TOTAL FEE L r Sg Nre of Applic t�r le Dade J SEE REVERSE FOR EXPLANATORY LANGUAGE