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Home My Public Portal About8704 HERMOSA DR_Building__ COUNTY OF LOS ANGELES BUILDING AND SAFETY WORKER'S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN BUILDING ADDRESS ,�..ffes�` r I hereby affirm that I have a certificate of consent to self insure, BUILDING ADDR 55 04 P,! or a certificate of Workers' Compensation Insurance,or a certified d PA M5 copy thereof (Sec.3800,Lab,C.) CITY ZIP TE Pia 17('r, C I LOCALITY Policy NO. Company SIZE OF LOT N0,OF BLDGS.1 NOW ON LOT G El Certified Copy is hereby furnished. NEAREST CROSS iijt ❑ Certified copy is,filed with the County building inspectionTRACT BLOCK LOT NO. department. USE ZONE MAP N0. [/ Date Applicant ASSESSOR MAP BOOK PAGE PARCEL n`/ [DSR. SPECIAL CONDITIONS CERTIFICATE OF EXEMPTION FROM WORKERS' QwNER TEL No. COMPENSATION INSURANCE - Pi e,ez r b - LA-__�.LAIA WITHIN 1000 FT.OF SCHOOL? ves No (This Section need not be Completed if the permit is for one hundred ADORED rn DISTRICT GROUP TYPE CONST, FIRE ZONE PROCESSED BY dollars($100)or less.) CITY ZIP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SO as to s CAR�ITEGT O ENGNEER TEL NO. become subject to the WorkerOm OSation La STATISTICAL CLASSIFICATION APT CONDO Date 1-2"3 Applicant ADDRESS CLASS NO. DWELL UNITS NOTICE TO APPLICANT. If, after makio this ertificate Of REQUIRED TOTAL SETBACK FROM EXIST Exemption, you Should become subject to the Workers' CONTRACTOR TEL NO. 2-13 SET BACK YARD HW V PROP LINE WIDTH AC Compensation provisions of the Labor Code, you must forthwith ' 111 2-6$-32- (� FRONT comply with such provisions or this permitshall be deemed revoked. ADDRESSW(A '�11 LIC.NO, P L LICENSED CONTRACTORS DECLARATION C CC# tot 4 SIDE ITV . LAS hereby affirm that I am licensed underprovisions of Chapter 9 �S LICCP L SEWER MAP (commencing with Section 7000)of Division 3 of the Business and SO FT.SIZE .OF STORIES NO.OF FAMILIES Professions Code,and my license is in full force and effect NEW ❑ BK PG d License Number Lic.Class _ DESCRIPTION OF WORK App ❑ VALUATION D Q Contractor�? $ Date I-Lq-�i y s w w t ooF ALTER $ U cc ❑ I am exempt under Sec. - +' '^ REPAIR Lz3' $ 0 `- 6&P.C.far this reason .DEMOL ❑ a G IOC —2+ p LOMA.P/C y W Date: USE OF EX?NG BL G. URM %0 I p- cri Signature j' _ p`�`�'� APPLICANT(PRINT TEL NO. zL 1• LOMA Perm� Z _ __ ❑ I, as owner of the property, or my employees with wages as 'Pe. t ZO 3307 446.61• their sole compensation, will do the work and the structure is ADDRESSI 1 - ITEM not intended Or Offered for sale (Section 7044, Business and Y�✓o w ISL� �tJ�L FINAL DATE - Q { 1��`!=' PfOfeS510f1S Code.) W1LL THE APPLIOANT OR FUTURE BUILDING OCCUPANT HANDLE A HAZARDOUS MATERIAL '�Lt .. I�I I j-)L - -{ m ❑ I, as Owner Of the peoperty, am exclusively contracting with OR A MIXTURE COMAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN THE FINAL///BY AMOUNTS SPECIFIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? ! licensed contractors to construct the project (Section 7044, CHECK 440.6: Business and Professions Code.) YES❑ No❑ !. WILL HNH]E ..00THE INTENDED USE OF THE BUIDLING BY THE APPLICANT OR FUTURE BUILDING OCCUPANT REQUIRE A.PERMIT FOR CONSTRUCTION OR MODIFICATION FROM THE SOUTH _. CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCACMD)SEE PERMITTING CHECKLIST FOR GUIDELINES I hereby affirm that there is a construction lending agency for YES❑ NO 13 pOUCf-GilFJi 1/25/93 the performance of the work for which this permit is Issued(Sea _ IHAVE READ THEHAZARDOUSMY REQUIREMELS NTS RMATION TSUNDER THE COUNTY DPERMITTINGCODE "- -- --____7715 -- { �,1 3OJ7,CIV.C.) DMLE 2,CHAPTER UNDERSTAND TI REQUIREMENTS UNDER THE LOS ANGELES COUNTY CODE 7j`i y q.y4 w TITLE ILSREP TNG SECTIONS 220AGG THROUGH 220.100E SCAO NTNG HAZARDOUS � Lenders Name MATERIALS REPORTING AND FOR OBTAINING A PERMIT FROM THE SCAOMD. -- o Lender's Address a weusa on ncExr o I certify that I have read this application and slate under penalty O of perjury that the above information is correct. I agree to comply PC.FEE PERMIT FEE with all county ordinances and State laws relating to building D m Construction, and hereby au"e representatives of this County ISSUANCE FEE �� to r up fh above-men property for inspection purposes. nA, �,i 1-2-S'-q INVESTIGATION FEE TOTAL FEE sgmw�m nnrrc.,i e.Axe mi. (O (O J SEE REVERSE FOR EXPLANATORY LANGUAGE wWORKERS' COMPENSATION DECLARATION affirm that haver certificate of consent to self APPLICATION FOR BUILDING PERMIT _ a certificate of Workers' Compensation Insurance, fied copy thereof (Sec. 3800•, Lab. C.) COUNTY OF LOS ANGELES.. - BUILDING.AND SAFETY Policy No. �y_Company�r� FU'19 f P/Certified copy is hereby furnished FOR APPLICANT TO FILL IN ADDRESS ElBUDING ❑ Certified copy is filed with the county`uil ing insp�c- BUILDING // nn _ tion department. / �,. f�- ADDRESS ( ` ' i•10 93 //ff f/ CITY ZIP Dae Applicant v t' / / LOCALITY NO. OF BLDGS. NEAREST CERTIFICATE OF EXEMPTION FROM WOR ERS' SIZE OF LOT NOW ON LOT CROSS ST' COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the permit is for one TRACT r BLOCK LOT NO. - MAP BOOK �V� /- - PAGE �LC PARCEL hundred dollars ($I00) or less.) GLS f}m0A/ Pf,PF� NO. OWNER USE MAP I certify that in the performance of the work for which this ./ 0/✓S0 NO. permit is issued, I shall not employ any person in any manner ADDRESS /Vlq - SPECIAL } so as to become subject to the Workers' Compensation Laws. CONDITIONS O 0/SDS-93 CITY ZIP U .Date Applicant - ARCHITECT OR TEL. DISTRICT GROUP TYPE FIRE PROCESSED BY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER NO, C 7 - Z Exemption, you should become subject to the .Workers' �v� -� U Compensation provisions of the Labor Code, you must forth- ADDRE55 I/ d with comply with such provisions or this permit shall be r�� TEL STATISTICAL CLASSIFICATION APT. CONDO. h deemed revoked. CONTRACTOR d 1uf; NO. 3 DD .- Z LICENSED CONTRACTORS DECLARATION ,[LIC CLASS Nb. DWELL. UNITS I hereby affirm that l am licensed under provisions of Chapter 9 ADDRESS .SEDU/!Jl/}//✓S/'NO.� 7 .7�/ EW n ^ (commencing with Section 7000)of Division 3 of the Business LIC SEWER MAP l /`7 and Professions Code,and my license is in full force and,effect. CITY �xt/ CLASS BK PG VALIDATION i• SQ. FT.' - NO. OF NO: OF - CHECK License Number 77 �7 Lic. Class B� / SIZE MI STORIES FALIES ONE L� lovA DEUEGOPM�h'% VALUATION Contractor �A/' Date 40 OS 93 DESCRIPTION OF WORK ,�} NEW �O 41`'❑I am exempt under Se p HL7C� LC��M'Y��• �J�///�/- L ADD ❑, V ., /y. r eLL/l� 'c-G IIT PNET— REPAIR ❑ $ B.BP.C. for this r as"n ' Date: - USE OF EXISTING BLDG. DEMOL ❑ Signatur mil APPLICANT TEL. AL + NER-BUILECLAR ION (PRINT) No. DATE I hereby affirm that I am exe t from a Contractor's License Low for the following rea' n (Secti n 7031.5, Business and ADDRESS - - - - FIN Professions Code): PRESENT _ By BUILDING ❑ I, as owner of the property, or m employees with ACCT a - ...... P P a YADDRESS 'T wages ct their sole compensation,will f o the workand ` ' ' 7 . — the structure is not intended or offered for sale(Section LOCALITY , J.}I�t iia,�•� 7044, Business and Professions Code.) MOVING TEL ' 1 ITEMS ❑ 1, as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- - - - - . . _ _ TOTAL- 113 . 63 tion 7044, Business and Professions Code.) ADDRESS uc - .REQUIRED YARD HWV TOTALSETBACK ROP. LINFROM EXIST. �CHECYt 113.63 CONSTRUCTION LENDING AGENCY SET BACK PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT CHANGE ,i]IT the performance of the work for which this permit is issued P.L. - _ -' 1 (Sec. 3097, Civ. C.). ,SIDE P.I. Obi OOU1 5/9'-"Lender's Name - I— _ D (j LDMA Ref. # _ 1/ 5/ P.C. Fee$ Permit Fee �!/• !1 742 1 AM &:`1 � Lender's Address � wJ'L - _ r' I certify that I ave//d t 'S application and state that the Issuance Fee 1FT �� LDMA P/C# Sabove infor tion s'come . I agr to comply,with all County Investigation Fee ordinance and qqtre s rel. ng to building construction, Total Fee / �/x J LDMA Perm. # a and her �au orVze eprese t.tives of this County to enter upon e a o -me toned rgperty'for inspection purposes. - T -' SEE REVERSE FOR EXPLANATORY LANGUAGE - Signatw. ofplica r'6 A 1, Dote -