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Home My Public Portal About6109 IVAR AVE_Building__ WORri RS' COMPENSATION DECLARATION \he affirm that I have r certificate of consent To self Q p p��CQ�PON.,��1 FOR p U 0 dID�Gil IG p E R �'.� • � a.certificate ofWorkers' Compensation Insurance, � - ted copy tke�eof (Sec, 3800,_Lab.'C.)' COUNTY OF LOS ANGELES BUILDING AND.SAFETY :,Policy No Company. I BUILDING ❑ Certified copy is,hereby,furnished. FOR APPLICANT TO FILL IN ADDRESS ! v STV _Certified:copy isfiled with the county building inspec- �g BUILDING Tion department. ADDRESS I n a �{�,`. rn CITY �c ( ZIP J 17$O LOCALITY , �y.. Date Applicant NO. OF BLDGS. NEAREST CERTIFICATE'OF EXEMPTION FROM WORKERS' SIZE OF LOT- S ,0b NOW ON LOT '�- O CROSS ST. " 'COMPENSATION INSURANCE P ASSESSOR (This section need not be completed if.the permit is for one TRACT 0�1 BLOCK LOT NO. �j MAP BOOK "' PAGE 'PARCEL hundred dollars'($100)or.less.) TEL. y OWNER LI J ��C- � NO�8i8 STJ,'c�S8L} USE ZONE" MAP ' I certify that in the performance,of the work for which This /�2 �^1 � SPEECIAL permit is issued, I shall not employ any person in any manner ADDRESS ';t072= Sib` �V S CONDITIONS d so as to become 'subject to the Workers' Compensation Laws: p� t �A �; h^ �-f /� O CITY /1 lC1 �"J 1� Fi ZIP )k? 6 Date Applicant ARCHITECT OR � f� TEL. �/ ? ZI DISTRICT ROUP TYPE FIRE PROCESSED BY NOTICE'TO APPLICANT: If, after,making.this:Certificate of ENGINEER SE!►IGtANO. 7% T7 ` v n CONST ZONE rl :.Exemption, you.should become•subject'.to The..Workers' ^ UUY ✓/� Compensation provisions of the Labor Code, you must forth, ' ADDRESS �'S 1��✓-w �V ��7p+ �d ` CL LL'with comply with,such provisions or this permit shall be TEL. STATISTICAL C 1 CATION APT•. CONDO.` N deemed=revoked.. CONTRACTOR NO. Z- LICENSED.CONTRACTORS.DECLARATION .- LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed'under provisions of Chapter ADDRESS NO. (commencing:with Section 7000)of Division 3 of.-the Business' LIC. SEWE P and Professions Code,and my license is in full force and effect. CITY. CLASS BK PG: ' VALIDATION ' SQ. FT. NO. OF NO. OF CHECK License.Number Lic.•Class /` SIZE G STORIES FAMILIES ONE Contractor " Date _. EW $A - -u ATION '' - DESCRIPTION OF WORK C-0 f4 JP�'R-�[' C4-T'�"[, N ❑ 0�,.0l/ _ ADD. .❑ ❑I am exempt under Sec: 0 ALTER D B.&P.C. for this reason k6 �e- REPAIR $ Date USE OF p n _ EXISTING BLDG. C'Z-� G-%1C. DEMOL ❑ Signature APPLICANT TEL./ FINAL f' OWNER-BUILDER DECLARATION. -(PRINT)_ tJAyK-f .WW 'NO 3-4n /{y�/' �B��S�I^/88� DATE l -( -6•�. I hereby affirm that I am exempt from the Contractor's Lice nse S G4fl +: Law for the following reason (Section 7031.5,Business'and ADDRESS 63Z YS TJ•E. (i• FINAL- Professions Code): PRESENT v By, j. IRI BUILDING Ac-C.T.B lLY I, as owner of'.the property, or my employees with ADDRESS s• wages as their sole compensation,,will'do the work and the structure is not intended or offered for'sale(Section LOCALITY 2,S.}�I 7044, Business and Professions.Code.) MOVING TEL. dd qq��, CONTRACTOR . NO. 1 i I Ci i=• ❑ I, as owner of the property, am•exclusively contracting _ with licensed contractors to construct the project (Sec- ADDRESS #•�OTAL '• 91-3 50 ..... 9..p®'— tion 7044,'Business.and Professions Code.) 1� �• ' 'REQUIRED YARD 'HWY TOTAL SETBACK FROM EXIST. t.L�f�- 298.50 CONSTRUCTION LENDING AGENCY SET BACK' PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT _�,ANGE'_ o 00 the performance.of the work for which this permit is issued P.L. . (Sec. 3097, Civ. C.). SIDE, P:L. Lender's Name. ,F (` s 1•Y5, i 1 tJ�li_I- CIS ��t/ItJr't:r LDMA Ref. # ti _ P.C. Fee$ Permit.Fee Y ,r Lender's Address6147 1 o y!I o I certify.that I have read this application and state that The Issuance Fee ' LDMA P/C# D above.information is correct. I agree to comply with all County Investigation Fee Q 8 ordinances and State laws relating to building construction, Total Fee S� LDMA Perm. # a and hereby authorize representatives of this County to enter upon he above-mentioned,propert for,inspection purposes. SEE-REVERSE FOR EXPLANATORY LANGUAGE nature of Applicant or Agent Date WORKERS' COMPENSATION DECLARATION '`I here affirm that. I have a..certificate of. consent'to self inslLrlS, o.certifico+fe'of Workers' Compensation (nsurpnce, ssr a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES '.'BUILDING ARID SAFETY `i Policy-No. Company A; ElCertified,copy is hereby furnished. : 'FOR APPLICANT jTO BUILDING.FILL IN ADDRESS 0 T'° Ave ❑ -"Certified copy is filed with the county building inspec- BUILDING ADDRESS f9 tion'department. . A pp Dare' Applicant CITY• �?� L"5I ZIP °,1 \80 LOCALITY N . OF BLDGS. —•' NEAREST CERTIFICATE OF`EXEMPTION'FROM WORKERS' SIZE OF LOT 'S. x 10'e>1 NOW ON LOT '[ ""�' CROSS ST. COMPENSATION'1NSURANCE ASSESSOR. (This section need not be'completed if the permit is for one TRACT 5�� BLOCK LOT NO. MAP.BOOK PAGE PARCEL hundred dollars ($100)or less.) ,, 1� }} p OWNER T J t44t l NO(8I8 ��Q US ON NOP I certify that. in the performance of,the.'work.for which this _ permit is issued, I shall not employ any person"in any manner ADDRESS 6 L � �✓ —�� SPECIAL .`. CONDITIONS so as to become subject to the Workers' Compensation Laws. O ' CITY Cfl e' zip �.1 7 6 u Date- - Applicant ARCHITECT ORa f TEL. � NOTICE TO APPLICANT:, If, after making.This Certificate of ENGINEER- :V. .�!1,�WSE-�I NO. 3'� .Z - 'DISTRICT: G OUP TYPE FIRE PROCE SED BY O Exemption,. you should become subject to the_ Workers' p , p hsAcoer4A D ,2 CONE . ZSE a Compensation provisions of the Labor Code, you must forth- ADDRESS O ff J .�Iy/�`— with -comply with such provisions or this permit•'shall be TEL. STATISTICAL.CLASS I TION APT. CONDO. N deemed revoked.revoked. CONTRACTOR_ NO. Z LICENSED CONTRACTORS,DECLARATION' LIC. CLASS NO. DWELL. UNITS I hereby affirm that I am licensed under provisions of•Chapte'r9 ADDRESS NO. (commencing with Section 7000)of Division 3 of the Business LIC SEWE P and Professions Code,and my license is in full force and effect. CITY CLASS BK. PG. VALIDATION SQ. FT. NO. OF NO. OF -CHECK LicenseNumber Lic:,Class SIZE STORIESFAMILIES ONE VALUATION Contractor Date DESCR,�IP{{TION OF WORK $V C .E!C'61M NEW ❑ _ $ El am exempt under Sec. 1 �T.�� S.F w[,Zc Wao �D ❑ , . -ALTER ❑ D B.&P.C. for this reason • 5 . REM $ Date: USE OF -� Iw`^^ .T' EXISTING BLDG. DEMOL Signature APPLICANT. TEL N0T IefN �� T g d,v t. (PRINT)..{-�J YP��' _AW4N NC�a18 '-� FINAL .�J l /,$ ptgNnit f1E4E7J£floy"ENAn+T OWNER-BUILDER DECLARATION. /^ DATE_ I hereby affirm that.I am exempt•from the Contractor's License - f 6 32 S. ' f, �i; �1`. Law for the following reason-(Section 7031.5, Business'and ADDRESS FINAL € rof 'sions Code): PRESENT _.:, _ By BUILDING 1, as owner of the property, or my employees with ADDRESS 3730 - t -. wages as their sole compensation;will do the work and 6(JF V GU , _01 6 io•-(.I the structure is not intended or offered for sale(Section LOCALITY i _ i,�rL ; 7044, Business and Professions-Code.) 'MOVING TEL. �;:. 'I 9 Et l CONTRACTOR NO. ❑ 1, as owner of,the property, am exclusively contracting is TOTAL I • � _� with licensed contractors to construct the project.(Sec- CSL 6 Q0ADDRESS tion 7044, Business and Professions Code.) Lfi.N � Iaf; REQUIRED- TOTAL SETBACK.FROM "EXIST. CONSTRUCTION LENDING AGENCY SET.BACK "YARD HWY PROP. LINE WIDTH - I hereby`affirm that there is a construction lending agency for FRONT �'tl`�L7 °`!=1 -the performance'of the work for which this permit is issued P.E. (Sec. 3097, Civ:C.). .SIDE ; Lender's Name. P.L. f 0 'I hl31 4L P.C. Fee$ Permit Fee �0, 90 . LDMA Ref. # Hi 3 Lender's Address 1 certify that I have-read this application and state"that the Issuance Fee' / �/ LDMA,P/C# above information is correct. I agree to comply with all County Investigation,Fee , r ordinances and State laws relating to.building construction; Total Fee /� LDMA Perm. # a and hereby authorize representatives of this County to enter upoMve-r entioned property for inspection purposes. a o ` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date "